Which points should a nurse includes in the discharge teaching plan for a client after cardiac surgery?

Correct Answer: B

Rationale: The correct answer is B. In the discharge teaching plan for a client after cardiac surgery, it is important for the nurse to include education on monitoring for signs of complications, such as notifying the physician if a painless lump is felt at the top of the chest incision. This could potentially indicate a seroma or hematoma, which may require medical attention. By educating the client on this specific point, the nurse helps to promote early detection and prompt management of any post-operative issues, which contributes to better outcomes for the client. The other options mentioned are important aspects of post-cardiac surgery care but do not address the specific concern of a painless lump at the chest incision site.

Correct Answer: A

Rationale: Performing monthly breast self-examination (BSE) after menstruation is recommended because during this time, the breasts are less likely to be swollen or tender, which can help to ensure a more accurate examination. Engaging in BSE on a regular basis can help individuals become familiar with their breast tissue and better recognize any changes that may occur. By performing BSE monthly after menstruation, individuals can actively monitor their breast health and potentially detect any abnormalities or signs of breast cancer at an early stage.

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired clot formation and increased risk of bleeding. With a low platelet count, there is an increased risk of internal bleeding and hemorrhage, which can affect vital organs such as the brain, heart, and gastrointestinal tract. Therefore, the priority nursing diagnosis for a client with thrombocytopenia receiving chemotherapy would be Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Monitoring for signs of internal bleeding, such as changes in mental status, chest pain, and abdominal pain, is crucial to prevent potential life-threatening complications.

Correct Answer: A

Rationale: This milestone is typically achieved around 4 months.

Correct Answer: C

Rationale: Aniridia and hemihypertrophy are features of WAGR syndrome, which increases the risk of Wilms tumor.