An older client who was recently admitted to the sub-acute setting after having a knee replacement, is very anxious and refuses to get out of bed, stating that it is too painful. Which intervention will the nurse implement?
Allow the client to remain in bed but share that getting up will be required at least twice a day starting the next morning.
Use the Hoyer lift to get her out of bed so that the knee will not experience much movement and so there will be little pain.
Share with the client that it is important to get out of bed and that there is pain medication available if it does hurt.
Offer pain medication, administer the medication, and wait 30 minutes before getting her out of bed.
The Correct Answer is D
Choice A reason: Allowing the client to remain in bed but sharing that getting up will be required at least twice a day starting the next morning is not an effective intervention, as it does not address the client's current pain or anxiety, and may increase the client's resistance or fear of mobilization.
Choice B reason: Using the Hoyer lift to get her out of bed so that the knee will not experience much movement and so there will be little pain is not an appropriate intervention, as it does not respect the client's autonomy or preference, and may cause more pain or injury to the knee or other joints.
Choice C reason: Sharing with the client that it is important to get out of bed and that there is pain medication available if it does hurt is not a sufficient intervention, as it does not provide the client with adequate pain relief or reassurance, and may imply that the client's pain is not taken seriously or validated.
Choice D reason: Offering pain medication, administering the medication, and waiting 30 minutes before getting her out of bed is the best intervention, as it provides the client with effective pain management, reduces the client's anxiety, and facilitates the client's mobilization and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Older adult declines company, is preoccupied with lethal weapons is the highest risk factor for suicide, as it indicates social isolation, hopelessness, and suicidal intent. The older adult may be suffering from depression, anxiety, or other mental health issues that impair their quality of life and increase their likelihood of harming themselves.
Choice B reason: Liver failure is due to alcohol abuse, older adult is popular at meals is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a chronic medical condition that affects their liver function, but they may also have a supportive social network and coping skills that reduce their risk of suicide.
Choice C reason: Refuses to allow a large, extended family to help him is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a preference for independence and autonomy, or they may have a strained relationship with their family. However, they may also have other sources of support and meaning in their life that lower their risk of suicide.
Choice D reason: The older adult had an overdose of acetaminophen 20 years ago; is in a sewing group is not the highest risk factor for suicide, as it does not indicate current suicidal ideation or behavior. The older adult may have a history of a suicide attempt, but they may also have recovered from their past crisis and found a positive outlet for their emotions and interests in the sewing group.
Choice E reason: None of the above is not the correct answer, as there is one choice that indicates the highest risk for suicide.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because issues related to the digestive system are not likely to be caused by UTIs or constipation. Digestive system issues can include gastritis, ulcers, irritable bowel syndrome, or inflammatory bowel disease, which can cause symptoms such as abdominal pain, nausea, vomiting, diarrhea, or bleeding. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice B reason: This is incorrect because vitamin B12 deficiency is not likely to be caused by UTIs or constipation. Vitamin B12 deficiency can occur due to poor dietary intake, malabsorption, or pernicious anemia, which can cause symptoms such as fatigue, weakness, numbness, tingling, or anemia. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice C reason: This is incorrect because malnutrition is not likely to be caused by UTIs or constipation. Malnutrition can occur due to inadequate food intake, poor food quality, or increased nutritional needs, which can cause symptoms such as weight loss, muscle wasting, edema, or poor wound healing. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice D reason: This is correct because dehydration can be caused by UTIs or constipation. UTIs can cause increased urination, fever, or vomiting, which can lead to fluid loss and dehydration. Constipation can cause reduced fluid intake, hard stools, or straining, which can also lead to fluid loss and dehydration. Dehydration can cause symptoms such as dry mouth, thirst, low urine output, dark urine, or low blood pressure. Dehydration can also worsen UTIs or constipation, creating a vicious cycle. Therefore, dehydration is a possible condition that the client might be suffering from.
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