The nurse is providing care for a patient after an above-the-knee amputation due to diabetes complications. Which nursing care is essential for promoting ambulation?
Lying prone as prescribed.
Promoting coordination exercises.
Building upper body strength.
Maintaining residual limb elevation.
The Correct Answer is C
Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.
Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.
Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.
Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Dehiscence refers to the separation of layers of a surgical wound, which may be partial or complete.
Choice B reason: Evisceration is a more severe complication where the wound opens and internal organs may protrude.
Choice C reason: Gaping refers to a wound that is open but does not necessarily indicate the layers have separated, as in dehiscence.
Choice D reason: Distention generally refers to swelling or enlargement of an organ or area, not specifically to the opening of a wound.
Correct Answer is D
Explanation
Choice A: "I’m sorry if I upset you. I just wanted to make sure you’re aware of the day’s schedule."
This response may seem empathetic, but it could potentially reinforce the client's aggressive behavior. The nurse is apologizing, which might give the impression that the client's rude behavior is acceptable¹.
Choice B: "Well, if you can read it yourself, then why don’t you?"
This response is confrontational and could escalate the situation. It's important for the nurse to maintain a neutral and respectful manner.
Choice C: "You don’t have to be so rude. I’m just doing my job."
This response is defensive and could provoke further aggression from the client. It's not recommended to respond defensively to clients with borderline personality disorder¹.
Choice D: "I didn’t mean to offend you. I’ll leave the schedule here for you to review."
This is the most appropriate response. The nurse acknowledges the client's feelings without reinforcing the aggressive behavior. The nurse also respects the client's autonomy by leaving the schedule for the client to review¹.
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