A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

I will need to massage my legs frequently to prevent a buildup of fluid

I will keep my legs in a dependent position

I will decrease my activity to prevent added stress on my legs

I will inspect my legs every day for changes in color, size and temperature

Answer and Explanation

The Correct Answer is D

A. Massaging the legs frequently can exacerbate symptoms of peripheral venous disease by increasing venous pressure and worsening edema. It is not recommended for managing this condition.

B. Keeping the legs in a dependent position can further impair venous return and exacerbate symptoms. Elevating the legs above the level of the heart when possible is recommended to reduce venous congestion.

C. Decreasing activity can lead to deconditioning and worsen symptoms over time. Encouraging regular, moderate physical activity is important for improving venous circulation and overall vascular health.

D. Inspecting the legs daily for changes in color, size, and temperature is an essential component of managing peripheral venous disease. Changes such as skin discoloration, swelling, or increased warmth can indicate worsening venous insufficiency or the development of complications such as venous ulcers. Early detection allows for prompt intervention and prevention of complications.

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Correct Answer is B

Explanation

B. Provide opportunities for education and continually evaluate the client's preferences and goals for care:
This is the most effective intervention. Providing education and involving the client (to the extent possible) in decision-making helps reduce anxiety and build trust. Even though individuals with Alzheimer's disease may have limited memory and cognitive abilities, ongoing communication about the transition and individualized care plans can help ease the process. Additionally, continuously evaluating the client's preferences and goals ensures that the care plan remains person-centered and aligns with their needs, helping to minimize relocation stress.

A. Administer acetaminophen by mouth for pain control B. Perform a thorough health history C. Prepare for a STAT non-contrast CT scan D. Insert an indwelling urinary catheter to monitor urine output

Correct Answer is C

Explanation

A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.

B. Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.

C. Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.

D. Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.

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A nurse is teaching a client who has peripheral venous disease about management of symptoms. Which of the following client statements indicates to the nurse an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Alzheimer's disease and is going to transition from home to a skilled nursing facility. Which of the following interventions should the nurse incorporate into the plan of care to help the client with this transition and avoid relocation stress syndrome?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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