An older adult client returned to the nursing home after a lower limb amputation. The client is scheduled for a prosthesis fitting and states, “I am too old to learn how to manage this.” Which of the following responses from the nurse is appropriate?

I will call your provider so we can discuss it.

What are you thinking that you would like to do?

You have the right to refuse if you don’t think you can do this.

Many clients your age are able to adjust surprisingly well to a prosthesis.

Answer and Explanation

The Correct Answer is D

Choice A Reason: I will call your provider so we can discuss it

While this response shows the nurse’s willingness to involve the healthcare provider, it does not directly address the client’s concern about their ability to manage the prosthesis. It is important to provide immediate reassurance and encouragement to the client, which this response lacks.

Choice B Reason: What are you thinking that you would like to do?

This response is open-ended and encourages the client to express their feelings and thoughts. While it is a good approach to understand the client’s perspective, it does not provide the immediate reassurance and encouragement that the client needs to feel confident about managing the prosthesis.

Choice C Reason: You have the right to refuse if you don’t think you can do this

This response acknowledges the client’s autonomy but may inadvertently reinforce their doubts and fears about managing the prosthesis. It is important to encourage and support the client rather than focusing on their right to refuse.

Choice D Reason: Many clients your age are able to adjust surprisingly well to a prosthesis

This response is the most appropriate as it provides reassurance and encouragement to the client. By sharing that many clients of a similar age have successfully adjusted to a prosthesis, the nurse helps to build the client’s confidence and reduce their anxiety about managing the new situation. This positive reinforcement can be very motivating for the client.

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

Explanation

Choice A Reason: Pupillary dilation

Pupillary dilation can be a sign of increased intracranial pressure or brain injury, which are potential complications following a motor vehicle accident with a loss of consciousness. Assessing for changes in pupil size and reactivity is crucial in identifying neurological impairments that may require immediate intervention.

Choice B Reason: Persistent headache

A persistent headache is a common symptom following a traumatic brain injury (TBI) or concussion. It can indicate ongoing issues such as intracranial bleeding or increased intracranial pressure. Monitoring the severity and duration of the headache is important for determining the need for further medical evaluation and treatment.

Choice C Reason: Presence of hand tremors

Hand tremors are not typically associated with acute brain injuries resulting from a motor vehicle accident. They are more commonly linked to conditions such as Parkinson’s disease, essential tremor, or other neurological disorders. While tremors should be noted, they are not a primary concern in the context of post-accident assessment.

Choice D Reason: Difficulty waking

Difficulty waking, or altered level of consciousness, is a significant indicator of potential brain injury or increased intracranial pressure. It is essential to monitor the client’s level of consciousness closely, as changes can signal worsening neurological status and the need for urgent medical intervention.

Choice E Reason: Foot drop

Foot drop is a condition characterized by difficulty lifting the front part of the foot, often due to nerve damage or muscle weakness. While it can occur in the context of neurological injury, it is not a primary manifestation to assess for immediately following a motor vehicle accident with a loss of consciousness. The focus should be on more acute signs of brain injury.

A. Droplet B. Indirect contact C. Vector D. Airborne

Correct Answer is B

Explanation

Choice A Reason:

Droplet transmission involves the spread of pathogens through respiratory droplets expelled when an infected person coughs or sneezes. Staphylococcus aureus is not typically spread this way.

Choice B Reason:

This is the correct answer. Indirect contact transmission occurs when a person touches a contaminated object or surface, such as a towel, and then touches their own body, allowing the bacteria to enter through breaks in the skin or mucous membranes.

Choice C Reason:

Vector transmission involves the spread of pathogens through insects or animals, such as mosquitoes or ticks. Staphylococcus aureus is not transmitted by vectors.

Choice D Reason:

Airborne transmission involves the spread of pathogens through the air over long distances, typically via tiny droplets that remain suspended in the air. Staphylococcus aureus is not commonly spread through airborne transmission.

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An older adult client returned to the nursing home after a lower limb amputation. The client is scheduled for a prosthesis fitting and states, “I am too old to learn how to manage this.” Which of the following responses from the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.)

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

Explanation

A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection?

Correct Answer is B

Explanation

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