A. Improving stress management skills might be beneficial for overall well-being, but it's not the primary goal in managing degenerative joint disease (DJD. Stress management could be a
secondary intervention to support pain management, but it's not the primary goal.
B. Achieving satisfactory pain control is crucial because pain management is a primary concern for clients with degenerative joint disease (DJD. It directly addresses the client's comfort and
quality of life.
C. While reducing the risk for infection is important in nursing care, it's not the primary goal specifically related to degenerative joint disease (DJD. Infection prevention measures are
important for overall health but aren't directly addressing the primary concern of pain management.
D. Obtaining adequate rest and sleep is important for overall health, but it's not the primary goal when planning nursing care for a client with degenerative joint disease (DJD. Pain control
typically takes precedence in the care plan because pain can significantly impact rest and sleep.

A. Observing body language and movement can provide valuable information about pain, but it doesn't directly assess the quality of the pain. It's more indicative of the client's physical response to pain rather than the pain itself.
B. Identifying effective pain relief measures is important for pain management but doesn't directly assess the quality of the pain. This approach focuses on interventions rather than understanding the nature of the pain.
C. Providing a numeric pain scale can quantify the intensity of pain, but it doesn't necessarily assess the quality of the pain. While useful for tracking pain levels over time, it doesn't provide insights into the characteristics or nature of the pain.
D. Asking the client to describe the pain allows for a subjective assessment of its quality,
intensity, duration, and any associated symptoms. This approach provides valuable information for tailoring pain management strategies and understanding the client's experience.

A. Administering the placebo as prescribed when the client reports pain is ethically questionable.
Placebos are typically used in research or clinical trials and should not be administered without the client's informed consent and understanding.
B. While informing the charge nurse about the prescribed placebo is appropriate, refusing to administer it without further action may not address the ethical concerns surrounding placebo use.
C. Informing the client that the provider prescribed a placebo instead of pain medication is important for transparency and informed consent. However, this should be accompanied by discussing the ethical considerations with the healthcare provider.
D. Discussing ethical concerns about placebo use with the healthcare provider is the most appropriate intervention. This ensures that the nurse advocates for the client's well-being and addresses any potential ethical issues surrounding the use of placebos in pain management.

A. Providing protective undergarments may be necessary as a temporary measure to manage urinary incontinence, but it does not address the underlying cause. It should not be the initial intervention.
B. Encouraging increased fluid intake may exacerbate urinary incontinence if the cause is related to an overactive bladder or other urinary tract issues. It's important to determine the cause before recommending changes in fluid intake.
C. Evaluating the client's response to bladder training efforts is a relevant intervention for urinary incontinence, but it assumes that bladder training is appropriate for the client's condition. Before initiating bladder training, it's essential to assess the client's condition through proper evaluation.
D. Obtaining a clean, voided urine specimen for analysis is the priority intervention. It allows for diagnostic testing to identify potential causes of urinary incontinence, such as urinary tract
infections, urinary retention, or other underlying medical conditions. Once the cause is determined, appropriate interventions can be implemented, which may include bladder training, medication, or other treatments.

A. Reinforcing bed rest until the analgesic is effective may not address the client's need to sit up and lean forward. It's important to respond to the client's discomfort and find a position that
provides relief.
B. Placing the bed in reverse Trendelenburg position (head elevated, feet lowered) may not be the most effective position for a client experiencing severe epigastric pain and nausea. This
position could potentially worsen symptoms or discomfort.
C. Raising the head of the bed to a 90-degree angle may not provide optimal relief for the client.
While it's essential to elevate the head of the bed for comfort and to prevent aspiration, it may not address the client's specific need to lean forward.
D. Positioning a bedside table for the client to lean across allows the client to assume a position that often provides relief for epigastric pain associated with pancreatitis. Leaning forward can
help reduce pressure on the pancreas and alleviate discomfort. This position also facilitates drainage of gastric contents and may help alleviate nausea.

A. Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA to help prevent airway obstruction during sleep. However, applying the
positive airway pressure device is a more immediate and direct intervention to ensure adequate breathing.
B. Removing dentures or other oral appliances may be necessary for comfort and safety during sleep, but it's not directly related to managing obstructive sleep apnea in this scenario.
C. Lifting and locking the side rails in place is a standard safety measure in healthcare settings but does not address the client's obstructive sleep apnea or ensure adequate ventilation.
D. Applying the client's positive airway pressure (PAP) device is the most important intervention before leaving the client. The PAP device helps maintain an open airway by delivering
continuous positive airway pressure, which is crucial for managing obstructive sleep apnea and preventing complications such as apnea episodes during sleep.

A. Asking the client how often episodes of sundowning are experienced is not relevant to a
functional assessment. Sundowning refers to increased confusion and agitation that typically occurs in the late afternoon or evening and is often associated with dementia.
B. Encouraging the client to lie as still as possible during the assessment may not provide accurate information about the client's functional status. It's important for the client to engage in activities that reflect their typical level of functioning.
C. Questioning the client about the frequency of falls in recent months is an essential component of a functional assessment, especially for an older adult being admitted to a rehabilitation facility.
Understanding the history of falls helps identify potential risk factors and informs the development of an appropriate care plan.
D. Assisting the client with values clarification about end-of-life care options is important but not typically part of a functional assessment focused on evaluating the client's physical and cognitive abilities.

A. Questioning the client about the frequency of falls in recent months is an essential component of a functional assessment, especially for an older adult being admitted to a rehabilitation facility.
Understanding the history of falls helps identify potential risk factors and informs the development of an appropriate care plan.
B. Asking the client how often episodes of sundowning are experienced is not relevant to a functional assessment. Sundowning refers to increased confusion and agitation that typically occurs in the late afternoon or evening and is often associated with dementia.
C. Assisting the client with values clarification about end-of-life care options is important but not typically part of a functional assessment focused on evaluating the client's physical and cognitive abilities.
D. Encouraging the client to lie as still as possible during the assessment may not provide accurate information about the client's functional status. It's important for the client to engage in activities that reflect their typical level of functioning.

- A) Magnesium level: While magnesium levels can affect cardiac and neuromuscular function, they are not the most critical assessment before potassium infusion. Hypomagnesemia may accompany hypokalemia, but the priority is ensuring renal function to avoid hyperkalemia.
- B) Size of the IV catheter: The size of the IV catheter is important for determining the flow rate of the infusion, but it is not the most critical assessment. The catheter size does not directly impact the safety of potassium administration.
- C)

Potassium chloride administration can cause hyperkalemia if the kidneys are not excreting potassium effectively. Ensuring adequate urinary output before infusion indicates the kidneys are functioning sufficiently to handle the potassium load, making this the most critical assessment.

- D) Serum glucose level:

Although glucose levels are monitored closely in DKA, they are not the primary concern before administering potassium chloride. The priority here is ensuring the kidneys can excrete potassium effectively, as hyperkalemia can be life-threatening.

A. Pulling the pinnae up and back helps straighten the ear canal in adults, allowing easier administration of the ear drops and better penetration into the ear canal. This technique is appropriate for adults.
B. Administering the drops with the head held upright may be necessary for some ear drop medications, but it is not the most appropriate technique for all types of ear drops.
C. Cooling and shaking the bottle before administering the drops may be necessary for certain types of medications but is not universally recommended for all ear drop preparations.
D. Inserting the tip of the dropper into the canal of the ear is appropriate for administering ear drops, but it should be accompanied by the correct technique of pulling the pinnae up and back to straighten the ear canal in adults.