The nurse is providing care for a patient after an above-the-knee amputation due to diabetes complications. Which nursing care is essential for promoting ambulation?
Lying prone as prescribed.
Promoting coordination exercises.
Building upper body strength.
Maintaining residual limb elevation.
The Correct Answer is C
Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.
Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.
Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.
Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response is calming and supportive. It addresses Mr. L's immediate distress by providing reassurance and a directive that can help him manage his panic, which is essential in a situation where a patient is experiencing extreme anxiety.
Choice B reason: While taking vital signs is an important step, it should not be the first response. The priority is to address the patient's acute distress and provide reassurance.
Choice C reason: This response minimizes the patient's feelings and does not address his immediate fear or offer any comfort or support.
Choice D reason: Asking why he thinks he's having a heart attack could increase his anxiety. It's important to first calm the patient before attempting to rationalize the situation.
Correct Answer is D
Explanation
Choice A reason: Signal anxiety refers to a specific concern or perceived threat, which is not indicated by the patient's statement.
Choice B reason: Severe anxiety is a high level of anxiety that would likely impair functioning, which cannot be determined from the patient's statement alone.
Choice C reason: Moderate anxiety is a manageable level of anxiety, but the patient's statement suggests a more pervasive and non-specific anxiety.
Choice D reason: Free-floating anxiety is a general feeling of dread or foreboding that is not attached to any specific issue or situation, which aligns with the patient's expression of a vague sense of impending doom.
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