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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
To answer this question, we need to use the formula:
IV flow rate (gtt/min) = (Volume to be infused in mL x Drop factor in gtt/mL) / Time of infusion in minutes
Plugging in the given values, we get:
IV flow rate (gtt/min) = (100 mL x 60 gtt/mL) / 60 min Simplifying, we get:
IV flow rate (gtt/min) = 100 gtt/min
Therefore, the nurse should set the IV flow rate to deliver 100 gtt/min.
Correct Answer is D
Explanation
A. Diminished urine output is a later sign of hypovolemic shock and is associated with decreased perfusion to the kidneys.
B. Cold clammy skin is also a later sign of shock, indicating poor tissue perfusion.
C. Unconsciousness is a late sign of hypovolemic shock and occurs when there is significant impairment of cerebral perfusion.
D. Tachycardia is an early compensatory mechanism in response to hypovolemia, aiming to maintain cardiac output and perfusion to vital organs.
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