A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?
“If my stockings feel tight, I’ll just roll them down for a while.”
“I’ll put on my elastic stockings at the first sign of swelling.”
“When I sit down to watch television, I’ll be sure to put my feet up.”
“It is okay to cross my legs as long as it is less than one hour.”
The Correct Answer is C
Choice A reason: Rolling down tight stockings creates a tourniquet effect, worsening venous insufficiency. Elevating feet improves circulation, making this incorrect, as it reflects a misunderstanding of compression therapy compared to the correct management taught by the nurse for venous insufficiency.
Choice B reason: Putting on stockings after swelling begins is less effective than wearing them preventatively. Elevating feet reduces edema, making this incorrect, as it shows partial understanding compared to the proactive elevation strategy indicating full comprehension of the nurse’s teaching.
Choice C reason: Elevating feet when sitting promotes venous return, reducing edema in venous insufficiency. This aligns with self-care education for the condition, making it the correct statement, as it demonstrates the client’s accurate understanding of the nurse’s teaching to manage lower extremity swelling.
Choice D reason: Crossing legs impairs venous return, exacerbating venous insufficiency, regardless of duration. Elevating feet is correct, making this incorrect, as it reflects a misconception about safe practices compared to the nurse’s teaching on managing venous insufficiency effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A respiratory rate of 10 breaths/min with deep breathing is low but less concerning than 8 breaths/min with snoring, indicating potential airway obstruction. Respiratory depression is the primary opioid risk, making this incorrect compared to the more severe respiratory compromise.
Choice B reason: A respiratory rate of 8 breaths/min with snoring suggests severe opioid-induced respiratory depression, a life-threatening side effect requiring immediate intervention. This aligns with opioid safety monitoring, making it the correct patient most likely experiencing a critical opioid adverse effect.
Choice C reason: Elevated blood pressure and heart rate suggest pain or stress, not respiratory depression, the primary opioid danger. A low respiratory rate with snoring is more critical, making this incorrect, as it doesn’t indicate a life-threatening opioid side effect.
Choice D reason: A temperature of 100.5°F and being easily roused suggest mild fever, not respiratory depression. Snoring with a rate of 8 breaths/min is more dangerous, making this incorrect, as it doesn’t reflect a life-threatening opioid effect in the patient.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Coffee, caffeinated or decaf, relaxes the esophageal sphincter and irritates the mucosa, worsening GERD. This aligns with dietary restrictions, making it a correct substance the nurse would teach the client to avoid to prevent GERD symptom exacerbation.
Choice B reason: Chocolate contains methylxanthines and fat, relaxing the esophageal sphincter and triggering GERD symptoms. This aligns with GERD dietary guidelines, making it a correct item the nurse would include for the client to avoid to reduce reflux.
Choice C reason: Peppermint relaxes the lower esophageal sphincter, increasing acid reflux in GERD. This aligns with dietary teaching, making it a correct substance the nurse would advise the client to avoid to minimize GERD symptom flare-ups effectively.
Choice D reason: Nonfat milk is less likely to trigger GERD, as high-fat dairy worsens reflux. Coffee is a stronger trigger, making this incorrect, as it’s not a primary substance the nurse would include on the GERD avoidance list.
Choice E reason: Fried chicken, high in fat, delays gastric emptying and exacerbates GERD symptoms. This aligns with dietary restrictions, making it a correct item the nurse would teach the client to avoid to prevent GERD symptom exacerbation.
Choice F reason: Scrambled eggs are low-fat and unlikely to trigger GERD compared to chocolate or coffee. This is incorrect, as it’s not a primary substance the nurse would include on the list of items to avoid for GERD management.
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