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: 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.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Lack of interest is a negative symptom of schizophrenia, characterized by a diminished ability to initiate and sustain planned activities.
Choice B reason: Hyperactivity is not typically considered a negative symptom of schizophrenia.
Choice C reason: Delusions are considered positive symptoms, not negative symptoms of schizophrenia.
Choice D reason: Neglect of personal hygiene is a negative symptom, reflecting a decrease in the ability to manage personal self-care.
Choice E reason: Irrational actions are more aligned with positive symptoms due to their active nature.
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