Nokea
The client who underwent a left above-the-knee amputation as a result of uncontrolled diabetes questions the nurse, asking, 'Why did this happen to me? I have always been a good person.' Which is the nurse’s most therapeutic response?
- A. Tell me about how it feels to have caused this to happen to you.'
- B. I know how you feel; having your leg cut off is sad.'
- C. Why do you think that you had to have your leg amputated?'
- D. I can see you are hurting. Would you like to talk?'
Correct Answer: D
Rationale: Acknowledging distress and offering to talk is therapeutic, validating emotions. Blaming the client, claiming empathy, or questioning beliefs is less supportive.
You may also like to solve these questions
Which instruction should the nurse include when reinforcing teaching with the parents about safety considerations for a child with a surgically corrected myelomeningocele?
- A. Make sure braces lie smoothly against the child's skin.
- B. Ensure that the child shifts position at least every 3 hours.
- C. Place a blanket between the child and the wheelchair seat.
- D. Check all of the child's skin daily for redness or irritation.
Correct Answer: D
Rationale: Daily skin checks are essential to prevent pressure ulcers and other skin complications in children with myelomeningocele.
The client is scheduled for a computed tomography (CT) scan. Which question is most important for the nurse to ask before the procedure?
- A. On a scale of 1 to 10, how do you rate your pain?'
- B. Do you feel uncomfortable in enclosed spaces?'
- C. Are you allergic to seafood or iodine?'
- D. Have you signed a permit for this procedure?'
Correct Answer: C
Rationale: Iodine/seafood allergies are critical to assess before CT with contrast to prevent anaphylaxis. Claustrophobia, pain, and consent are secondary.
Which information is most appropriate to teach the client before the arthroscopy procedure?
- A. Signs and symptoms of arthritis
- B. Technique for using crutches
- C. Adverse effects of drug therapy
- D. The need to balance rest and exercise
Correct Answer: B
Rationale: Crutch use is critical post-arthroscopy for safe ambulation.
The client has an external fixator for reduction of a tibia fracture. The nurse is evaluating the client's effectiveness in ambulating with crutches. Place an X on each of the three areas where the client should be bearing weight When crutch walking.
- A. The client should be bearing weight on the hand grips when bringing legs forward. When moving crutches, the weight should be borne on the unaffected leg.
Correct Answer: image
Rationale: The client should be bearing weight on the hand grips when bringing legs forward and on the unaffected leg when moving crutches to ensure proper crutch-walking technique and stability.
Which antiepileptic medication is associated with gingival hyperplasia?
- A. Gingival hyperplasia (overgrowth of gum tissue) is unique to phenytoin (Dilantin) among antiepileptic medications. About 20% of people taking phenytoin have gingival hyperplasia. This can be minimized with thorough oral care.
- B. Valproic acid (Depakote) does not have a side effect of gingival hyperplasia.
- C. Gingival hyperplasia is not a side effect of carbamazepine (Tegretol).
- D. Gingival hyperplasia is not a side effect of phenobarbital (Luminal).
Correct Answer: A
Rationale: Phenytoin (Dilantin) is uniquely associated with gingival hyperplasia, which can be mitigated with good oral hygiene.