Nokea
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse knows that the client has understood the nurse's instructions when he states he will:
- A. Avoid exercise
- B. Lose weight
- C. Perform leg lifts every 4 hours
- D. Wear support hose, using rubber bands to hold the stockings up
Correct Answer: B
Rationale: Weight loss reduces pressure on veins and improves circulation, critical for managing DVT and thrombophlebitis in an obese client. Avoiding exercise increases stasis, leg lifts are insufficient alone, and rubber bands can cause constriction, negating support hose benefits.
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What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
- A. "You will need to accept the necessity for a quiet and inactive lifestyle."
- B. "Keep active, use stress reduction strategies, and avoid fatigue."
- C. "Follow good health habits to change the course of the disease."
- D. "Practice using the mechanical aids that you will need when future disabilities arise."
Correct Answer: B
Rationale: Encouraging activity, stress reduction, and fatigue management supports the client's quality of life and symptom control. Inactivity, changing disease course, or premature focus on aids are less appropriate.
The client asks the nurse, 'Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?' On which of the following should the nurse base the response?
- A. The need to remove as much of the leg as possible.
- B. The adequacy of the blood supply to the tissues.
- C. The ease with which a prosthesis can be fitted.
- D. The client's ability to walk with a prosthesis.
Correct Answer: B
Rationale: The extent of amputation depends on tissue viability, determined by blood supply intraoperatively.
After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following?
- A. How much does your family need to be involved in learning about your condition?'
- B. What is required for your family to manage your symptoms?'
- C. What activities are most important for you to be able to maintain control of your diabetes?'
- D. What do you know about your medications and condition?'
Correct Answer: D
Rationale: An empowerment approach focuses on the client's knowledge and needs. Starting with what the client already knows about their condition and medications helps tailor education effectively.