A patient who is obese reports severe pain and is unable to bear weight on the right ankle after making dietary changes 3 weeks ago for weight loss.
The patient’s medical history includes hypertension, gouty arthritis, and cholecystitis.
Which instruction should the nurse include in the discharge teaching?

Substitute natural fruit juices for carbonated drinks.

Avoid the consumption of wine, beer, and coffee.

Use an electric heating pad when pain is at its worst.

Encourage active range of motion to limit stiffness.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While substituting natural fruit juices for carbonated drinks can be a healthy dietary change, it is not directly related to the patient’s reported symptoms of severe pain and inability to bear weight on the right ankle.

Choice B rationale

Avoiding the consumption of wine, beer, and coffee can have various health benefits, but it is not directly related to the patient’s current symptoms. Furthermore, there is no indication in the patient’s history that these beverages are contributing to the patient’s condition.

Choice C rationale

Using an electric heating pad when pain is at its worst can provide temporary relief, but it does not address the underlying issue causing the pain. Additionally, heat therapy is not typically recommended for acute gout attacks, which could be a potential cause of the patient’s symptoms given their history of gouty arthritis.

Choice D rationale

Encouraging active range of motion can help to limit stiffness and improve joint function, which could potentially alleviate the patient’s pain and improve their ability to bear weight on the right ankle. This advice is relevant to the patient’s symptoms and medical history.

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Free Nursing Study Resources

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

Explanation

Choice A rationale

An increased pulse rate can be a sign of pain in infants. The heart rate increases as the body’s way of coping with the stress of pain.

Choice B rationale

Skin showing peripheral pallor is not typically associated with pain. It can be a sign of other conditions, such as anemia or shock, but it’s not a reliable indicator of pain.

Choice C rationale

Clenched fists can be a sign of pain in infants. It’s a common non-verbal cue that infants use to express discomfort.

Choice D rationale

An increased respiratory rate can also be a sign of pain. Like an increased heart rate, it’s a physiological response to stress.

Choice E rationale

Restlessness can be a sign of discomfort or pain in infants. Infants may squirm, fidget, or have trouble settling down when they’re in pain.

Choice F rationale

An elevated temperature is not typically a direct sign of pain, but it can indicate an underlying condition that might be causing pain, such as an infection.

A. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB). B. An older client with scabies who is admitted from an extended care facility. C. Twin siblings admitted with scarlet fever that is complicated with pneumonia. D. A female adolescent admitted with multiple genital Herpes simplex II lesions.

Correct Answer is A

Explanation

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.

Choice B rationale

Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.

Choice C rationale

Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.

Choice D rationale

Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

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

Explanation

The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is A

Explanation

A patient is receiving linezolid IV for nosocomial pneumonia.Which assessment finding is most important for the nurse to report to the healthcare provider?

The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter.The new nurse has a luer-lock tipped syringe.What action should the charge nurse take?

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

A patient has been prescribed 1 L of Lactated Ringer’s IV to be infused over a 12-hour period. The IV administration set delivers 15 gtt/mL. What should be the infusion rate in gtt/min? (Provide a numerical value only. If rounding is required, round to the nearest whole number.)

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.