A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding effectively?

d. Apply the dressing loosely over the incision.

Explanation:

The correct answer is d. Apply the dressing loosely over the incision.

When caring for an older adult client, it is important for the nurse to be sensitive to age-related changes and promote their comfort and well-being. Applying the dressing loosely over the incision allows for beter circulation and ventilation, which can help prevent complications such as skin breakdown and infection.

Option a is not the correct answer. Asking the client to help with the dressing change may not be appropriate, as postoperative clients, especially older adults, may have limited mobility or dexterity. It is the nurse's responsibility to provide the necessary care and support during the dressing change.

Option b is not the correct answer. Waiting for the client to approach the nurse for assistance may lead to delays in care and could potentially compromise the client's healing process. The nurse should proactively assess the client's needs and provide appropriate care.

Option c is not the correct answer. Using paper tape for securing the new dressing does not specifically address sensitivity to age-related changes. While paper tape may be gentle on the skin, it is not the primary consideration in this situation.

By applying the dressing loosely over the incision, the nurse demonstrates sensitivity to age-related changes and promotes the client's comfort and optimal healing. This approach takes into account the potential for decreased skin elasticity and fragility in older adults, allowing for proper circulation and reducing the risk of complications.

Answer: A. Frequently remind the client of the expectations for her behavior.

Rationale:

A) Frequently remind the client of the expectations for her behavior:

Clients experiencing mania may have difficulty maintaining appropriate behavior due to their heightened energy levels and impulsivity. Frequently reminding them of behavioral expectations helps provide structure and boundaries, which can promote a safer and more controlled environment.

B) Encourage the client to participate in a group activity in the dayroom:

While social interaction can be beneficial, clients in a manic state might be overly stimulated by group activities. This can exacerbate their symptoms, leading to increased agitation or disruptive behavior. It's often more appropriate to provide a calm and low-stimulation environment.

C) Allow the client to pick her own choice of clothing:

Allowing a manic client to choose their own clothing can lead to choices that are inappropriate for the setting or the weather, as judgment may be impaired during mania. Providing guidance in clothing choices can help ensure the client is dressed suitably and safely.

D) Encourage the client to increase physical activity during the day:

While physical activity is generally beneficial, clients in a manic state may already be overly active and may not need encouragement to increase their activity. Overexertion can lead to exhaustion and further exacerbate manic symptoms. It is often more beneficial to encourage activities that promote relaxation and calmness.