A nurse is contributing to the plan of care for a client who is postoperative following a below-the-knee amputation.
Which of the following strategies should the nurse include to help the client progress toward acceptance of this body image alteration?
Suggest that the client wear facility clothing until the prosthesis fitting.
Encourage the client to visit with someone who has had an amputation.
Discourage the client from touching the residual limb for the first week.
Reassure the client that the rehabilitation program is optional.
The Correct Answer is B
Encourage the client to visit with someone who has had an amputation.
This strategy can help the client cope with the loss of a body part and learn from the experience of others who have gone through a similar situation.
Choice A is wrong because suggesting that the client wear facility clothing until the prosthesis fitting can delay the client’s acceptance of the body image alteration and increase the risk of infection.
Choice C is wrong because discouraging the client from touching the residual limb for the first week can interfere with the healing process and prevent the client from becoming familiar with the new body part.
Choice D is wrong because reassuring the client that the rehabilitation program is optional can discourage the client from participating in physical therapy and hinder the recovery and adaptation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.
Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.
Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.
Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.
Correct Answer is A
Explanation
Proteinuria is the presence of excess protein in the urine, which is a hallmark of nephrotic syndrome. Nephrotic syndrome is a kidney disorder that causes increased permeability of the glomerular basement membrane, leading to loss of protein and other substances in the urine.
Choice B is wrong because hypolipidemia is a low level of lipids in the blood, which is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome causes hyperlipidemia, which is a high level of lipids in the blood, due to increased synthesis and decreased clearance of lipoproteins.
Choice C is wrong because hyperalbuminemia is a high level of albumin in the blood, which is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome causes hypoalbuminemia, which is a low level of albumin in the blood, due to loss of albumin in the urine and decreased synthesis by the liver.
Choice D is wrong because increased hemoglobin is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome can cause anemia, which is a low level of hemoglobin in the blood, due to loss of iron and erythropoietin in the urine and decreased production of red blood cells by the bone marrow.
Normal ranges for proteinuria are less than 150 mg per day or less than 10 mg per deciliter on a random urine sample. Normal ranges for serum lipids are total cholesterol less than 200 mg per deciliter, LDL cholesterol less than 100 mg per deciliter, HDL cholesterol more than 40 mg per deciliter for men and more than 50 mg per deciliter for women, and triglycerides less than 150 mg per
deciliter. Normal ranges for serum albumin are 3.5 to 5.0 grams per deciliter.
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