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 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: 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.
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