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: The 'thinking/content of thought' section of the Mental Health Status Examination assesses the logical process of thought, presence of delusions, obsessions, and preoccupations.
Choice B reason: 'Memory' assesses the person's ability to recall past events, which is not directly related to their current thought content.
Choice C reason: 'Judgment' evaluates the ability to make reasoned decisions, which, while important, is distinct from the content of thought.
Choice D reason: 'Speech and the ability to communicate' assesses the clarity, relevance, and coherence of speech, not the internal thought process.
Correct Answer is D
Explanation
Choice A reason: Bursting open of the wound is a description that could imply evisceration, but it is not as specific as choice D.
Choice B reason: Wound edges not approximating is a general description of a wound that is not healing properly, but does not specifically describe evisceration.
Choice C reason: Opening of the wound could refer to any situation where a wound has opened, not necessarily evisceration.
Choice D reason: Evisceration specifically refers to the viscera spilling out of the abdomen, usually through a surgical wound.
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