A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?
Check on the client every 10 min during the bath.
Add bath oil to the water after the client gets into the tub.
Drain the tub water before the client gets out.
Allow the client to remain in the bath for 30 min.
The Correct Answer is C
Answer is: Drain the tub water before the client gets out.
Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:
- Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort. The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
- Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling. The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
- Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation. The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Maintaining abduction of the residual limb with a pillow is not relevant to promoting mobility and independence for a client with an above-the-knee amputation.
B. Correct. Encouraging the client to use the overbed trapeze can help the client perform upper body movements and reposition independently, which is essential for maintaining mobility.
C. Incorrect. Avoiding a prone position may not be necessary for the client after an above-the-knee amputation and does not directly contribute to mobility and independence.
D. Incorrect. Keeping a loose, absorbent dressing over the surgical site is important for wound care, but it does not directly promote mobility and independence.
Correct Answer is D
Explanation
A. Incorrect. The Patient Health questionnaire is used to assess depression severity.
B. Incorrect. The Mental Status Examination assesses cognitive function and psychiatric symptoms.
C. Incorrect. The Brief Psychiatric Rating Scale assesses psychiatric symptoms but not specifically tardive dyskinesia.
D. Correct. The Abnormal Involuntary Movement Scale (AIMS. is specifically designed to screen for and assess the severity of tardive dyskinesia, which is a movement disorder associated with antipsychotic medications.
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