A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss.
The client's medical history includes hypertension, gouty arthritis, and cholecystitis.
Which instruction should the nurse include in the discharge teaching?
Substitute natural fruit juices for carbonated drinks.
Encourage active range of motion to limit stiffness.
Use electric heating pad when pain is at its worst.
Avoid the consumption of wine, beer, and coffee.
The Correct Answer is B
Choice A rationale:
Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.
Choice B rationale:
Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.
Choice C rationale:
Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.
Choice D rationale:
Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The neurology unit supervisor is not the most appropriate nurse to coordinate the progression of care for a client with a spinal cord injury (SCI). While they may have expertise in neurology, the nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including SCI. They can facilitate communication between various healthcare providers and ensure that the client receives comprehensive care throughout their stay.
Choice B rationale:
An adult nurse practitioner may have specialized knowledge in the care of adults, but they may not have the specific skills and training required to coordinate the care of a client with a spinal cord injury in the ICU. Nurse case managers are better equipped to manage complex cases and ensure the continuity of care for the client.
Choice D rationale:
A risk management nurse focuses on minimizing healthcare-related risks and ensuring the safety of patients and staff. While their role is essential, it is not the primary responsibility to coordinate the progression of care for a client with a spinal cord injury. The nurse case manager is better suited for this role as they specialize in care coordination.
Correct Answer is B
Explanation
Choice A rationale:
CP being one of the most common permanent physical disabilities in children is a general statement but does not directly address the mother's question about the progression of her child's impaired movements. It does not provide an explanation for the potential course of CP.
Choice B rationale:
Brain damage with CP is not progressive but does have a variable course. This response provides the best explanation to the mother's question. CP is a static neurological condition, which means that the initial brain injury that led to CP does not worsen over time. However, the functional abilities and impairments of a child with CP can vary widely and may change as the child grows and develops. Some children may improve with therapy and interventions, while others may have relatively stable impairments.
Choice C rationale:
Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.
Choice D rationale:
Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro
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