Patient Data

Exhibits

For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease.

Inquires about blood pressure

Asks questions about self-care

Requests nurse to perform wound care

Executes pull-ups on trapeze bar

Avoids looking at residual limb

Turns side to side

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Positive health promotion activities include inquiring about blood pressure, asking questions about self-care, executing pull-ups on a trapeze bar, and turning side to side.

Negative health promotion activities include requesting the nurse to perform wound care and avoiding looking at the residual limb.

Rationale

POSITIVE:

Inquires about blood pressure:

Inquiring about blood pressure shows awareness of cardiovascular health, which is important for individuals with peripheral vascular disease. Monitoring blood pressure regularly can help prevent complications and manage hypertension, a common comorbidity in peripheral vascular disease.

Asks questions about self-care:

Asking questions about self-care indicates engagement in the management of one's health post- amputation. Understanding self-care tasks, such as wound care, prosthetic use, and rehabilitation exercises, is crucial for optimal recovery and adjustment to life after amputation. Executes pull-ups on trapeze bar:

Engaging in physical activity, such as pull-ups on a trapeze bar, demonstrates motivation for rehabilitation and adaptation to life after amputation. Strengthening exercises can improve overall physical function and assist in adjusting to mobility with a prosthetic limb.

Turns side to side:

Turning side to side suggests mobility and activity post-amputation. Movement and repositioning are important for preventing complications such as pressure ulcers and promoting circulation in individuals with peripheral vascular disease.

NEGATIVE

Requests nurse to perform wound care:

Negative: While it's understandable for a client to initially require assistance with wound care post-amputation, relying solely on the nurse to perform wound care may indicate a lack of engagement in self-management and may hinder the client's transition to independence in managing their health post-amputation.

Avoids looking at residual limb:

Negative: Avoiding looking at the residual limb may indicate psychological distress or difficulty accepting the amputation. It's important for individuals post-amputation to gradually become comfortable with their changed body image and to address any psychological challenges through counseling or support groups.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This choice involves culturing a sputum sample collected from the patient to identify the presence of Mycobacterium tuberculosis, the bacterium that causes tuberculosis. A positive result confirms the diagnosis of TB.
B. Hemoccult tests are used to detect hidden (occult) blood in stool samples. While hemoptysis (coughing up blood) can be a symptom of TB, a hemoccult test is not specific for TB diagnosis. It is more commonly used in detecting gastrointestinal bleeding.
C. Imaging studies like chest x-ray or CT scans can reveal abnormalities in the lungs suggestive of TB, such as infiltrates, cavitations, or lymph node enlargement. While these tests can support the diagnosis, they are not definitive on their own.
D. The PPD skin test is a common screening tool for TB exposure. It detects the presence of a delayed hypersensitivity reaction to proteins derived from Mycobacterium tuberculosis. A positive PPD indicates exposure to TB but does not confirm active disease.

A. Release the traction so the client can use a bedpan. B. Log roll the client and place adult disposable briefs beneath the client. C. Insert an indwelling urinary catheter preoperatively. D. Maintain traction while the client uses a urinal.

Correct Answer is D

Explanation

A. Releasing traction to use a bedpan may cause pain and discomfort to the client and risk exacerbating the fracture or compromising the alignment needed for surgery.
B. Log rolling the client and placing adult disposable briefs beneath them may not be suitable because it involves movement that can disrupt traction and worsen the client's pain.
Additionally, disposable briefs may not adequately manage urinary output, especially for a client awaiting surgery.

C.While using a catheter can be an option, it is generally not the first intervention unless the client is unable to void by other means or has a specific indication for catheterization. It carries risks, including infection, and should be considered carefully.
D. The nurse can assist the client in using a urinal while ensuring that traction is maintained. This allows the client to urinate without disrupting the traction setup, minimizing the risk of complications associated with the fracture.

View Question and Answer

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Patient Data Exhibits For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Correct Answer is A

Explanation

A client who fractured the right femur from a fall at home is placed in traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?

Correct Answer is D

Explanation

Patient Data Exhibits Based on the laboratory data, the client has dropdown related to dropdown

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A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider, the nurse should evaluate which laboratory value?

Patient Data

Exhibits

For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease.