Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?

2+ pitting edema of the feet.

Pallor.

Orthopnea.

Right-sided paralysis.

Answer and Explanation

The Correct Answer is C

A.   2+ pitting edema of the feet. While edema requires monitoring and may necessitate some adjustments in care, it does not directly impact the ability to provide a bed bath.
B.   Pallor. Pallor indicates potential anemia or poor circulation but does not directly impact the provision of a bed bath.

C.   Orthopnea. Orthopnea, difficulty breathing when lying flat, is critical to consider when planning a bed bath. The client may need to be positioned with the head elevated to facilitate breathing and ensure comfort during the bath.
D.   Right-sided paralysis. Paralysis requires careful handling to prevent injury, but it is not as

immediately critical to the bathing process as orthopnea, which directly affects the client's ability to breathe comfortably.

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Correct Answer is C

Explanation

Activity restriction does not directly decrease abdominal pain. Pain management in Crohn’s disease is typically achieved through medications, dietary adjustments, and addressing inflammation.

B. While activity restriction may indirectly help decrease abdominal pain by reducing inflammation and promoting healing, it is not the primary purpose of the restriction.
C.The primary goal of activity restriction in Crohn's disease is to reduce intestinal activity. By limiting physical exertion, the intestines are less stimulated, which can help reduce inflammation and give the digestive system a chance to rest and recover.
D. While activity restriction may help control diarrhea episodes by reducing physical stress on the intestines, the primary purpose is to promote healing and reduce inflammation. Control of diarrhea may be achieved through other interventions such as dietary modifications and
medication management.

A. A Repeated requests for attention from the nurse. B. B Periodic sighing and shaking the head. C. C Argumentativeness and use of profanity. D. D Decreased activity level and change in affect.

Correct Answer is C

Explanation

A. While repeated requests for attention from the nurse might indicate distress, they are not necessarily indicative of potential aggression or disruptive behavior.
B. Periodic sighing and shaking the head could suggest the client's emotional state, but they are not as indicative of potential aggression or disruptive behavior as argumentativeness and profanity.
C. Monitoring for argumentativeness and the use of profanity is crucial as they can escalate into disruptive or potentially aggressive behavior. It's important to assess the client's agitation level and ensure the safety of both the client and others on the mental health unit.

D. Decreased activity level and a change in affect may suggest a worsening of the client's mental state but are not immediate concerns in terms of safety on the unit.

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Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?

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Naxlex Comprehensive Predictor Exams

Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

Correct Answer is C

Explanation

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is C

Explanation

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