A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
No matter how hard I work in physical therapy I can’t seem to make any progress.
I have not always made good choices in life I deserve to lose my leg.
When I look in the mirror all I see is a person without a leg.
The Correct Answer is D
A. This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.
B. This statement may indicate frustration with physical therapy progress but does not directly address body image.
C. This statement reflects guilt or self-blame but may not necessarily indicate a body image disturbance.
D. This statement directly addresses the client's perception of their body image following the amputation.
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Related Questions
Correct Answer is C
Explanation
A. Before looking for evidence, the nurse should formulate a specific clinical question related to CAUTIs.
B. Implementation should follow the evidence-based recommendations, but formulating a clear question is the initial step.
C. Asking a clinical question is the first step in the EBP process, as it helps guide the search for relevant evidence.
D. Reviewing information comes after formulating a question and searching for evidence to answer that question.
Correct Answer is ["B","C","G","H"]
Explanation
A. Providing oxygen at 6 L/min via nasal cannula is not indicated based on the information provided. The client denies shortness of breath, and vital signs are within normal limits.
B. Applying cold compresses to joints can help reduce swelling and alleviate pain in the extremities.
C. Performing passive range of motion (ROM) exercises is appropriate to maintain joint flexibility and prevent contractures.
D. Administering IV fluids is not explicitly indicated based on the information provided. Fluid management should be individualized based on the client's condition and underlying factors.
E. Obtaining consent for a blood transfusion is not necessary unless the client has severe anemia or bleeding.
F. Restricting fluid intake to 1,400 mL/day may cause dehydration and electrolyte imbalance.
G. Administering meperidine (a narcotic analgesic) may be considered for pain relief.
H. Encouraging bedrest is appropriate to minimize joint stress and promote healing, especially when there is pain and swelling in the extremities.
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