The nurse is caring for a patient with venous stasis ulcers. What actions should the nurse take?

Instruct the patient to wear constrictive clothing.

Encourage the patient to keep legs in a dependent position.

Encourage frequent ambulation.

Apply compression stockings.

Answer and Explanation

The Correct Answer is D

Choice A reason: Instructing the patient to wear constrictive clothing is incorrect, as it can worsen venous stasis ulcers by impeding blood flow.

Choice B reason: Encouraging the patient to keep legs in a dependent position is not recommended, as elevation helps in reducing venous pressure.

Choice C reason: Frequent ambulation is encouraged to promote blood circulation and prevent stasis.

Choice D reason: Applying compression stockings is a standard care practice to help reduce venous pressure and prevent fluid from pooling in the legs.

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Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

A. Serve individual items that have sealed packaging. B. Serve warm foods that arrive from the kitchen with lids in place. C. Serve the same food that other clients in the dining room are eating. D. Serve the client's favorite foods in an attractive arrangement.

Correct Answer is A

Explanation

Choice A reason: Serving food in sealed packaging can help alleviate the client's fears of poisoning, as the intact seals provide visual assurance that the food has not been tampered with.

Choice B reason: While serving warm foods with lids may keep the food warm, it does not necessarily provide the same level of reassurance against the fear of poisoning as sealed packaging does.

Choice C reason: Serving the same food as others may not be effective if the client's delusions include beliefs that they are being specifically targeted.

Choice D reason: Although serving the client's favorite foods in an attractive arrangement may be appealing, it does not address the specific paranoid delusion of food being poisoned.

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The nurse is caring for a patient with venous stasis ulcers. What actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging nutritional intake?

Correct Answer is A

Explanation

Debridement is:

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