Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Balance and posture.

Risk for disuse syndrome.

Pressure sore risk.

Upper body muscle strength.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Balance and posture: Although relevant for general mobility, a trapeze bar is primarily used while in bed, where balance and posture are less critical than the strength to use the device effectively.

B. Risk for disuse syndrome: This risk supports the need for mobility aids like a trapeze, but it does not determine whether the client can use the device safely and independently.

C. Pressure sore risk: This is important for overall care planning, but not the most relevant assessment for determining safe and effective trapeze use.

D. Upper body muscle strength: Adequate arm and shoulder strength are essential for the client to grasp and lift themselves using the trapeze bar. Without this, using the bar could lead to falls or injuries.

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Correct Answer is C

Explanation

Rationale:

A. Manages activities of daily living independently: Preserving functional independence is not a direct clinical outcome related to managing chronic pyelonephritis. The primary concern with this condition is preserving renal function and preventing long-term complications like hypertension.

B. Measures oral temperature daily: Monitoring temperature can help detect infections early, but chronic pyelonephritis may not always present with fever. It’s a short-term strategy and less critical than preventing progression to renal damage or cardiovascular complications.

C. Maintains blood pressure within normal limits: Chronic pyelonephritis can lead to kidney scarring, which often contributes to secondary hypertension. Controlling blood pressure is vital in slowing renal deterioration and preventing cardiovascular events, making it the most important long-term goal.

D. Restricts fluid intake to 1 L/day: Fluid restriction is not appropriate unless the client is in advanced kidney failure with fluid overload. Adequate hydration is usually encouraged to help flush bacteria from the urinary tract and support renal function.

A. Confirm that the desired effect of the medication has been achieved. B. Explain that it may take several weeks for the medication to be effective. C. Evaluate when and how the medication is being administered to the client. D. Notify the healthcare provider that a change in dosage may be needed.

Correct Answer is A

Explanation

Rationale:

A. Confirm that the desired effect of the medication has been achieved: Trazodone is prescribed to improve mood and aid sleep, not to enhance cognitive function. Since the caregiver reports improvement in those areas, the medication is achieving its intended therapeutic outcomes.

B. Explain that it may take several weeks for the medication to be effective: While some antidepressants require time to reach full effectiveness, the caregiver already reports improved mood and sleep. There is no indication of delayed onset.

C. Evaluate when and how the medication is being administered to the client: No signs of improper administration or ineffective dosing are indicated. The caregiver's feedback suggests the medication is being given correctly and is having a beneficial effect.

D. Notify the healthcare provider that a change in dosage may be needed: Cognitive decline in Alzheimer's disease is progressive and not expected to improve with trazodone, so no dosage change is warranted based on this feedback.

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Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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