A nurse in a long-term care facility is providing care for a client who has gastroesophageal reflux (GERD). Which of the following interventions should the nurse implement?
A. Isolate the client in their room.
Encourage the client to ambulate with a staff member.
Administer a prescribed oral dose of trazodone to the client.
Apply bilateral wrist restraints to the client.
The Correct Answer is B
Choice A rationale
Isolating the client in their room is not necessary for managing GERD. Isolation measures are typically used for contagious diseases, not for GERD, which is a non-infectious condition.
Choice B rationale
Encouraging the client to ambulate with a staff member helps promote gastrointestinal motility and reduce the risk of reflux. Physical activity can aid in digestion and reduce GERD symptoms.
Choice C rationale
Trazodone is an antidepressant and is not typically prescribed for managing GERD. It is not relevant to the care plan for a client with GERD.
Choice D rationale
Applying bilateral wrist restraints is not indicated for GERD management. Restraints are used for patients who pose a risk to themselves or others, not for those with GERD. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ensuring the weights hang freely prevents interference with the traction, which helps maintain alignment and reduce pain.
Choice B rationale
Maintaining 6.8 kg (15 lb) of weight is not specific to skin traction and could be inappropriate, as the weight should be based on the physician's orders.
Choice C rationale
Loosening the ropes of the pulleys when repositioning the client can interfere with the effectiveness of the traction.
Choice D rationale
Inspecting the client's skin every 12 hours for signs of breakdown is not frequent enough; skin should be checked more often to prevent complications.
Correct Answer is B
Explanation
Choice A rationale
Placing the client near the nurses' station may increase sensory overload due to increased noise and activity.
Choice B rationale
Breaking up nursing care into small, frequent sessions helps prevent overwhelming the client and reduces sensory overload.
Choice C rationale
Keeping the blinds open can add to sensory overload from excessive light and external stimuli.
Choice D rationale
Playing quiet music may be calming, but it does not directly address the need to reduce sensory input from various sources. .
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