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":"None"}}

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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Redness, tenderness, and drainage around the catheter site are classic signs of an exit site infection in peritoneal dialysis. Exit site infections are a common complication of peritoneal dialysis and can lead to more serious complications, such as peritonitis, if not promptly treated. Preventing exit site infections through proper catheter care and hygiene is essential in peritoneal dialysis management.
A. While outflow obstruction can occur in peritoneal dialysis, it typically presents with symptoms such as poor drainage of dialysate fluid, abdominal discomfort, and a decrease in dialysis efficiency. The described findings of redness, tenderness, and drainage around the catheter site are more indicative of a localized issue rather than outflow obstruction.
C. Atelectasis refers to the collapse of a part or the entire lung. While it can occur in hospitalized patients, especially those with underlying respiratory conditions, the described findings are not indicative of atelectasis. Atelectasis typically presents with symptoms such as dyspnea, cough, and decreased breath sounds on auscultation.
D. Peritonitis is a severe complication of peritoneal dialysis characterized by inflammation and infection of the peritoneal lining. While redness, tenderness, and drainage around the catheter site may precede peritonitis, the focus of concern in this scenario is primarily on preventing exit site infection, which, if left untreated, can progress to peritonitis.

A. Sputum culture positive for Mycobacterium tuberculosis. B. Hemoccult test on sputum collected from hemoptysis. C. Chest x-ray or computed tomography (CT). D. Positive purified protein derivative (PPD) skin test.

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.

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

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?

Correct Answer is B

Explanation

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 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?

In assessing a client with skin ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

Review Hand P and laboratory results Exhibits What item(s) should be included in the treatment regimen for this client? Select all that apply.

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

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?

Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding or no understanding of the education given

A family suspects that AIDS dementia is occurring in their adult child who is HIV positive. Which symptom confirms the suspicion?

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.

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.