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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.

Provide oxygen at 6 L/min via nasal cannula.

Apply cold compresses to joints.

Perform passive ROM exercises.

Administer IV fluids

Obtain consent for a blood transfusion

Restrict fluid intake to 1,400 mL/day

Administer meperidine

Encouraging bedrest

Answer and Explanation

Correct Answer : B,C,G,H

A.   Providing oxygen at 6 L/min via nasal cannula is not indicated based on the information provided. The client denies shortness of breath, and vital signs are within normal limits.
B.   Applying cold compresses to joints can help reduce swelling and alleviate pain in the extremities.
C.   Performing passive range of motion (ROM) exercises is appropriate to maintain joint flexibility and prevent contractures.
D.   Administering IV fluids is not explicitly indicated based on the information provided. Fluid management should be individualized based on the client's condition and underlying factors.
E.   Obtaining consent for a blood transfusion is not necessary unless the client has severe anemia or bleeding.
F.   Restricting fluid intake to 1,400 mL/day may cause dehydration and electrolyte imbalance.
G.   Administering meperidine (a narcotic analgesic) may be considered for pain relief.
H.   Encouraging bedrest is appropriate to minimize joint stress and promote healing, especially when there is pain and swelling in the extremities.

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Correct Answer is C

Explanation

A. Seeking a second opinion suggests the client may be exploring different treatment options, indicating some level of hope for improvement.
B. Expressing plans to stop treatment may indicate frustration or dissatisfaction but does not necessarily reflect acceptance of the prognosis.
C. Expressing a desire for symptom relief (in this case, discomfort) is indicative of an understanding and acceptance of palliative care.
D. Stating that the treatment is making the client stronger every day may reflect a positive attitude but does not necessarily indicate acceptance of the prognosis.

A. Allow the client to choose free-time activities B. Post a written schedule of daily activities. C. Provide a consistent daily routine. D. Use an overhead loudspeaker to announce events

Correct Answer is C

Explanation

Individuals with dementia often benefit from routine, but too many choices can be overwhelming.
B: While a written schedule can be helpful, a consistent routine is generally more beneficial for clients with dementia.
C: Providing a consistent daily routine helps decrease anxiety and confusion for clients with dementia.
D: Overhead loudspeakers may cause agitation and confusion in clients with dementia.

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A nurse is contributing to the plan of care for an adolescent client. Exhibits Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.

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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.