Nokea
A nurse is caring for a client who has diabetes mellitus and had a below-the-knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
- A. When I look in the mirror, all I see is a person without a leg.
- B. I have not always made good choices in life. I deserve to lose my leg.
- C. If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
- D. No matter how hard I work in physical therapy, I can't seem to make any progress.
Correct Answer: A
Rationale: A body image disturbance is reflected in the client's negative perception of their physical self.
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A nurse is reinforcing teaching with a client about crutch walking using the swing-through gait. Which of the following statements should the nurse include?
- A. Look down at your feet before moving the crutches.
- B. Place one crutch forward with the opposite foot and then place the second crutch forward with the other foot.
- C. Move both crutches forward, then lift and move your body past the crutches.
- D. Bear your weight against the underarm crutch pads.
Correct Answer: C
Rationale: The correct answer is C: Move both crutches forward, then lift and move your body past the crutches. This statement correctly describes the swing-through gait technique where both crutches are moved forward simultaneously followed by the client lifting and moving their body past the crutches. This technique helps maintain balance and stability during crutch walking. Looking down at your feet before moving the crutches (Choice A) is incorrect as it can cause the client to lose their balance. Placing one crutch forward with the opposite foot and then the second crutch forward with the other foot (Choice B) is the incorrect description of the swing-to gait technique. Bearing weight against the underarm crutch pads (Choice D) is incorrect as it can cause discomfort and potential nerve damage.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?
- A. I am thinking of getting a second opinion.
- B. I am hoping this will help relieve my discomfort.
- C. This is making me stronger every day.
- D. This is not working, and I plan to stop treatment.
Correct Answer: B
Rationale: Palliative care focuses on symptom relief, and the statement reflects an understanding of this goal.
A nurse is providing discharge teaching to a client following a right mastectomy. Which of the following statements should indicate to the nurse that the client has a healthy body image?
- A. Do I have to go home with drains?
- B. The incision looks like it is healing.
- C. My sister will change the dressing every day.
- D. When will all this pain start to go away?
Correct Answer: B
Rationale: A statement acknowledging the healing process suggests the client is adjusting positively to body image changes.
A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?
- A. Recent exposure to poison ivy
- B. Scaling and redness between the toes
- C. Circular, erythematous patches on the scalp
- D. A recent prescription for an antiseizure medication
Correct Answer: B
Rationale: Tinea pedis, or athlete's foot, commonly presents as scaling and redness between the toes due to fungal infection.