A nurse is providing teaching with a client who has severe arthritis and has difficulty with stairs. What should the nurse include in the teaching?
"Keep your eyes on your feet when ascending or descending the stairs."
"Maintain your arms in a slightly bent position when using the handrails."
"Move your right leg forward as you lower yourself to the next step."
"Support yourself with the handrail when transferring to or from the stairs."
The Correct Answer is B
Choice A reason: This is not the correct answer because it distracts the client from the surroundings and could cause loss of balance or coordination.
Choice B reason: This is the correct answer because it enables the client to use the handrails as a support and reduces the stress on the arms and shoulders.
Choice C reason: This is not the correct answer because it creates an uneven distribution of weight and could cause instability or pain.
Choice D reason: This is not the correct answer because it requires the client to shift the body weight abruptly and could cause muscle strain or joint damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer because greenish-yellow drainage is a normal color for gastric secretions and does not indicate a problem.
Choice B reason: This is not the correct answer because a report of hunger is common for a client with an NG tube and does not require intervention.
Choice C reason: This is the correct answer because gastric contents in the air vent mean that the NG tube is clogged or kinked and needs to be flushed or replaced. This is the correct answer because it indicates that the NG tube is not functioning properly and could cause aspiration or infection. The other findings are expected or normal for a client with an NG tube.
Choice D reason: This is not the correct answer because abdominal distention is a common reason for placing an NG tube and should improve with gastric decompression.
Correct Answer is A
Explanation
Choice A reason: Calf swelling is a sign of deep vein thrombosis, which is a blood clot that forms in a deep vein, usually in the lower leg or thigh. The clot can block the blood flow and cause inflammation, pain, and edema. The nurse should measure the circumference of both calves and compare them for any difference. The nurse should also report any other signs of deep vein thrombosis, such as warmth, redness, or tenderness.
Choice B reason: Clammy skin is not a sign of deep vein thrombosis, but of shock. Shock is a life-threatening condition that occurs when the body's organs do not receive enough blood and oxygen. The nurse should monitor the client's vital signs, such as blood pressure, pulse, and temperature, and report any abnormal findings.
Choice C reason: Tortuous veins are not a sign of deep vein thrombosis, but of varicose veins. Varicose veins are enlarged and twisted veins that appear near the surface of the skin, usually in the legs. They are caused by weak or damaged valves that allow blood to pool and stretch the veins. The nurse should assess the client's skin for any ulcers, bleeding, or infection.
Choice D reason: Bradycardia is not a sign of deep vein thrombosis, but of a slow heart rate. Bradycardia is a condition that occurs when the heart beats less than 60 times per minute. It can be caused by various factors, such as medication, heart disease, or hypothyroidism. The nurse should check the client's pulse and rhythm, and report any irregularities.
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