A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.

Choice A rationale:

While music therapy can be a helpful adjunct for pain management, it is not a replacement for all pain medications. Pain management should be individualized, and the statement that music therapy alone will eliminate the need for all medication is not accurate.

Choice B rationale:

Discontinuing music therapy when the patient is no longer responsive may not be the best approach. Music therapy can still provide comfort and support even if the patient is not responsive in the traditional sense. It should be continued if it benefits the patient.

Choice C rationale:

Playing music is not intended to increase alertness but rather to provide comfort and relaxation. This statement reflects a misunderstanding of the purpose of music therapy in pain management.

Choice D rationale:

This statement correctly indicates an understanding of the purpose of music therapy. Music can distract the patient from pain and provide a sense of comfort and relaxation without completely eliminating awareness of pain.