A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?

Dietary salt restriction

Absence of symptoms

Addition of a new medication

A detailed plan of care

Answer and Explanation

The Correct Answer is B

A. Dietary salt restriction can be challenging, but patients often adapt over time with education and support; it is not usually the greatest barrier.

B. Many clients with high blood pressure feel well despite elevated readings, so the absence of symptoms can lead them to underestimate the seriousness of their condition and skip medications, making this the most significant barrier.

C. Adding a new medication may complicate the regimen, but understanding its purpose can improve adherence; it is less influential than asymptomatic disease.

D. A detailed plan of care is intended to guide the client, and while complexity can be a barrier, it is typically easier to address with education and support than the lack of perceived need due to no symptoms.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Administering methylergonovine maleate is indicated if the uterus is boggy (atonic), as it helps to contract the uterus and reduce the risk of postpartum hemorrhage.

B. Massaging a firm fundus is not appropriate; instead, the nurse should massage a boggy (soft) fundus to promote uterine contraction.

C. Documenting fundal height is a necessary action to assess uterine involution and ensure it is progressing as expected after delivery.

D. Observing the lochia during palpation of the fundus is important to assess for any abnormal findings, such as heavy bleeding, which could indicate complications.

E. Determining whether the fundus is midline is crucial; a displaced fundus may indicate bladder distention, which can affect uterine contraction.

A. Assess a client who has hypomania for exhaustion B. Accompany a client who has depression to occupational therapy C. Check the position of a client in soft wrist restraints D. Sit with a client who has alcohol use disorder and whose last drink was five days ago E. Set limits with a client who has mania

Correct Answer is D

Explanation

Assessing a client requires clinical judgment and should not be delegated to an AP.

B. Accompanying a client to occupational therapy is a task that can be safely assigned to an AP as it does not require clinical judgment.

C. Checking the position of a client in soft wrist restraints is a routine task that can be assigned to an AP as long as the AP has been trained in restraint protocols.

D. Sitting with a client who has alcohol use disorder (5 days after their last drink) is a task that an AP can perform, especially if the client does not require close monitoring for medical complications such as delirium tremens.

E. Setting limits with a client requires therapeutic communication skills and clinical judgment, so this should not be delegated to an AP.

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A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D","E"]

Explanation

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Correct Answer is D

Explanation

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