The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Middle-aged man experiencing the acute phase of myocardial infarction (MI)

Older adult with a history of dementia admitted for dehydration

Young adult in the rehabilitative phase after arthroscopic surgery

Middle-aged woman just diagnosed with terminal lung cancer

Answer and Explanation

The Correct Answer is A

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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Correct Answer is ["A","C","D","E"]

Explanation

A. The hot water heater is set at 54°C (130° F): This temperature poses a risk of burns, especially for a client who may have impaired mobility or sensation due to a stroke. Water temperatures above 49°C (120°F) can cause burns, and 54°C (130°F) increases that risk significantly, making it a safety hazard.

B. Grab bars are installed in the bathroom: This is a safety feature rather than a hazard. Grab bars can help prevent falls and provide support for clients with mobility issues, making them an important aspect of home safety, particularly for someone who has experienced a stroke.

C. Area rugs are placed in the living room: Area rugs can create tripping hazards, especially for clients who may have difficulty with balance or mobility after a stroke. If not secured properly, they can lead to falls, making this a safety hazard.

D. Medications are stored in a clear bag: While storing medications in a clear bag may provide visibility, it does not ensure safety. If the bag is not clearly labeled or is accessible to children or pets, it can pose a risk of accidental ingestion or misuse, thus representing a safety hazard.

E. Dim lighting installed throughout the house: Dim lighting can increase the risk of falls, especially for clients with visual impairments or those who may not be able to navigate their environment safely after a stroke. Proper lighting is essential for ensuring safety and preventing accidents, making this a safety hazard.

A. Move the client's limbs through their complete range of motion. B. Have the client move each limb independently through its complete range of motion. C. Ask the client to move her arms and legs while applying slight resistance. D. Instruct the client to tighten muscle groups for a short period, and then relax.

Correct Answer is D

Explanation

A. Move the client's limbs through their complete range of motion: This action describes passive range-of-motion exercises, where the nurse assists the client in moving their limbs. While this is beneficial for clients who cannot move independently, it does not align with the plan for isometric exercises, which focus on muscle contraction without joint movement.

B. Have the client move each limb independently through its complete range of motion: This describes active range-of-motion exercises, which involve the client actively moving their limbs. Although these exercises are important for maintaining joint flexibility and preventing stiffness, they are not isometric exercises, which are intended to be performed without changing the length of the muscle.

C. Ask the client to move her arms and legs while applying slight resistance: This action combines movement with resistance training, which is not consistent with isometric exercises. Isometric exercises focus solely on muscle contraction without joint movement or changing muscle length, making this option inappropriate for the prescribed plan of care.

D. Instruct the client to tighten muscle groups for a short period, and then relax: This accurately describes isometric exercises, where the client contracts specific muscle groups (e.g., arms, legs, abdomen) without moving the joints. These exercises help maintain muscle strength and prevent atrophy while the client is on bedrest. The nurse should guide the client to perform these contractions for a few seconds, followed by relaxation, as directed by the plan of care.

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The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client? (Select All that Apply.)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Correct Answer is D

Explanation

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