A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client’s bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?
To help the nurse validate the client’s reports of pain
To increase positive pressure in the chest
To assist the client with ADLS
To modify the client’s perception of pain
The Correct Answer is C
A. To help the nurse validate the client’s reports of pain
This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.
B. To increase positive pressure in the chest
This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.
C. To assist the client with ADLs (Activities of Daily Living)
This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.
D. To modify the client’s perception of pain
This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I will call for pain medication before the previous dose wears off.”
The statement "I will call for pain medication before the previous dose wears off" indicates an understanding of proactive pain management. In postoperative pain control, it is generally more effective to stay ahead of the pain by taking pain medication on a scheduled basis rather than waiting until the pain becomes severe. This approach helps to maintain a more consistent level of pain relief.
B. “I will call for pain medication as my pain becomes intolerable.”
Waiting until the pain becomes intolerable may result in suboptimal pain control. It's more effective to take pain medication before reaching a point of intolerable pain.
C. “I will wait for you to evaluate my pain before asking for more.”
Waiting for the nurse to evaluate pain before requesting more medication may result in delays in pain relief. Pain management often involves collaboration between healthcare providers and patients, and timely communication about pain levels is essential.
D. “I will ask for less medication to avoid addiction.”
This statement reflects a concern about addiction but may lead to inadequate pain relief. Pain management should prioritize effective pain control while balancing the risks and benefits of medications. The goal is to provide sufficient pain relief without compromising the client's well-being.
Correct Answer is A
Explanation
A. Fiber
For a client with hypothyroidism, the nurse should reinforce the importance of increasing daily intake of fiber. Hypothyroidism can sometimes lead to constipation, and a diet rich in fiber can help alleviate this symptom.
B. Monounsaturated fats
While monounsaturated fats are considered heart-healthy and can be included in a balanced diet, they are not particularly emphasized or increased for clients with hypothyroidism.
C. Protein
Adequate protein intake is important for overall health, but there is no specific recommendation to increase protein intake solely because of hypothyroidism.
D. Polyunsaturated fats
Similar to monounsaturated fats, polyunsaturated fats are part of a healthy diet, but there is no specific emphasis on increasing their intake for clients with hypothyroidism.
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