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A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
- A. I would like to meet with another client who has had an amputation.
- B. I would rather not look at my stump during a dressing change.
- C. I am glad that I no longer have to deal with my infected leg.
- D. I understand that I will be unable to return to my job.
Correct Answer: A
Rationale: The correct answer is A: "I would like to meet with another client who has had an amputation." This statement indicates acceptance of the altered body image as the client is actively seeking connection with others who have gone through a similar experience. By expressing a desire to meet someone with a similar amputation, the client is acknowledging and normalizing their own situation, showing acceptance and readiness to engage in discussions about their body image.
Summary of why other choices are incorrect:
B: "I would rather not look at my stump during a dressing change." - This statement suggests avoidance and discomfort with the amputation, indicating a lack of acceptance.
C: "I am glad that I no longer have to deal with my infected leg." - While this statement may indicate relief from a health issue, it does not necessarily demonstrate acceptance of the altered body image.
D: "I understand that I will be unable to return to my job." - This statement reflects resignation to a limitation but does not directly address body
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A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Dry skin
- B. Alopecia
- C. Increased salivation
- D. Dolichocephaly
Correct Answer: A
Rationale: The correct answer is A: Dry skin. Malnutrition can lead to a deficiency in essential nutrients like vitamins and minerals, causing skin to become dry and flaky. This occurs due to a lack of proper hydration and nourishment. Alopecia (B) is more commonly associated with conditions like stress or hormonal imbalances. Increased salivation (C) is not typically linked to malnutrition but can be seen in conditions like GERD. Dolichocephaly (D) refers to an elongated shape of the head and is not directly related to malnutrition. In summary, dry skin is a manifestation of malnutrition due to the lack of essential nutrients, while the other choices are more likely associated with different conditions or factors.
A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the nurse include?
- A. Limit fluids to 1.5 L per day.
- B. Avoid extremely hot or cold temperatures.
- C. Avoid getting a flu vaccination.
- D. Limit alcohol intake to one drink per day.
Correct Answer: B
Rationale: The correct answer is B: Avoid extremely hot or cold temperatures. This instruction is crucial for a client recovering from a sickle cell crisis as extreme temperatures can trigger or worsen a sickle cell crisis. Hot temperatures can lead to dehydration and increase the risk of vaso-occlusive events, while cold temperatures can cause vasoconstriction, leading to further sickling of red blood cells. Limiting fluids (A) is incorrect as hydration is important to prevent complications. Avoiding a flu vaccination (C) is also incorrect as it is recommended to protect against infections that can trigger a crisis. Limiting alcohol intake (D) is not directly related to sickle cell crisis recovery.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is planning care for a client who has *Clostridium difficile* gastroenteritis. Which of the following is an appropriate nursing action?
- A. Place the client in a protective environment.
- B. Clean surfaces with chlorhexidine.
- C. Obtain a stool specimen with gloves.
- D. Wash hands with alcohol-based hand rub.
Correct Answer: C
Rationale: The correct answer is C: Obtain a stool specimen with gloves. This is important because *Clostridium difficile* is a highly contagious bacterium that spreads through fecal-oral route. By obtaining a stool specimen with gloves, the nurse can prevent the spread of the infection to themselves and others. Placing the client in a protective environment (choice A) is not necessary as standard precautions are sufficient. Cleaning surfaces with chlorhexidine (choice B) is important, but obtaining a stool specimen is a higher priority. Washing hands with alcohol-based hand rub (choice D) is important, but gloves should be used when handling stool specimens for extra protection.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.