A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?

If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.

No matter how hard I work in physical therapy I can’t seem to make any progress.

I have not always made good choices in life I deserve to lose my leg.

When I look in the mirror all I see is a person without a leg.

Answer and Explanation

The Correct Answer is D

A.   This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.
B.   This statement may indicate frustration with physical therapy progress but does not directly address body image.
C.   This statement reflects guilt or self-blame but may not necessarily indicate a body image disturbance.
D.   This statement directly addresses the client's perception of their body image following the amputation.

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Correct Answer is ["B","D","E"]

Explanation

A. Dry crust on the incision line may indicate normal healing, not necessarily infection.
B. Adventitious breath sounds can be indicative of pneumonia, a potential infection.
C. Increased urine output is not a sign of infection but may suggest other issues.
D. Decreased level of consciousness suggests a systemic issue, which could include infection affecting the central nervous system.
E. Oral temperature of 38.3° C (101° F) indicates fever which is a common sign of infection.

A. A single dose of diazepam is unlikely to cause side effects. B. Diazepam can cause drowsiness. C. Avoid foods that contain tyramine. D. Grapefruit juice inactivates this medication.

Correct Answer is B

Explanation

A. Diazepam can cause side effects, especially drowsiness, even with a single dose.
B. One of the common side effects of diazepam is drowsiness, and the client should be advised not to operate heavy machinery or engage in activities requiring alertness until the effects are known.
C. Avoiding foods that contain tyramine is more relevant for certain antidepressant medications, not diazepam.
D. Grapefruit juice is known to interact with certain medications, but it does not inactivate diazepam.

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A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?

Nursing Test Bank

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Correct Answer is ["B","D","E"]

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Correct Answer is B

Explanation

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