A nurse is caring for a patient who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?
Consumed 35% of meals for 12 hr.
Been on bedrest for 3 days.
Last bowel movement 2 days ago.
Reports pain as 5 on a scale of 0 to 10.
The Correct Answer is D
Choice A rationale
While nutrition is important for recovery, consuming 35% of meals for 12 hours is not an immediate concern. The patient’s nutritional status can be addressed after more urgent issues are resolved.
Choice B rationale
Bedrest for 3 days post-surgery is not uncommon. While prolonged bedrest can lead to complications such as deep vein thrombosis, it is not the most immediate concern in this scenario.
Choice C rationale
A last bowel movement 2 days ago is not necessarily a concern unless the patient is experiencing discomfort or other symptoms of constipation. This can be addressed after more urgent issues are resolved.
Choice D rationale
This is the correct answer. Pain in the lower extremities following surgery could indicate a serious condition such as a blood clot. It is important to address this first to rule out any serious complications.
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Correct Answer is B
Explanation
Choice A rationale
While acetaminophen can be used to relieve discomfort, it should be used with caution in patients with liver disease like cirrhosis, as it can potentially cause further liver damage.
Choice B rationale
Patients with cirrhosis, especially those with ascites, are often advised to limit their sodium intake. High-sodium foods can contribute to fluid retention and worsen ascites. Therefore, avoiding high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged frozen dinners is a key part of managing cirrhosis.
Choice C rationale
While maintaining adequate nutrition is important in cirrhosis, eating three large meals per day is not typically recommended. Instead, smaller, more frequent meals are often suggested.
Choice D rationale
While physical activity is generally beneficial, patients with cirrhosis and particularly those with complications such as ascites or encephalopathy may need to modify their activity levels based on their symptoms and overall health.
Correct Answer is B
Explanation
Choice A rationale
Asking why the patient thinks the copper helps with their arthritis might seem like a good way to understand their beliefs, but it could come off as challenging or dismissive.
Choice B rationale
Acknowledging that the patient feels better wearing the bracelet is a respectful response. It validates the patient’s experience without endorsing the effectiveness of copper bracelets, which lack scientific evidence for treating arthritis.
Choice C rationale
This response could be seen as dismissive of the patient’s beliefs and experiences. It’s important to respect patients’ choices in managing their symptoms, as long as those choices aren’t harmful.
Choice D rationale
While it’s true that there’s no scientific basis for believing objects have powers to make you feel better, saying this could come off as dismissive or disrespectful.
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