A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:
Encourage the client to increase physical activity and engage with peers.
Suggest the client remain in bed to avoid unnecessary exertion.
Teach the caregiver how to monitor for signs of infection in pressure injuries.
Assist the client in using the restroom to avoid incontinence.
Correct Answer : A,C,D
The correct answers are Choices A, C, and D.
Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.
Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.
Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.
Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Severe motor dysfunction indicates the degree of impairment but does not determine the extent of successful habilitation. Habilitation depends on various factors, including individual capabilities, intervention quality, and environmental support.
Choice B rationale
Brain damage with CP is not progressive, meaning it does not worsen over time. However, the effects and manifestations can vary, leading to a range of functional outcomes. This provides a realistic and hopeful perspective for the child's future.
Choice C rationale
CP is indeed one of the most common permanent physical disabilities in children, but this statement does not directly address the mother's concern about the potential progression of impaired movements.
Choice D rationale
The continued development of the brain lesion is not a characteristic of CP. The brain damage is static, meaning it does not change, although its effects may become more apparent as the child grows and develops.
Correct Answer is C
Explanation
Choice A rationale
Consulting with a nurse who shares the same religious beliefs may provide insight, but it may not fully address the client's unique care preferences and individual needs.
Choice B rationale
Researching the religion on social media platforms can offer information, but it is not a substitute for understanding the client's specific preferences and requirements.
Choice C rationale
Asking the client about individual care preferences is the best approach, ensuring that care is personalized and respectful of the client's religious beliefs, leading to better compliance and satisfaction.
Choice D rationale
Explaining that every client receives the same high level of care is important but does not address the client's specific religious concerns and preferences.
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