Nokea
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
- A. Place the arm in the sling
- B. Apply cold soaks to the affected arm
- C. Introduce variations in styles of clothing
- D. Tie a tight bandage to the arm
Correct Answer: C
Rationale: Introducing variations in styles of clothing can help the client feel more comfortable and confident despite the abnormal enlargement of her arm due to lymphedema. By wearing different styles of clothing that accommodate the affected arm, the client can still express her personal style and feel good about her appearance. This approach can help improve the client's self-image and self-esteem, supporting her emotionally as she copes with the condition. Placing the arm in a sling, applying cold soaks, or tying a tight bandage are not appropriate suggestions for addressing the client's anxiety and self-image concerns in this situation.
You may also like to solve these questions
The nurse has been caring for a newborn who just died. The parents are present but say they are "afraid" to hold the dead newborn. Which is the most appropriate nursing intervention?
- A. Tell them there is nothing to fear.
- B. Insist that they hold newborn "one last time."
- C. Respect their wishes and release body to morgue.
- D. Keep newborn's body available for a few hours in case they change their minds.
Correct Answer: D
Rationale: The most appropriate nursing intervention in this situation is to keep the newborn's body available for a few hours in case the parents change their minds. It is important to respect the parents' feelings and fears while also providing them with the opportunity to hold their child if they decide to do so later on. By keeping the newborn's body available, the parents can have the time and space they need to process their emotions and make a decision that feels right for them. This approach supports the parents' autonomy and allows them to grieve in a way that is meaningful to them.
Which of the following assessment findings would suggest to the home health nurse that the patient is developing congestive heart failure?
- A. orthopnea
- B. fever
- C. weight loss
- D. calf pain A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET O
Correct Answer: A
Rationale: Orthopnea is a common symptom of congestive heart failure. It is defined as difficulty in breathing when lying flat, which improves when sitting up or standing. This occurs due to the redistribution of blood in the body when changing positions. As fluid accumulates in the lungs in congestive heart failure, lying down increases pressure on the chest and impairs breathing. Therefore, orthopnea is a significant assessment finding that would suggest to the home health nurse that the patient is developing congestive heart failure. Fever, weight loss, and calf pain are not typically associated with congestive heart failure.
The nurse is teaching about congenital clubfoot in infants. The nurse evaluates the teaching as successful when the parent states that clubfoot is best treated when?
- A. Immediately after diagnosis.
- B. At age 4 to 6 months.
- C. Prior to walking (age 9 to 12 months).
- D. After walking is established (age 15 to 18 months).
Correct Answer: A
Rationale: Congenital clubfoot is best treated when started immediately after diagnosis. Early intervention and treatment are crucial for better outcomes in correcting clubfoot deformities. Tendons and ligaments are more flexible in infants, making it easier to manipulate and correct the foot. Starting treatment as early as possible can help prevent long-term complications and improve the child's ability to walk normally. Therapy may involve stretching exercises, casting, or surgery, depending on the severity of the condition. Therefore, early intervention is key in the successful management of congenital clubfoot in infants.
The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in the blood of an adult is typically between 12-18 grams per deciliter (g/dL). Hemoglobin is a protein found in red blood cells that is responsible for carrying oxygen from the lungs to the tissues in the body. Having an adequate level of hemoglobin is essential for proper oxygen delivery throughout the body. Values outside of the normal range may indicate anemia (low hemoglobin levels) or other underlying health conditions. It's important to consult a healthcare provider for interpretation of specific hemoglobin test results.
Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
- A. The nurse checks the clients BP every hour
- B. The nurse checks the site and progress of the infusion every hour
- C. The nurse checks the progress of the infusion once a day
- D. The nurse checks the client's pulse rate every hour
Correct Answer: B
Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.