A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, then relax.

Move the client's limbs through their complete range of motion.

Ask the client to move her arms and legs while applying slight resistance.

Have the client move each limb independently through its complete range of motion.

Answer and Explanation

The Correct Answer is A

A.   Isometric exercises involve contracting or tensing muscles without actually moving the joint. Instructing the client to tighten muscle groups for a short period and then relax is the correct approach for isometric exercises. This action helps activate and strengthen specific muscle groups without moving the joints.
B.   Moving the client's limbs through their complete range of motion is known as passive range of motion exercises. These exercises are important for maintaining joint flexibility but are not isometric.
C.   Asking the client to move her arms and legs while applying slight resistance is known as resisted range of motion exercises. These exercises involve active movement against resistance and are not considered isometric.
D.   Having the client move each limb independently through its complete range of motion is known as active range of motion exercises. These exercises involve voluntary
movement of each joint through its full range of motion and is not isometric.

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Correct Answer is B

Explanation

A. Requesting a prescription for an indwelling urinary catheter should be considered a last resort. Catheters come with risks of infection and other complications, so they should only be used when other interventions have failed.
B. Taking the client to the bathroom every 2 hours is a proactive approach to managing urinary incontinence in older adults with dementia. This helps ensure that the client has regular opportunities to empty their bladder, reducing the likelihood of accidents.
C. Reminding the client to tell the nurse when he has to urinate may not be effective in clients with dementia, as they may have difficulty recognizing or communicating their need to urinate.
D. Using adult diapers should also be considered a last resort and should not be the primary intervention. While they can provide a temporary solution, they do not address the underlying issue and can contribute to skin problems if not changed frequently.

A. Assessment B. Planning C. Implementation D. Evaluation

Correct Answer is A

Explanation

A. During the Assessment phase, the nurse gathers information about the client's health status, including any potential allergies. This information is crucial for planning safe and effective care.
B. The Planning phase involves developing a care plan based on the assessment data.
While allergies are an important consideration in planning care, they are first identified during the assessment phase.
C. The Implementation phase involves carrying out the care plan. While it is important to be aware of allergies during this phase to ensure the safe administration of treatments, the initial identification of allergies occurs in the assessment phase.
D. The Evaluation phase involves assessing the client's response to interventions and determining if goals have been met. While allergies are relevant in evaluating the client's response to certain treatments, they are initially identified during the assessment phase.

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A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?

Correct Answer is A

Explanation

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