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Client Statement

Exhibits

The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.

I purchased a large magnifying glass.

I’m adding bananas to my oatmeal every morning.

Instead of being barefoot, I wear socks.

I moved my medicine bottles into the living room.

I switched to eating apples and oranges for a nighttime snack.

I placed a lamp on my bedside table.

I prepared a large batch of beans, so I have a fast meal every night.

I added a nonslip throw rug at my kitchen sink.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Choice A Reason:

The client states, “I purchased a large magnifying glass.” While this shows an attempt to address the issue of blurred vision, it does not fully address the safety concerns related to macular degeneration. The client should be encouraged to use additional visual aids, such as better lighting and possibly electronic magnifiers, to ensure they can see clearly and avoid accidents. Therefore, this statement indicates that the client needs further teaching.

Choice B Reason:

The client states, “I’m adding bananas to my oatmeal every morning.” This is a positive dietary change. Bananas are rich in potassium, which can help manage blood pressure, a crucial aspect for someone with hypertension. Additionally, adding fruit to breakfast can improve overall nutrition. Therefore, this statement indicates that the client understood the teaching.

Choice C Reason:

The client states, “Instead of being barefoot, I wear socks.” While wearing socks is better than being barefoot, it is not the safest option. Socks can still be slippery on certain surfaces, increasing the risk of falls. The client should be encouraged to wear non-slip shoes or slippers inside the house. Therefore, this statement indicates that the client needs further teaching.

Choice D Reason:

The client states, “I moved my medicine bottles into the living room.” While this might make the medications more accessible, it is not the safest practice. Medications should be stored in a cool, dry place, away from direct sunlight and moisture. Additionally, they should be kept in a location where they are easily visible and accessible but not in a high-traffic area where they could be knocked over. Therefore, this statement indicates that the client needs further teaching.

Choice E Reason:

The client states, “I switched to eating apples and oranges for a nighttime snack.” This is a positive dietary change. Apples and oranges are rich in vitamins and fiber, which are beneficial for overall health. This change also indicates an understanding of the need to incorporate more fruits into the diet. Therefore, this statement indicates that the client understood the teaching.

Choice F Reason:

The client states, “I placed a lamp on my bedside table.” This is a good practice as it ensures that the client has adequate lighting when getting in and out of bed, reducing the risk of falls. Therefore, this statement indicates that the client understood the teaching.

Choice G Reason:

The client states, “I prepared a large batch of beans, so I have a fast meal every night.” This is a positive change as it ensures that the client has a nutritious meal readily available, reducing the reliance on processed frozen meals. Beans are a good source of protein and fiber, which are important for overall health. Therefore, this statement indicates that the client understood the teaching.

Choice H Reason:

The client states, “I added a nonslip throw rug at my kitchen sink.” While the intention is good, throw rugs can still pose a tripping hazard, even if they are nonslip. It would be safer to use a mat that is securely fixed to the floor. Therefore, this statement indicates that the client needs further teaching.

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Correct Answer is A

Explanation

Choice A reason:

A sudden decrease in abdominal pain can indicate that the appendix has perforated. When the appendix bursts, the pressure is relieved, leading to a temporary reduction in pain. However, this is quickly followed by severe pain and signs of peritonitis, such as a rigid abdomen and high fever.

Choice B reason:

The absence of Rovsing’s sign is not a specific indicator of a perforated appendix. Rovsing’s sign is a clinical test used to diagnose appendicitis, where pain is elicited in the right lower quadrant when the left lower quadrant is palpated. Its absence does not necessarily indicate perforation.

Choice C reason:

A low-grade fever is a common symptom of appendicitis but does not specifically indicate perforation. A perforated appendix typically leads to a high fever due to the spread of infection within the abdomen.

Choice D reason:

A rigid abdomen is a sign of peritonitis, which can occur after the appendix has perforated. While this is an important symptom, the sudden decrease in pain followed by severe symptoms is more indicative of perforation.

A. Wrap the stump with an elastic bandage in a figure-eight configuration. B. Remove the elastic bandage and re-wrap the stump once per day. C. Perform passive range of motion exercises once daily. D. Secure the elastic bandage to the lowest joint.

Correct Answer is A

Explanation

Choice A reason: Wrap the stump with an elastic bandage in a figure-eight configuration

Wrapping the stump with an elastic bandage in a figure-eight configuration is a standard practice in postoperative care for below-the-knee amputations. This method helps to shape and shrink the residual limb, preparing it for a prosthesis fitting. The figure-eight wrap provides even compression, which helps to reduce swelling and promote proper healing. It also helps to prevent the formation of edema and ensures that the residual limb maintains a conical shape, which is ideal for fitting a prosthetic socket.

Choice B reason: Remove the elastic bandage and re-wrap the stump once per day

While it is important to regularly check and adjust the bandage, removing and re-wrapping the stump only once per day may not be sufficient. The bandage should be checked more frequently to ensure it remains properly positioned and provides consistent compression. In some cases, it may need to be adjusted multiple times a day to maintain the desired level of compression and to prevent any issues such as slippage or uneven pressure.

Choice C reason: Perform passive range of motion exercises once daily

Performing passive range of motion exercises is beneficial for maintaining joint flexibility and preventing contractures. However, these exercises should be performed more frequently than once daily, especially in the early postoperative period. Regular exercises help to maintain muscle strength, improve circulation, and promote overall mobility. The frequency and type of exercises should be tailored to the individual needs of the client and guided by a physical therapist.

Choice D reason: Secure the elastic bandage to the lowest joint

Securing the elastic bandage to the lowest joint is not recommended. The bandage should be wrapped in a way that provides even compression without restricting movement or circulation. The figure-eight configuration is preferred because it allows for better control of the compression and helps to shape the residual limb effectively. Securing the bandage to a joint can lead to discomfort and may impede proper blood flow.

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Client Statement Exhibits The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child’s appendix is perforated?

Correct Answer is A

Explanation

A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide?

A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?

A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?

A nurse is preparing to administer amitriptyline 150 mg PO at bedtime. The amount available is amitriptyline 75 mg tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?

Client Statement

Exhibits

The nurse returns in 1 week for a follow-up appointment. For each client statement, indicate if the client understood the teaching or needs further teaching.