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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I will be back in 30 minutes to help you get out of bed and walk around the room today.”.
Choice B rationale:
Telling the client that she must ambulate to avoid complications (Choice B) may be true, but it comes across as authoritarian and may further upset the client. It is essential to address the client's feelings of anger and approach the situation with empathy and understanding.
Choice C rationale:
Acknowledging the client's anger about the pain of ambulation (Choice C) is a good start, but it is not enough. The nurse should follow up with a plan to assist and encourage the client to walk later, promoting collaboration in the healing process.
Choice D rationale:
Informing the client about specific instructions to ambulate (Choice D) is important, but the response lacks empathy and fails to address the client's feelings. The nurse needs to consider the client's mental disability and approach the situation with sensitivity.
Correct Answer is A
Explanation
Choice A rationale:
Pantoprazole is a proton pump inhibitor used to treat GERD by reducing stomach acid production. If the client reports not experiencing heartburn after eating lunch, it indicates that the medication is effectively reducing stomach acid and alleviating GERD symptoms.
Choice B rationale:
The ability to swallow food without difficulty is not directly related to the desired effect of pantoprazole. It may be an important aspect of the client's overall condition, but it does not specifically indicate the efficacy of the medication in treating GERD.
Choice C rationale:
Having no difficulty straining for a bowel movement is unrelated to the desired effect of pantoprazole in treating GERD. Pantoprazole does not directly influence bowel movements.
Choice D rationale:
Having a great appetite and feeling hungry are not relevant indicators of the effectiveness of pantoprazole in treating GERD. These statements are more related to the client's appetite and overall well-being rather than the response to the medication.
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