A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

The client leans on the crutches for support while standing still.

The client advances the unaffected leg first while climbing stairs.

The client stands 5 cm (2 in) from the front of a chair before sitting.

The client bears weight on their axilla while standing in the tripod position.

Answer and Explanation

The Correct Answer is B

A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

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Correct Answer is C

Explanation

A: Asking the client why they are angry may come across as confrontational and defensive, potentially escalating the situation. It does not promote open communication or therapeutic rapport.
B: Sharing personal information about diabetes running in the nurse's family is not relevant to the client's feelings or concerns and may not be helpful in addressing the client's anger.
C: Correct. Acknowledging the client's feelings of anger and offering to sit down and talk provides an opportunity for therapeutic communication. This response demonstrates empathy and a willingness to listen and address the client's concerns about insulin therapy.
D: While it is true that insulin therapy can help reduce the risk of complications in type 2 diabetes, this response may come across as dismissive of the client's feelings and concerns. It does not address the emotional aspect of the client's anger.

A. Neurological findings B. Incisional drainage C. Urinary output D. Reported pain level E. Gastrointestinal findings F. Vital signs

Correct Answer is ["C","D","F"]

Explanation

A: The neurological findings were already noted in the nurse's initial assessment, and the client's orientation and movement of extremities are within the expected range postoperatively.
Therefore, it does not require immediate reporting.
B: While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time.
C: Monitoring urinary output is essential, especially in a postoperative client, as it helps assess renal function and hydration status. Any significant changes in urinary output should be reported to the provider promptly.
D: The client's reported pain level of 6 on a scale of 0 to 10 indicates moderate pain, and the provider should be informed to address the pain and consider adjustments to the pain management plan.

E.Gastrointestinal assessment is incorrect. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide.

F.Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

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A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

Nurse is caring for a client following abdominal surgery. Exhibits Select the findings the nurse should report to the provider.

Correct Answer is ["C","D","F"]

Explanation

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

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A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a lowpotassium diet. Which of the following food by the client demonstrates an understanding of the teaching?

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