A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

Encourage the client to talk about his feelings regarding his body image.

Discuss alternative coping strategies to relieve stress he feels about his body image.

Determine the client’s perception of his body image.

Assist the client to acknowledge he has a distorted body image.

Answer and Explanation

The Correct Answer is C

A.   Encouraging the client to talk about his feelings is important, but understanding the client's current perception of his body image comes first to guide appropriate interventions.
B.   Discussing coping strategies is relevant, but understanding the client's current perception helps tailor coping strategies to his specific concerns.
C.   Determining the client's perception of his body image is the first step to assess the extent of the issue and plan interventions accordingly.
D.   Assisting the client to acknowledge a distorted body image may be necessary, but understanding the client's current perception precedes interventions.

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Correct Answer is C

Explanation

A. Before looking for evidence, the nurse should formulate a specific clinical question related to CAUTIs.
B. Implementation should follow the evidence-based recommendations, but formulating a clear question is the initial step.
C. Asking a clinical question is the first step in the EBP process, as it helps guide the search for relevant evidence.
D. Reviewing information comes after formulating a question and searching for evidence to answer that question.

A. Dry crust on the incision line B. Adventitious breath sounds C. Increased urine output D. Decreased level of consciousness E. Oral temperature of 38.3° C (101° F)

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.

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A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using evidence-based practice (EBP) to decrease the incidence of catheter- associated urinary tract infections (CAUTIS) on a unit. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)

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

Explanation

A nurse is assisting in the care of a client. Exhibits The nurse is assisting with catheter care for the client to prevent a central line-associated bloodstream infection (CLABSI bundle). Which of the following actions should the nurse take? Select all that apply.

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