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Zorluk: OrtaBasic Care and Comfort

The nurse is developing a basic care and comfort plan for an 82-year-old client who is recovering from a right-sided modified radical mastectomy. The client has a baseline of mild cognitive impairment. Which interventions should the nurse include in the plan of care? Select all that apply.

  1. Support the client's right arm on a pillow while they are resting in bed.Cevap
  2. Assist the client with a partial bed bath, ensuring the skin is patted dry rather than rubbed.Cevap
  3. C
    Position the client on their right lateral side to apply pressure to the incision and reduce pain.
  4. D
    Direct the unlicensed assistive personnel (UAP) to evaluate the surgical dressing for signs of excessive drainage.
  5. E
    Attribute any sudden onset of severe confusion to the client's baseline cognitive impairment and advanced age.
  6. Provide a warm blanket and minimize environmental noise to encourage restful sleep.Cevap

Cevap

The correct interventions are to support the right arm on a pillow, assist with a gentle partial bed bath by patting the skin dry, and provide a warm, quiet environment to promote sleep.
Elevating the affected arm on a pillow facilitates lymphatic drainage and reduces edema. Patting the skin dry during a bed bath prevents sheer and trauma to the healing tissues. Providing a warm blanket and a quiet environment are fundamental non-pharmacologic comfort measures that promote rest and physiological adaptation.

Adım Adım Çözüm

1
Analyze the client's surgical procedure (right-sided modified radical mastectomy) and related comfort needs.
The client requires fundamental interventions that prevent lymphedema, manage pain, and promote hygiene without causing trauma to the surgical site.
Basic care must align with anatomical safety and post-surgical protocols.
2
Evaluate the positioning options for physiological integrity.
Elevating the affected arm on a pillow promotes venous return. Conversely, lying on the operative side is strictly contraindicated.
Gravity assists in preventing fluid accumulation, whereas direct pressure impedes drainage and increases discomfort.
3
Assess the delegation and geriatric assessment components.
UAPs cannot perform clinical evaluations; furthermore, sudden confusion must be treated as acute delirium rather than normal aging.
The registered nurse retains responsibility for all clinical assessments and must accurately differentiate between baseline dementia and acute pathological changes.

Anahtar Kavram

Basic Care and Comfort Post-Mastectomy
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Basic Care and Comfort

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