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 B

Explanation

A. Hypovolemic shock typically results in low blood pressure (BP) and a compensatory increase in pulse rate to maintain cardiac output.
B. Low BP and high pulse rate are characteristic findings in hypovolemic shock, reflecting decreased circulating blood volume.
C. High BP is not a typical finding in hypovolemic shock; the BP tends to decrease due to reduced blood volume.
D. Low BP and low pulse rate are not consistent with the compensatory response seen in hypovolemic shock.

A. Elevate the head of the client’s bed to 45° during meals. B. Instruct the client to tilt their head back while swallowing. C. Turn on the television for the client during meals. D. Provide the client with oral hygiene.

Correct Answer is A

Explanation

A. Elevating the head of the client's bed to 45° during meals helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the airway.
B. Instructing the client to tilt their head back while swallowing is not recommended, as it may increase the risk of aspiration.
C. Turning on the television during meals is unrelated to reducing the risk of aspiration pneumonia.
D. Providing the client with oral hygiene is important for overall health but does not specifically address the risk of aspiration pneumonia.

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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 measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client’s risk of aspiration pneumonia?

Correct Answer is A

Explanation

A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?

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?

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