Nokea
Which statement by the nurse provides the best explanation about the purpose of antiembolism stockings?
- A. Antiembolism stockings prevent blood from pooling in the legs.
- B. Antiembolism stockings reduce blood flow to the exercises.
- C. Antiembolism stockings keep the blood pressure lower in the legs.
- D. Antiembolism stockings keep the blood vessels constricted.
Correct Answer: A
Rationale: Antiembolism stockings apply graduated compression to promote venous return, preventing blood pooling and reducing the risk of deep vein thrombosis in immobile clients. The other options are inaccurate.
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Which psychosocial problem should the nurse identify for a client with an external fixator device?
- A. Ineffective coping.
- B. Alteration in body image.
- C. Grieving.
- D. Impaired communication.
Correct Answer: B
Rationale: External fixators alter appearance, causing body image disturbance. Coping, grieving, and communication are less specific without evidence.
The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?
- A. Encouraging deep breathing
- B. Asking him if he understands the full effects of the planned surgery
- C. Discussing the effects of diabetes on the vascular system
- D. Having a recovered amputee visit him
Correct Answer: D
Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.
The nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.
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.
The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately?
- A. Localized edema and discoloration occurring hours after the injury.
- B. Generalized weakness and increasing sensitivity to touch.
- C. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain.
- D. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.
Correct Answer: C
Rationale: Absent pulses and increasing pain suggest compartment syndrome or arterial occlusion, requiring urgent HCP notification. Edema is expected, weakness is nonspecific, and pain relief is positive.