A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

Encourage the client to talk about his feelings regarding his body image.

Discuss alternative coping strategies to relieve stress he feels about his body image.

Determine the client’s perception of his body image.

Assist the client to acknowledge he has a distorted body image.

Answer and Explanation

The Correct Answer is C

A.   Encouraging the client to talk about his feelings is important, but understanding the client's current perception of his body image comes first to guide appropriate interventions.
B.   Discussing coping strategies is relevant, but understanding the client's current perception helps tailor coping strategies to his specific concerns.
C.   Determining the client's perception of his body image is the first step to assess the extent of the issue and plan interventions accordingly.
D.   Assisting the client to acknowledge a distorted body image may be necessary, but understanding the client's current perception precedes interventions.

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Correct Answer is C

Explanation

A. Shock typically results in tachycardia as the body compensates for decreased perfusion.
B. In shock, there is often decreased urine output due to decreased perfusion to the kidneys.
C. A hallmark sign of shock is low blood pressure as a result of inadequate tissue perfusion.
D. Bowel sounds may be diminished rather than hyperactive in cases of shock.

A. The client draws his legs up into a fetal position. B. The facial muscles relax. C. The respiratory rate increases. D. The shoulders droop. E. The pulse is within the expected range

Correct Answer is ["B","D","E"]

Explanation

A. Drawing legs up into a fetal position may indicate discomfort or agitation.
B. Facial muscle relaxation is indicative of a therapeutic response to the massage.
C. An increased respiratory rate may suggest distress or discomfort.
D. Drooping shoulders suggest relaxation and a positive response to the massage.
E. Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.

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A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for shock. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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