Patient Data

Exhibits

For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease.

Inquires about blood pressure

Asks questions about self-care

Requests nurse to perform wound care

Executes pull-ups on trapeze bar

Avoids looking at residual limb

Turns side to side

Answer and Explanation

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

Positive health promotion activities include inquiring about blood pressure, asking questions about self-care, executing pull-ups on a trapeze bar, and turning side to side.

Negative health promotion activities include requesting the nurse to perform wound care and avoiding looking at the residual limb.

Rationale

POSITIVE:

Inquires about blood pressure:

Inquiring about blood pressure shows awareness of cardiovascular health, which is important for individuals with peripheral vascular disease. Monitoring blood pressure regularly can help prevent complications and manage hypertension, a common comorbidity in peripheral vascular disease.

Asks questions about self-care:

Asking questions about self-care indicates engagement in the management of one's health post- amputation. Understanding self-care tasks, such as wound care, prosthetic use, and rehabilitation exercises, is crucial for optimal recovery and adjustment to life after amputation. Executes pull-ups on trapeze bar:

Engaging in physical activity, such as pull-ups on a trapeze bar, demonstrates motivation for rehabilitation and adaptation to life after amputation. Strengthening exercises can improve overall physical function and assist in adjusting to mobility with a prosthetic limb.

Turns side to side:

Turning side to side suggests mobility and activity post-amputation. Movement and repositioning are important for preventing complications such as pressure ulcers and promoting circulation in individuals with peripheral vascular disease.

NEGATIVE

Requests nurse to perform wound care:

Negative: While it's understandable for a client to initially require assistance with wound care post-amputation, relying solely on the nurse to perform wound care may indicate a lack of engagement in self-management and may hinder the client's transition to independence in managing their health post-amputation.

Avoids looking at residual limb:

Negative: Avoiding looking at the residual limb may indicate psychological distress or difficulty accepting the amputation. It's important for individuals post-amputation to gradually become comfortable with their changed body image and to address any psychological challenges through counseling or support groups.

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Free Nursing Study Resources

Correct Answer is C

Explanation

C. Peptic ulcer disease involves the formation of open sores in the lining of the stomach or the duodenum. The characteristic symptom of PUD is abdominal pain, typically located in the upper mid abdomen. This pain is often described as gnawing, burning, or aching in nature. The pain may occur shortly after eating, especially when the stomach is empty (gastric ulcer), or it may occur 2-3 hours after eating, typically at night (duodenal ulcer).
A. describes symptoms more suggestive of irritable bowel syndrome (IBS) or gastrointestinal sensitivity to spicy foods, leading to cramps and diarrhea, but it is less specific to PUD.
B. indicates frequent use of antacids for indigestion, which may suggest symptoms of acid reflux or gastritis but do not specifically point to the presence of peptic ulcers.
D. suggests more severe systemic issues such as malignancy or chronic diseases rather than solely PUD.

A. Review need for pneumococcal vaccine. B. Implement bleeding precautions. C. Place the client in protective isolation. D. Assess vital signs every 4 hours.

Correct Answer is C

Explanation

C. An ANC of 500/mm3 (0.5 x 10/L) is indicative of severe neutropenia, which places the client at a significantly increased risk of developing infections due to the decreased ability of the immune system to fight off pathogens. Placing the client in protective isolation is essential to minimize the risk of exposure to infectious agents that could lead to severe infections
A. While reviewing the need for pneumococcal vaccine is important for preventing infections in immunocompromised clients, it may not be the most immediate priority in this scenario.
B. Implementing bleeding precautions is relevant for clients with thrombocytopenia but is not the most critical intervention for a client with severe neutropenia.
D. Assessing vital signs every 4 hours is a routine nursing intervention, but it may not directly address the heightened risk of infection associated with severe neutropenia.

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Patient Data Exhibits For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

Correct Answer is C

Explanation

A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2.500 to 5,800/mm (2.5 to 5.8 x 10/L)]

Correct Answer is C

Explanation

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While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider, the nurse should evaluate which laboratory value?

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Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding or no understanding of the education given

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A family suspects that AIDS dementia is occurring in their adult child who is HIV positive. Which symptom confirms the suspicion?

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

Patient Data

Exhibits

For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease.