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A nurse in an emergency department is caring for a client.

Exhibits

Which of the following information provided by the client indicates improvement? Select all that apply.

“I have gained 1.8 kg (4 lb) recently, and my BMI is 18.9.”

“My adult child prepares two meals per day for me.”

“My clothing is always clean and appropriate for the weather.”

“I receive three baths per week from a home care aide.”

“I frequently have toothaches and haven’t had dental care in a while.”

“I make eye contact and smile while speaking.”

Answer and Explanation

Correct Answer : A,B,E

The correct answer is choice a, b, e.

Choice A rationale: A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.

Choice B rationale: Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.

Choice C rationale: Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.

Choice D rationale: Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.

Choice E rationale: Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.

Choice F rationale: Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.

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Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is A. I can lift objects that are less than 10 pounds.

Here's a breakdown of why the other options are incorrect:

B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.

A. Align a trochanter wedge between the client’s legs. B. Apply an orthotic to the client’s foot. C. Place a towel roll under the client’s neck. D. Position a pillow under the client’s knees. E. undefined

Correct Answer is B

Explanation

The correct answer is choice B. Applying an orthotic to the client’s foot.

An orthotic is a device that supports or corrects the function of a body part.

In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients.

Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.

Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.

Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.

Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.

Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.

Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.

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A nurse in an emergency department is caring for a client. Exhibits Which of the following information provided by the client indicates improvement? Select all that apply.

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Correct Answer is A

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A nurse in an emergency department is caring for a client.

Exhibits

Which of the following information provided by the client indicates improvement? Select all that apply.