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 B

Explanation

A. Twist at the waist when she moves an object to one side: Twisting at the waist can place excessive strain on the lower back and increase the risk of injury. Instead, the client should pivot her whole body to move an object, which helps maintain spinal alignment and reduces strain.

B. Bend at the knees when picking up an object: This instruction is crucial for preventing back strain. Bending at the knees allows the client to use her legs' strength to lift the object rather than putting pressure on the back. This technique helps protect the spine and promotes safe lifting practices.

C. Hold an object away from her body as she lifts it: Holding an object away from the body increases leverage and strain on the back muscles. The client should keep the object close to her body while lifting to maintain better balance and reduce the risk of injury.

D. Relax her abdominal muscles when she lifts an object: Engaging the abdominal muscles provides support to the spine during lifting. Relaxing the abdominal muscles can lead to a lack of core stability, increasing the risk of back injury. The client should be encouraged to engage her core muscles while lifting.

A. Diarrhea B. Contractures of the extremities C. Polyuria D. Pressure ulcers E. Crackles in the lungs

Correct Answer is ["B","D","E"]

Explanation

A. Diarrhea: Diarrhea is not a typical finding associated with immobility. In fact, immobility often leads to constipation due to decreased gastrointestinal motility. Factors such as diet and medication can influence bowel habits, but diarrhea is not a direct complication of immobility.

B. Contractures of the extremities: Contractures are a common complication of immobility. When a joint is not moved regularly, the muscles and tissues can shorten, leading to stiffness and loss of mobility in the affected area. This is especially common in patients who are bedridden or have limited range of motion.

C. Polyuria: Polyuria, or increased urine output, is not typically associated with immobility. Immobility can lead to decreased kidney function and fluid retention, potentially resulting in oliguria (decreased urine output) rather than polyuria.

D. Pressure ulcers: Pressure ulcers, also known as bedsores, are a significant risk for individuals with limited mobility. They develop due to prolonged pressure on the skin, particularly over bony prominences, leading to skin breakdown and tissue damage. Regular repositioning and skin care are essential to prevent this complication.

E. Crackles in the lungs: Crackles can be heard during auscultation in patients who are immobile. They may develop due to fluid accumulation in the lungs, atelectasis (collapse of lung tissue), or pneumonia, which are all more likely to occur in individuals with limited mobility. Immobility can impair respiratory function, leading to these complications.

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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?

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Explanation

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Correct Answer is ["B","D","E"]

Explanation

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