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","C","D"]
Explanation
Choice A reason: This is incorrect because providing antiseptic mouthwash (such as Listerine) for the patient can worsen xerostomia, or dry mouth. Antiseptic mouthwash can contain alcohol, which can dry out the oral mucosa and reduce saliva production. Saliva is important for lubricating the mouth, preventing infections, and facilitating chewing and swallowing. Therefore, antiseptic mouthwash should be avoided or used sparingly in patients with xerostomia.
Choice B reason: This is correct because encouraging the patient to brush and floss teeth regularly can help prevent dental caries, gingivitis, and periodontitis, which are common complications of xerostomia. Xerostomia can increase the risk of oral infections and tooth decay, as saliva helps wash away food particles, bacteria, and plaque. Therefore, oral hygiene is essential for patients with xerostomia.
Choice C reason: This is correct because encouraging the patient to drink water frequently can help moisten the mouth and relieve the discomfort of xerostomia. Water can also help flush out food debris and bacteria, and prevent dehydration, which can exacerbate xerostomia. Therefore, water intake is beneficial for patients with xerostomia.
Choice D reason: This is correct because providing saliva substitutes can help mimic the functions of natural saliva and improve the symptoms of xerostomia. Saliva substitutes are artificial saliva products that contain water, electrolytes, and lubricants, such as glycerin, carboxymethylcellulose, or xylitol. They can be applied as sprays, gels, rinses, or lozenges, and can help lubricate the mouth, prevent infections, and facilitate chewing and swallowing. Therefore, saliva substitutes are useful for patients with xerostomia.
Correct Answer is D
Explanation
Choice A reason: Evaluating the medication list is a possible step that the nurse can take, as some medications can affect urine concentration or cause dehydration. However, it is not the first step that the nurse should implement, as it does not address the immediate problem of fluid balance.
Choice B reason: Reviewing laboratory reports is another possible step that the nurse can take, as some laboratory tests can indicate the level of hydration or kidney function of the patient. However, it is not the first step that the nurse should implement, as it does not provide a direct assessment of fluid status.
Choice C reason: Increasing oral fluid intake is a potential intervention that the nurse can suggest, as it can help to dilute the urine and prevent dehydration. However, it is not the first step that the nurse should implement, as it may not be appropriate for some patients who have fluid restrictions or other medical conditions.
Choice D reason: Determining fluid volume status is the first step that the nurse should implement, as it can help to identify the cause and severity of urine concentration and guide further actions. The nurse can assess the patient's fluid intake and output, weight, blood pressure, pulse, skin turgor, mucous membranes, and urine specific gravity to determine fluid volume status.
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