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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

Choice B rationale:

Stroke is a condition that occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. Facial drooping and garbled speech are common signs of stroke, especially if they occur suddenly and on one side of the face.Stroke is a medical emergency that requires immediate treatment to prevent further brain damage and complications

Choice C rationale:

An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.

Choice D rationale:

Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.

A. Whatever the parents decide, the staﬀ will be available to support the decision. B. The child's prognosis will not develop complications if surgery is delayed. C. Some children do outgrow this type of problem and waiting may be beneficial. D. Ask the parents to explain what they understand about the child's diagnosis.

Correct Answer is D

Explanation

The correct answer is choiced. Ask the parents to explain what they understand about the child’s diagnosis.

Choice A rationale:

While it is important to support the parents’ decisions, this choice does not address the need for the parents to have accurate information about the condition and its potential complications.

Choice B rationale:

This statement is incorrect.Delaying surgery for hypospadias can lead to complications such as urinary problems, infections, and issues with sexual function later in life.

Choice C rationale:

This is misleading.Hypospadias does not typically resolve on its own, and waiting can result in complications that may require more complex surgical interventions.

Choice D rationale:

This choice is correct because it encourages the parents to share their understanding of the diagnosis, allowing the nurse to provide accurate information and address any misconceptions.This approach ensures that the parents make an informed decision based on a clear understanding of the condition and its implications.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse (PN) that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?

Correct Answer is D

Explanation

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A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching?

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After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

What is the most common type of shock in children?

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