An older adult who has been diagnosed with COPD wants to perform self-care activities. Which instruction should the nurse include in client teaching to help achieve this goal?
Perform all activities of daily living (ADLs) and then rest
Bathe and eat slowly with periodic rest
Walk short distances without oxygen
Bathe right after eating and then rest
The Correct Answer is B
Choice A reason: Performing all activities of daily living (ADLs) and then resting is not a good instruction for the older adult who has COPD, as it can cause fatigue, shortness of breath, and anxiety. The nurse would advise the older adult to pace themselves and prioritize the most important activities, and to take breaks between tasks.
Choice B reason: Bathing and eating slowly with periodic rest is a good instruction for the older adult who has COPD, as it can help conserve energy, prevent dyspnea, and improve digestion. The nurse would advise the older adult to use a shower chair or a handheld showerhead, to avoid hot water or steam, and to use a fan or an open window for ventilation. The nurse would also advise the older adult to eat small, frequent meals, to avoid foods that cause gas or bloating, and to drink fluids between meals rather than with them.
Choice C reason: Walking short distances without oxygen is not a safe instruction for the older adult who has COPD, as it can cause hypoxia, which is a low level of oxygen in the blood. The nurse would advise the older adult to use oxygen therapy as prescribed by their doctor, and to monitor their oxygen saturation with a pulse oximeter. The nurse would also advise the older adult to exercise regularly, but to start slowly and gradually increase the intensity and duration, and to stop if they feel dizzy, chest pain, or severe breathlessness.
Choice D reason: Bathing right after eating and then resting is not a helpful instruction for the older adult who has COPD, as it can cause indigestion, reflux, or aspiration. The nurse would advise the older adult to wait at least an hour after eating before bathing, and to avoid lying down right after eating or bathing. The nurse would also advise the older adult to elevate their head with pillows when resting or sleeping, and to avoid napping during the day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect because wellness is not only dependent on the absence of disease, but also on the physical, mental, emotional, social, and spiritual aspects of health. The nurse should educate the client on how to cope with his condition and enhance his quality of life, not focus on the negative aspects of his disease.
Choice B reason: This statement is incorrect because aggressive medical interventions may not be appropriate or beneficial for a terminally ill client. The nurse should respect the client's wishes and preferences regarding his care, and provide comfort and palliative measures, not cause unnecessary pain or suffering.
Choice C reason: This statement is incorrect because wellness is still a real option for a terminally ill client. The nurse should not assume that the client has given up on his health or happiness, but rather support him in finding meaning and purpose in his life, and achieving his goals and values.
Choice D reason: This statement is correct because it reflects the nurse's role in promoting wellness for a terminally ill client. The nurse should provide nursing interventions that can help the client maintain his dignity, autonomy, and sense of control, as well as address his physical, emotional, social, and spiritual needs. The nurse should also empower the client to make informed decisions about his care, and facilitate his communication with his family and health care team.
Correct Answer is B
Explanation
Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.
Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.
Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.
Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.
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