A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?
Use a cushion when sitting.
Perform range of motion exercises.
Document abdominal girth.
Weigh every morning.
The Correct Answer is D
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
A. Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.
B. Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.
C. Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of fluid status.
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Related Questions
Correct Answer is C
Explanation
Instruct the UAP to lower the bed for safety.
This is the best action for the PN to take because it ensures the client's safety and prevents potential falls or injuries. The PN should also educate the UAP on the importance of lowering the bed when providing care to a bedfast client.
A. Assuming care of the client immediately is not necessary and may undermine the UAP's confidence and competence.
B. Remaining in the room to supervise the UAP is not appropriate and may interfere with the client's privacy and dignity.
D. Determining if the UAP would like assistance is not a priority and may not address the safety issue.
Correct Answer is A
Explanation
Glaucoma is a group of eye diseases that damage the optic nerve and cause vision loss. It is often associated with increased intraocular pressure, which can compress the nerve fibers and reduce blood flow to the retina. The most common type of glaucoma, open-angle glaucoma, causes gradual loss of peripheral vision.
The other options are not correct because:
- Macular edema is a condition that causes swelling and fluid accumulation in the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, but it does not affect the optic nerve or the peripheral vision.
- Cataract is a condition that causes clouding of the lens, which is the transparent structure that focuses light onto the retina. It can cause blurred, dim, or yellowed vision, but it does not affect the optic nerve or the intraocular pressure.
- Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina and causes bleeding, leakage, or scarring. It can cause blurred, fluctuating, or darkened vision, but it does not affect the optic nerve or the intraocular pressure.
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