Nokea
A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Restrict visitors to family members until the client is able to wear a prosthesis.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Instruct the client to ignore phantom pain sensations.
- D. Suggest that family members bring clothing for the client from home.
- E. Ask the client to describe her feelings about the loss of the affected limb.
Correct Answer: B,D,E
Rationale: Peer support, familiar clothing, and addressing feelings promote psychological adjustment and rehabilitation; restricting visitors or ignoring phantom pain is not therapeutic.
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A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can decrease my risk for a stroke by losing excess weight.
- B. My risk for a stroke increases if my HbA1c level is 5 percent or less.
- C. Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.
- D. My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.
Correct Answer: A
Rationale: Losing excess weight reduces risk factors such as hypertension and diabetes complications, which are linked to stroke risk, indicating understanding of the teaching.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, and this statement reflects an understanding of breast self-examination teaching.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Season foods with spices.
- C. Provide a high-calorie diet.
- D. Administer an antiemetic after each meal.
Correct Answer: C
Rationale: A high-calorie diet addresses malnutrition in AIDS clients, supporting nutritional needs and immune function.
A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?
- A. Empty the pouch when it is 1/3 to 1/2 full.
- B. Use a standard enema set to irrigate the colostomy.
- C. Cleanse the skin surrounding the stoma with moisturizing soap.
- D. Cut the opening in the skin barrier 1/4 inch larger than the stoma.
Correct Answer: A
Rationale: Emptying the pouch when 1/3 to 1/2 full prevents leakage and maintains skin integrity, a key aspect of ostomy care.
A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?
- A. Prefers not to look at the stoma site
- B. Participates in performing ostomy care
- C. Denies feelings of sadness about the ostomy
- D. Accepts that sexual activity will decrease
Correct Answer: B
Rationale: Participating in ostomy care demonstrates acceptance and adaptation to the altered body image.