A nurse in a clinic is teaching preventative measures with a female client who has a history of deep-vein thrombosis. Which of the following statements should the nurse include in the teaching?
"Sit with your legs in a dependent position when in a chair."
"Prevent dehydration by drinking at least 2.5 liters fluids each day."
"Massage your calves after sitting for 2 hours."
"Roll stretchy nylon stockings down to the upper part of your calves."
The Correct Answer is B
A) "Sit with your legs in a dependent position when in a chair."
Sitting with legs in a dependent position can decrease blood flow and increase the risk of clot formation. It's important to elevate the legs when sitting to promote venous return and reduce the risk of deep-vein thrombosis (DVT).
B) "Prevent dehydration by drinking at least 2.5 liters fluids each day."
Staying well-hydrated helps maintain good blood circulation and prevents blood from becoming too viscous, reducing the risk of clot formation. Adequate fluid intake is crucial in preventing DVT.
C) "Massage your calves after sitting for 2 hours."
Massaging the calves is not recommended for someone with a history of DVT, as it may dislodge a clot. Instead, clients should be encouraged to move or stretch their legs regularly to improve circulation.
D) "Roll stretchy nylon stockings down to the upper part of your calves."
Proper use of compression stockings involves wearing them as prescribed, which typically means keeping them fully extended to ensure consistent pressure along the leg. Rolling them down can create a tourniquet effect and is not recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "A parent is supposed to pass before their child": This statement reflects ongoing grief and a struggle with the loss, indicating the client is still grappling with the emotional impact rather than moving toward reorganization and acceptance.
B) "My partner and I have plans to open a small business": This statement demonstrates that the client is beginning to focus on future goals and engaging in activities that signify a return to normalcy and investment in life. This reflects reorganization and acceptance of the loss as they are planning for the future.
C) "I have put all the pictures of my child in the attic": Putting away pictures of the child might indicate avoidance or difficulty coping with reminders of the loss. This action suggests the client may still be in the process of dealing with grief rather than having reached acceptance.
D) "My partner says I seem to forget things frequently": Frequent forgetfulness can be a symptom of ongoing grief and emotional distress. This indicates that the client may still be experiencing significant emotional and cognitive impacts from the loss.
Correct Answer is C
Explanation
A) Administering risperidone 25 mg IM is not typically appropriate for treating a panic attack. Risperidone is an antipsychotic medication used for treating conditions like schizophrenia and bipolar disorder, not for the immediate management of panic attacks. Immediate pharmacological intervention is not generally the first line of treatment in acute panic attacks unless the client has a specific medication prescribed for such episodes.
B) Teaching the client how to perform guided imagery can be beneficial for long-term anxiety management but is not the most effective intervention during an acute panic attack. During a panic attack, the client's ability to focus and learn new techniques may be impaired, making it less effective in the immediate situation.
C) Staying with the client until the panic attack subsides is the most appropriate action. Presence and reassurance from the nurse can help the client feel safer and more grounded. This approach provides emotional support and can help reduce the severity and duration of the panic attack by addressing the client's immediate need for security and stability.
D) Encouraging the client to take quick, shallow breaths can exacerbate hyperventilation and increase anxiety during a panic attack. Instead, slow, deep breathing techniques are recommended to help calm the client's physiological response and reduce the intensity of the panic attack.
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