A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

I will need to massage my legs frequently to prevent a buildup of fluid

I will keep my legs in a dependent position

I will decrease my activity to prevent added stress on my legs

I will inspect my legs every day for changes in color, size and temperature

Answer and Explanation

The Correct Answer is D

A. Massaging the legs frequently can exacerbate symptoms of peripheral venous disease by increasing venous pressure and worsening edema. It is not recommended for managing this condition.

B. Keeping the legs in a dependent position can further impair venous return and exacerbate symptoms. Elevating the legs above the level of the heart when possible is recommended to reduce venous congestion.

C. Decreasing activity can lead to deconditioning and worsen symptoms over time. Encouraging regular, moderate physical activity is important for improving venous circulation and overall vascular health.

D. Inspecting the legs daily for changes in color, size, and temperature is an essential component of managing peripheral venous disease. Changes such as skin discoloration, swelling, or increased warmth can indicate worsening venous insufficiency or the development of complications such as venous ulcers. Early detection allows for prompt intervention and prevention of complications.

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Correct Answer is A

Explanation

A. Changes to social cognition and challenges to inhibitory control: Neurologic injuries such as increased intracranial pressure can lead to changes in social cognition, including difficulties in understanding social cues, interpreting emotions, and maintaining appropriate social interactions. Additionally, inhibitory control may be impaired, leading to impulsivity and disinhibition in behavior.

B. Improved mood stability and improved temper control: Neurologic injuries are more likely to result in mood instability and difficulties with temper control rather than improvement in these areas. Changes in mood, including irritability, anxiety, depression, and emotional lability, are common psychosocial consequences of neurologic injuries.

C. Improved rehabilitation outcomes and temporary behavior changes: While rehabilitation efforts may lead to improvement in functional abilities over time, neurologic injuries often result in persistent psychosocial challenges rather than improved outcomes. Temporary behavior changes may occur during the recovery process, but individuals may continue to experience long-term psychosocial sequelae.

D. Sense of purpose, improved motivation, and stable relationships: Neurologic injuries can significantly impact an individual's sense of purpose, motivation, and relationships. Clients may struggle to find meaning and motivation in their lives following a neurologic injury, and relationships may be strained due to changes in behavior, cognition, and communication.

A. Administer acetaminophen by mouth for pain control B. Perform a thorough health history C. Prepare for a STAT non-contrast CT scan D. Insert an indwelling urinary catheter to monitor urine output

Correct Answer is C

Explanation

A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.

B. Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.

C. Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.

D. Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.

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A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

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