Patient Data

Exhibits

The nurse is implementing the plan of care to increase mobility

Complete the diagram by dragging from the choices area to specify which type of exercises the client needs, two actions the nurse should take to facilitate the exercises, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Type of Exercises

Isometric exercises

Actions to Take

Support the extremity during exercise routine

Providing support helps to ensure that the extremity is not subjected to undue stress or movement that could disrupt healing or cause pain.

Teach family how to participate in exercise program

Involving family members can ensure that the client receives consistent support and assistance with exercises, which is particularly important for adherence and progress.

Parameters to Monitor

Pain level

Monitoring pain levels is crucial to ensure that the exercises are not causing undue discomfort or exacerbating the client's condition.

Ability to perform activities of daily living

Assessing the client’s ability to perform ADLs helps gauge functional progress and overall recovery, indicating how well the exercises and rehabilitation are supporting daily functioning.

Nursing Test Bank

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Correct Answer is B

Explanation

A. While incontinence briefs can provide comfort and protection, they do not address the underlying issue of fecal incontinence and may contribute to a sense of helplessness.
B. This is the most appropriate option. Establishing a regular bowel routine is crucial for bowel training. After meals, the gastrocolic reflex stimulates bowel motility, making this an ideal time to attempt bowel movements.
C. Suppositories can stimulate bowel movements but they should not be used routinely as they can lead to dependency. The goal of bowel training is to establish a regular pattern without relying on medications.
D. Similar to suppositories, rectal tubes should be avoided as they can disrupt the natural bowel function and lead to dependency.

A. Complete an adverse occurrence/incident report. B. Demonstrate proper securing of the restraints. C. Ensure that the restraints are not too tight. D. Initiate the facility's restraint flow sheet.

Correct Answer is C

Explanation

A. While this may be necessary after assessing the situation, it is not the immediate priority.
B. Demonstrating proper securing of the restraints is important, but it does not address the immediate safety concern of the client.

C. Ensuring that the restraints are not too tight is the most critical action. Tight restraints can compromise circulation and cause injury.
D. This is a necessary step in the restraint process, but it should be done after ensuring the client's safety.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is C

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?