Which of the following is part of client teaching regarding antiembolism stockings?
- A. Instruct the client to roll the top portion of the stocking down if it is too long
- B. Stockings are applied with the toes uncovered at the end
- C. Measure for thigh-high stockings from the foot to the knee
- D. Stockings are to be smooth from end to end without wrinkles
Correct Answer: D
Rationale: When educating clients about antiembolism stockings, it is essential to emphasize that the stockings should be smooth from end to end without wrinkles. Wrinkles in the stockings can impede circulation, defeating the purpose of wearing them to prevent blood clot formation. Instructing the client to roll the top portion of the stocking down if it is too long (Choice A) is incorrect as it can create unnecessary pressure points. Stockings should be applied with the toes covered at the end (Choice B) to ensure proper compression. Measuring for thigh-high stockings should be done from the knee to the foot (Choice C) to ensure the correct fit and compression gradient.
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Which of the following is an example of physical abuse?
- A. A slap to the person's hand
- B. Threatening the person
- C. Ignoring and isolating a person
- D. Leaving a patient soiled for hours
Correct Answer: A
Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.
A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?
- A. Is something wrong with the bath water?
- B. Just calm down, we'll finish your bath soon.
- C. Are you trying to tell me something?
- D. Shall I turn on the television?
Correct Answer: A
Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.
Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?
- A. A physical therapist
- B. A speech therapist
- C. A social worker
- D. An occupational therapist
Correct Answer: D
Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.
A client is being instructed on how to use crutches. Which of the following information should be included in the teaching?
- A. Place the majority of body weight on the axilla.
- B. Dry crutch tips with a paper towel if they become wet.
- C. Use the crutches for support to lift both feet simultaneously when ascending stairs.
- D. Both B and C.
Correct Answer: B
Rationale: When instructing a client on how to use crutches for ambulation, it is important to emphasize keeping the crutch tips dry to prevent slipping while bearing weight on them. Moisture on the crutch tips can lead to accidents. Therefore, the correct answer is to dry the crutch tips with a paper towel if they become wet. Choice A, placing the majority of body weight on the axilla, is incorrect as the weight should be borne through the hands, not the axilla, to avoid nerve damage. Choice C, using the crutches to lift both feet simultaneously when ascending stairs, is incorrect as the client should ascend stairs by placing weight on the unaffected leg first, followed by the crutches and then the affected leg. This method provides stability and safety during stair climbing.
A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?
- A. The client lies on his side with the upper leg flexed
- B. The client lies on his back with his head lower than his feet
- C. The client lies on his abdomen with a pillow supporting his head
- D. The client is sitting up at a 90-degree angle
Correct Answer: A
Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.