Nokea
The patient, age 52, is recovering from a modified radical mastectomy. For which reason will the nurse ensure postoperative elevation of the patient's arm after this procedure?
- A. To prevent vascular and lymph stasis, thus lymphedema.
- B. To prevent drainage accumulation at the incisional site.
- C. To prevent wound infection and dehiscence.
- D. To prevent pleural effusion and respiratory distress.
Correct Answer: A
Rationale: If the arm is not restricted by dressings, it may be elevated on a pillow with the hand and wrist higher than the elbow and the elbow higher than the shoulder joint. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema.
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The nurse is assisting the health care provider in removing a small sample of tissue from the patient's cervix to have it evaluated. This procedure is called a cervical ___
Correct Answer: conization
Rationale: Conization of the cervix is indicated when eroded or infected tissue is to be removed or when there is a need for confirmation of cervical cancer. A cone-shaped section is removed when the mass is confined to the epithelial tissue.
Which instruction will a nurse give a patient with genital herpes who does not have lesions at the present?
- A. Continued use of acyclovir will prevent reinfection by the virus.'
- B. Condoms should be used during all sexual activity to prevent transmission of the virus, even when lesions are not present.'
- C. Acyclovir ointment should be applied to the lesions to increase comfort and speed healing.'
- D. Recurrent genital herpes is promoted by any sexual stimulation.'
Correct Answer: B
Rationale: Sexual transmission of HSV (genital herpes, a virus) has been documented even in the absence of clinical lesions, and the use of condoms should be encouraged. Acyclovir does not cure the disease but makes the attacks less virulent.
Which factor is an advantage of a vaginal hysterectomy over the abdominal hysterectomy?
- A. Less postoperative discomfort
- B. Reduced hospital stay
- C. Less expensive
- D. Better visualization of the intrapelvic area
- E. Faster recovery
Correct Answer: A,B,C,E
Rationale: The vaginal approach allows for less postoperative discomfort, a reduced hospital stay, is less expensive, and offers a faster recovery.
The young woman comes to the free clinic for the complaint of stomach cramps. During the examination, the nurse recommends that she be tested for chlamydia. The woman says 'I don't need any test...I don't have any symptoms for a sexual infection...I just came for irregular bleeding.' Which response is most informative?
- A. Well, if you get more symptoms come back for testing.'
- B. The health care provider may have to order medicine for syphilis and chlamydia. You probably have that too. You need to be tested today!'
- C. Testing is not mandatory...I probably wouldn't bother either since you have no symptoms.'
- D. The irregular bleeding may be part of a chlamydia infection.'
Correct Answer: D
Rationale: Chlamydia frequently displays no signs or symptoms in women. Some patients do have symptoms of vaginal pruritis, burning, dull pelvic pain, low-grade fever, vaginal discharge or irregular bleeding.
For which reason will the nurse encourage the patient who is recovering from a modified radical mastectomy to exercise the affected arm?
- A. To reduce pain.
- B. To stimulate appetite.
- C. To reduce lymphedema.
- D. To increase muscle tension.
Correct Answer: C
Rationale: An exercise regimen, built up gradually, can help reduce lymphedema following a modified radical mastectomy.