A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?
Advise the UAP to resume positioning the client on schedule.
Encourage the UAP to provide comfort care measures only.
Assume total care of the client to monitor neurologic function.
Assign a practical nurse to assist the UAP in turning the client.
The Correct Answer is A
Choice A: Advise the UAP to resume positioning the client on schedule.
Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.
Choice B: Encourage the UAP to provide comfort care measures only.
Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.
Choice C: Assume total care of the client to monitor neurologic function.
Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.
Choice D: Assign a practical nurse to assist the UAP in turning the client.
Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Reducing the risk for infection is important but not the primary goal for DJD as it is not primarily an infectious condition.
Choice B reason: Achieving satisfactory pain control is the primary goal in the management of DJD to improve the client's quality of life and functional ability.
Choice C reason: Obtaining adequate rest and sleep is beneficial for overall health but is secondary to pain control in the management of DJD.
Choice D reason: Improving stress management skills can help with overall well-being but is not the primary focus of care for a client with DJD.
Correct Answer is ["A","B","D","E","G"]
Explanation
Choice A reason: Learned coping skills are essential for managing the psychological aspects of obesity and the lifestyle changes required after bariatric surgery. The patient’s engagement with a psychologist and learning coping techniques can help her deal with postoperative stress and maintain the lifestyle modifications necessary for long-term success.
Choice B reason: A psychological assessment helps in understanding the patient’s readiness for surgery and ability to adhere to the postoperative regimen. It can identify any psychological barriers to weight loss and ensure that the patient is mentally prepared for the changes ahead.
Choice C reason: The term “unstained weight loss” seems to be a typographical error, possibly intending to mean “sustained weight loss.” However, sustained weight loss is not applicable in this context as the patient has not yet undergone surgery. Therefore, it does not contribute to the chances of positive outcomes post-surgery.
Choice D reason: Recovery close to the hospital can be beneficial as it allows for easier follow-up visits and quicker access to medical care if complications arise. It also reduces the stress associated with travel for postoperative care.
Choice E reason: Recent weight loss prior to surgery is a positive indicator as it shows the patient’s commitment to lifestyle changes and weight management. It can also reduce surgical risk and improve postoperative recovery1.
Choice F reason: While age can be a factor in surgical risk, there is no direct correlation between the client’s age and the chance for positive outcomes after bariatric surgery. Therefore, it is not a contributing factor in this scenario.
Choice G reason: Family support is crucial for a patient’s recovery and long-term success after bariatric surgery. The patient’s plan to go home with her mother, who lives close to the hospital, indicates a strong support system which can help with adherence to dietary and lifestyle changes.
Choice H reason: A high BMI, such as 41.4 kg/m^2, indicates severe obesity, which is the reason for undergoing bariatric surgery. While it is a factor for considering surgery, it does not inherently increase the chance for positive outcomes post-surgery.
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