A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Determine if the stockings are binding.

Fold the top of the stocking over neatly.

Apply the stockings after the client is in a chair.

Massage the client's legs once every 8 hr while the stockings are in place.

Answer and Explanation

The Correct Answer is A

A. Determine if the stockings are binding. It is important to assess that antiembolic stockings are not too tight, especially around the top, as this can impair circulation. Proper fit ensures they function effectively to promote venous return and prevent deep vein thrombosis.
B. Fold the top of the stocking over neatly. Folding or rolling the tops can cause constriction and act like a tourniquet, reducing circulation and increasing the risk of complications such as venous stasis or skin breakdown.
C. Apply the stockings after the client is in a chair. Antiembolic stockings should be applied while the client is lying down, before getting up, to prevent blood pooling in the legs. Applying them after the client is upright may reduce their effectiveness.
D. Massage the client's legs once every 8 hr while the stockings are in place. Massaging the legs, especially in clients at risk for thrombosis, is not recommended as it could dislodge a clot and lead to embolism. Passive or active leg movement is safer and more effective.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Provide the client with high-calorie fluids every hr: Clients in manic states often experience poor nutritional intake due to hyperactivity and distractibility. Frequent, easy-to-consume high-calorie fluids help support caloric and hydration needs without requiring the client to sit for meals, making this an appropriate intervention.
Minimize environmental stimuli for the client: Clients experiencing mania are often overstimulated and agitated due to their heightened sensitivity and rapid thought processes. A low-stimulation environment helps reduce agitation, prevent escalation, and promote safety.
Weigh the client each day: While weight monitoring may be important in some psychiatric or medical conditions, daily weights are not a priority in the acute management of mania, particularly when the client is hyperactive, distracted, and unable to participate reliably. This could also increase agitation or preoccupation in some clients.
Encourage the client to avoid napping during the day: Manic clients often suffer from significantly reduced sleep, which contributes to worsening symptoms. Encouraging rest and short naps would be more therapeutic than promoting wakefulness, so avoiding naps is contraindicated in this scenario.

A. Wear loose-firing clothing. B. Return in two weeks for a follow-up MRI. C. Expect to have a rapid pulse rate for the first few weeks D. Resume tub baths and swimming after 24 hr

Correct Answer is A

Explanation

A. Wear loose-fitting clothing. After ICD implantation, the site may be sore or swollen, and tight clothing can cause irritation or pressure. Loose-fitting clothes help protect the incision and device, reducing discomfort and risk of complications.
B. Return in two weeks for a follow-up MRI. Most implantable cardioverter/defibrillators are not MRI-compatible unless specifically labeled as such. MRI exposure can interfere with device function and is generally avoided unless approved by a cardiologist.
C. Expect to have a rapid pulse rate for the first few weeks. The purpose of an ICD is to monitor and correct life-threatening arrhythmias, not to increase the heart rate. A rapid pulse is not expected and may indicate a complication requiring immediate evaluation.
D. Resume tub baths and swimming after 24 hr. Immersing the incision site in water within the first few weeks post-op increases the risk of infection. The client should avoid soaking the incision until it is fully healed, typically 1 to 2 weeks post-procedure.

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A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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