A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?
Check on the client every 10 min during the bath
Add bath oil to the water after the client gets into the tub
Drain the tub water before the client gets out
Allow the client to remain in the bath for 30 min
The Correct Answer is C
A. If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items such as shower chairs and grab bars.
B. Adding bath oil to the water after the client is in the tub can create a slippery surface, increasing the risk of falls. Bath oil should be added before the client enters the tub or avoided if there is a risk of slipping.
C. Draining the tub water before the client gets out helps prevent slips and falls that can occur if the client attempts to exit the tub while the water is still present. This practice enhances safety by reducing the risk of accidents.
D. Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The AIMS is specifically designed to assess for the presence and severity of abnormal involuntary movements, which can be a side effect of long-term antipsychotic medication use, including tardive dyskinesia. It consists of a series of standardized movements and observations that assess different body regions for abnormal movements. The nurse can use this tool to monitor the client's movements and identify any signs of tardive dyskinesia.
Mental Status Examination (MSE): The MSE is a comprehensive assessment of a client's mental status, including their cognition, mood, and thought processes. While the MSE is an important tool in assessing overall mental health, it is not specific to tardive dyskinesia. Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a screening tool for depression that assesses the severity of depressive symptoms. While depression can be a comorbidity in individuals with schizophrenia, the PHQ-9 does not directly assess for tardive dyskinesia. Brief Psychiatric Rating Scale (BPRS): The BPRS is a rating scale used to assess the severity of psychiatric symptoms in individuals with mental disorders. While it is useful in evaluating overall symptomatology in schizophrenia, it does not specifically target tardive dyskinesia.
Correct Answer is A
Explanation
a.This requires intervention because creases in the stockings can create pressure points that may lead to skin irritation or impaired circulation. The stockings should be applied smoothly and evenly to ensure proper compression and to avoid skin complications.
b.This is not necessary and can actually be incorrect. Antiembolic stockings should be applied with the correct side facing the client's skin. Turning them inside out could alter their effectiveness in providing the required compression.
c.This is appropriate. Applying antiembolic stockings before the client gets out of bed is recommended because it helps to promote venous return and prevent blood clots, especially if the client is immobile or has limited mobility.
d.This is appropriate. Asking the client to point their toes helps to ensure that the stockings can be applied correctly and fit well, reducing the risk of creating pressure points or causing discomfort.
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