The client is at risk for impaired skin integrity related to the need for several weeks of bed rest. The nurse evaluates the client after one week and finds the skin integrity is not impaired. In evaluating the plan of care, what is the nurse’s best action?
Remove the nursing diagnosis in the plan of care since it has not occurred.
Keep the nursing diagnosis in the plan of care the same since the risk factors are still present.
Modify the nursing diagnosis in the plan of care to impaired skin integrity.
Change the nursing diagnosis in the plan of care to impaired mobility.
The Correct Answer is B
Choice A reason: Removing the nursing diagnosis in the plan of care since it has not occurred is not a good action, because it does not account for the possibility of future impairment. The client is still at risk for impaired skin integrity due to the prolonged bed rest, and the nurse should continue to monitor and prevent any skin breakdown.
Choice B reason: Keeping the nursing diagnosis in the plan of care the same since the risk factors are still present is the best action, because it reflects the current situation and the potential problem. The client has not developed impaired skin integrity, but the risk factors have not changed. The nurse should maintain the interventions that have been effective in preventing skin impairment, such as turning, repositioning, moisturizing, and inspecting the skin.
Choice C reason: Modifying the nursing diagnosis in the plan of care to impaired skin integrity is not a good action, because it does not match the data. The client has not shown any signs of impaired skin integrity, such as redness, blanching, breakdown, or ulceration. The nurse should not change the diagnosis based on assumptions or predictions, but on evidence.
Choice D reason: Changing the nursing diagnosis in the plan of care to impaired mobility is not a good action, because it does not address the original problem. The client may have impaired mobility due to the bed rest, but that is not the focus of the question. The question is about the risk for impaired skin integrity, which is a different issue that requires different interventions. The nurse should not ignore or replace the existing diagnosis without justification.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the highest priority client because a urinary tract infection (UTI) is a common and treatable condition that affects the lower urinary system, such as the bladder or urethra. A fever of 38.5°C and flank pain can indicate that the infection has spread to the upper urinary system, such as the kidneys, which can cause pyelonephritis. Pyelonephritis is a serious but not lifethreatening complication that requires antibiotic therapy and hydration. The nurse should monitor the client's vital signs, urine output, and pain level and administer the prescribed medication and fluids.
Choice B reason: This is not the highest priority client because a deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the lower extremities. A positive Homans' sign and edema in the affected leg can indicate that the clot is causing inflammation and obstruction of the blood flow. DVT is a serious but not lifethreatening complication that requires anticoagulant therapy and compression therapy. The nurse should monitor the client's vital signs, leg circumference, and pain level and administer the prescribed medication and stockings.
Choice C reason: This is the highest priority client because a myocardial infarction (MI) is a heart attack that occurs when the blood flow to a part of the heart muscle is blocked, causing tissue damage or death. Chest pain and shortness of breath can indicate that the client is experiencing acute cardiac ischemia, which can lead to cardiac arrest or heart failure. MI is a lifethreatening emergency that requires immediate intervention and treatment. The nurse should activate the rapid response team, monitor the client's vital signs, electrocardiogram, and oxygen saturation, and administer the prescribed medication and oxygen.
Choice D reason: This is not the highest priority client because a stroke is a brain attack that occurs when the blood flow to a part of the brain is interrupted, causing tissue damage or death. Slurred speech and facial droop can indicate that the client is experiencing acute neurological impairment, which can affect their communication and facial expression. Stroke is a serious but not lifethreatening complication that requires prompt evaluation and treatment. The nurse should monitor the client's vital signs, neurological status, and glucose level and administer the prescribed medication and fluids.
Correct Answer is D
Explanation
Choice A reason: These drugs kill the virus is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is inaccurate and misleading. Antiretroviral drugs do not kill the virus, but rather block or interfere with the enzymes or proteins that the virus needs to replicate or integrate into the host cells. Antiretroviral drugs can reduce the viral load, which is the amount of virus in the blood, but they cannot eliminate the virus completely.
Choice B reason: Only certain licensed drugs are effective is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is vague and incomplete. Antiretroviral drugs are licensed and approved by the regulatory authorities, such as the Food and Drug Administration (FDA), based on their safety and efficacy. However, not all licensed drugs are equally effective for all people with HIV, as the virus can develop resistance or mutation to some drugs over time. Therefore, the choice and combination of antiretroviral drugs may vary depending on the individual's viral genotype, drug history, and drug interactions.
Choice C reason: A few missed doses per month are OK is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is incorrect and dangerous. Antiretroviral drugs require strict adherence and compliance, which means taking the drugs exactly as prescribed, without missing or skipping any doses. A few missed doses per month are not OK, as they can reduce the effectiveness of the drugs and increase the risk of viral resistance or mutation, which can lead to treatment failure or disease progression.
Choice D reason: These drugs inhibit viral replication is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it describes the mechanism and outcome of the drugs. Antiretroviral drugs inhibit viral replication, which means they prevent or slow down the multiplication or reproduction of the virus. Antiretroviral drugs can inhibit viral replication by targeting different stages of the viral life cycle, such as reverse transcription, integration, or maturation. Antiretroviral drugs can improve the immune function and quality of life of people with HIV.
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