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 B
Explanation
Choice A reason: This is incorrect because over-the-counter NSAIDs are not generally harmless, especially for older adults. NSAIDs can cause gastrointestinal bleeding, renal impairment, hypertension, and increased risk of cardiovascular events. Older adults are more susceptible to these adverse effects due to age-related changes in pharmacokinetics and pharmacodynamics, as well as the presence of comorbidities and polypharmacy. Therefore, NSAIDs should be used with caution and at the lowest effective dose for the shortest duration possible in older adults.
Choice B reason: This is correct because stool softeners and laxatives should be used with opioids. Opioids can cause constipation, which can lead to abdominal pain, nausea, vomiting, fecal impaction, and bowel obstruction. Older adults are more prone to constipation due to decreased intestinal motility, reduced fluid intake, and use of other medications that affect bowel function. Therefore, stool softeners and laxatives should be prescribed along with opioids to prevent and treat constipation in older adults.
Choice C reason: This is incorrect because opioids are not less effective in older clients than in younger clients. Opioids are potent analgesics that can relieve moderate to severe pain in older adults. However, opioids can also cause respiratory depression, sedation, confusion, delirium, falls, and dependence. Older adults are more sensitive to these side effects due to altered pharmacokinetics and pharmacodynamics, as well as the presence of cognitive impairment and frailty. Therefore, opioids should be used with caution and at the lowest effective dose for the shortest duration possible in older adults.
Choice D reason: This is incorrect because the dose limit for acetaminophen is not difficult to reach for older adults. Acetaminophen is a safe and effective analgesic for mild to moderate pain in older adults. However, acetaminophen can cause hepatotoxicity, especially at high doses or in combination with other medications that contain acetaminophen. The recommended maximum daily dose of acetaminophen for older adults is 3 grams, which can be easily reached if the patient is not aware of the amount of acetaminophen they are taking. Therefore, acetaminophen should be used with caution and at the lowest effective dose for the shortest duration possible in older adults.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because any exertion on the part of an older adult with heart disease does not necessarily result in death. Exertion can increase the oxygen demand of the heart and cause angina, or chest pain, but it can also be beneficial for the cardiovascular health and fitness of the older adult, if done within the limits of their tolerance and under medical supervision.
Choice B reason: This is incorrect because myocardial infarction is not the same as heart attack, cardiac arrest, or coronary thrombosis, although they are related terms. Myocardial infarction is the medical term for the death of a part of the heart muscle due to lack of blood supply. Heart attack is the common term for myocardial infarction. Cardiac arrest is the sudden loss of heart function, which can be caused by myocardial infarction or other factors. Coronary thrombosis is the formation of a blood clot in a coronary artery, which can lead to myocardial infarction.
Choice C reason: This is correct because both excessive undernutrition and overnutrition can contribute to heart disease. Undernutrition can cause malnutrition, anemia, and low immunity, which can increase the risk of infections and inflammation that can damage the heart. Overnutrition can cause obesity, diabetes, and high cholesterol, which can increase the risk of atherosclerosis and hypertension that can impair the blood flow to the heart.
Choice D reason: This is incorrect because a person with diabetes should have their blood pressure checked regularly, but this is not a statement about heart disease in Kenya. Diabetes is a risk factor for heart disease, as it can damage the blood vessels and nerves that control the heart. However, this statement is applicable to any person with diabetes, regardless of their location.
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