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 B
Explanation
Choice A rationale:
Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.
Choice B rationale:
Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.
Choice C rationale:
Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.
Choice D rationale:
Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.
Correct Answer is C
Explanation
Choice A rationale: While monitoring temperature is important for a client with meningitis to track the resolution of infection, it is not a prerequisite for administering penicillin. It does not prevent life-threatening complications.
Choice B rationale: Assessing the level of consciousness is a critical part of the neurological assessment for meningitis. However, it is not the specific priority action required before administering a first dose of an antibiotic.
Choice C rationale: Penicillin carries a high risk of anaphylaxis. The nurse must verify the client's allergy history to ensure safety, as a previous reaction to penicillin or cephalosporins could lead to a fatal allergic response.
Choice D rationale: While cultures must be obtained before starting antibiotics, this question specifies the provider has already ordered the medication for an identified organism (Streptococcus pneumoniae), implying the diagnostic cultures have already been completed.
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