A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client’s bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?
To help the nurse validate the client’s reports of pain
To increase positive pressure in the chest
To assist the client with ADLS
To modify the client’s perception of pain
The Correct Answer is C
A. To help the nurse validate the client’s reports of pain
This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.
B. To increase positive pressure in the chest
This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.
C. To assist the client with ADLs (Activities of Daily Living)
This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.
D. To modify the client’s perception of pain
This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Stress incontinence
Stress incontinence is the involuntary loss of urine during activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, or lifting heavy objects. In stress incontinence, the pelvic floor muscles are weakened, leading to inadequate support of the bladder and urethra. This results in leakage of urine during moments of increased pressure on the bladder.
B. Urge incontinence
Urge incontinence involves a strong and sudden urge to urinate, leading to involuntary urine loss. It is often associated with an overactive bladder and may not be related to increased abdominal pressure.
C. Overflow incontinence
Overflow incontinence occurs when the bladder is unable to empty completely, leading to constant dribbling of urine. It is often associated with conditions that obstruct urine flow, such as an enlarged prostate in men.
D. Reflex incontinence
Reflex incontinence is characterized by the involuntary loss of urine due to a reflex arc that bypasses normal control mechanisms. It is often associated with neurological conditions that affect bladder control.
Correct Answer is A
Explanation
A. Check that the client lifts the walker and then places it down in front of her.
To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.
B. Walk in front of the client to guide her in moving the walker.
The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.
C. Have the client move one leg forward with the walker.
The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.
D. Make sure that the upper bar of the walker is level with the client’s waist.
The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.
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