A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching?

I can wear heels up to 2 inches in height.

I should sleep lying flat with my legs extended straight.

I should keep my weight within 10 percent of my ideal weight.

I should increase high potassium foods in my diet.

Answer and Explanation

The Correct Answer is C

Choice A reason: Wearing heels up to 2 inches in height can contribute to lower back pain by altering posture and increasing the strain on the lower back muscles. It is generally recommended to wear low-heeled or flat shoes to reduce the risk of exacerbating back pain.

Choice B reason: Sleeping lying flat with legs extended straight is not the best position for someone with lower back pain. It is often recommended to sleep on the side with knees slightly bent or on the back with a pillow under the knees to maintain the natural curve of the spine and reduce strain.

Choice C reason: Keeping weight within 10 percent of ideal weight is important for managing lower back pain. Excess weight, especially around the abdomen, can put additional strain on the lower back muscles and spine, exacerbating pain. Maintaining a healthy weight through diet and exercise can help alleviate back pain.

Choice D reason: Increasing high potassium foods in the diet is beneficial for overall health but is not specifically related to managing lower back pain. Potassium helps with muscle function and can prevent cramps, but it does not directly address the causes of lower back pain.

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Correct Answer is D

Explanation

Choice A reason: Client reports knee pain changed from 4/10 to 6/10 is an important finding, but it is not as critical as a significant drop in blood pressure. Pain levels can fluctuate postoperatively, and while increased pain should be addressed, it does not typically require immediate notification of the provider unless it is severe or unmanageable.

Choice B reason: Pulse oximetry changed from 98% to 96% is a minor change and still within normal limits. A pulse oximetry reading of 96% is generally acceptable and does not indicate a critical issue that requires immediate provider notification.

Choice C reason: Temperature changed from 37.2°C (99.0°F) to 37.5°C (99.5°F) is a slight increase and still within the normal range. Postoperative patients can experience minor fluctuations in temperature, and this change does not typically indicate a serious problem.

Choice D reason: Systolic blood pressure changed from 140 mm Hg to 110 mm Hg is a significant drop and could indicate hypotension, which can be a serious complication, especially in an older adult post-surgery. Hypotension can result from various causes, including blood loss, dehydration, or effects of anesthesia, and requires prompt assessment and intervention.

A. Ask the client to blow his nose. B. Suction the nostril. C. Notify the physician. D. Test the drainage for glucose.

Correct Answer is D

Explanation

Choice A reason: Ask the client to blow his nose

Asking the client to blow his nose is not advisable in this situation. Blowing the nose can increase intracranial pressure and potentially worsen the condition by causing more cerebrospinal fluid (CSF) to leak or even lead to further complications. Therefore, this action should be avoided.

Choice B reason: Suction the nostril

Suctioning the nostril is also not recommended. This action can introduce infection and increase the risk of further complications. It is important to handle any potential CSF leak with care to prevent infection and other issues.

Choice C reason: Notify the physician

While notifying the physician is important, it is not the immediate first step. The nurse should first confirm whether the clear drainage is CSF. Once confirmed, notifying the physician would be the next appropriate step.

Choice D reason: Test the drainage for glucose

Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive glucose test would confirm that the drainage is indeed CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures. Confirming the presence of CSF will guide further medical interventions and management.

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A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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