A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Engage the client in relaxation exercises.

Offer to sit with the client until she relaxes.

Administer a prescribed PRN analgesic.

Assist the client to a different position.

Answer and Explanation

The Correct Answer is D

A. Engaging the client in relaxation exercises may be helpful but should be considered after addressing potential physical causes of discomfort, such as positioning.
B. Offering to sit with the client is supportive, but the primary issue of physical discomfort should be addressed first.
C. Administering a PRN analgesic may be necessary if the discomfort persists, but repositioning the client is a less invasive intervention to try first.
D. Assisting the client to a different position is the first action the nurse should take. A change in position can often alleviate discomfort for bedfast clients and is a simple, non-invasive intervention.

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Correct Answer is B

Explanation

A. Including the caregiver in discussions about pain relief strategies is important, but addressing the client’s immediate concerns and fears should come first.
B. Encouraging the client to talk about her fear related to pain allows the nurse to understand her specific concerns and provide personalized reassurance and support. Addressing the client’s emotional needs is crucial in hospice care.
C. Explaining that analgesics will be given as needed is important for reassurance but may not fully address the client’s fear or allow for an open discussion about her concerns.
D. Providing therapeutic touch and comfort is supportive but does not directly address the client’s fear. Engaging in a conversation about her specific fears allows for more targeted and effective reassurance.

A. Avoids adjusting the height of the hand grips. B. Holds the crutch 6 inches (15 cm) to the side. C. Fits the crutch 2 finger widths from axilla. D. Walks with the arms fully extended.

Correct Answer is C

Explanation

A. Adjusting the hand grips is necessary to ensure that the client can bear weight comfortably through the arms without placing stress on the wrists or shoulders, so avoiding this adjustment is incorrect.
B. Holding the crutch 6 inches to the side is a common guideline, but it is not as crucial as ensuring the correct fit of the crutches to avoid axillary nerve damage and ensure proper posture.
C. The crutch should fit 2 finger widths below the axilla to prevent pressure on the brachial plexus nerves, which can lead to nerve damage. This demonstrates an understanding of proper crutch fit and use.
D. Walking with the arms fully extended is incorrect; the arms should be slightly bent at the elbows to allow for proper weight distribution and movement.

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A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

Correct Answer is C

Explanation

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