A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:
Encourage the client to increase physical activity and engage with peers.
Suggest the client remain in bed to avoid unnecessary exertion.
Teach the caregiver how to monitor for signs of infection in pressure injuries.
Assist the client in using the restroom to avoid incontinence.
Correct Answer : A,C,D
The correct answers are Choices A, C, and D.
Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.
Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.
Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.
Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale: Involving the mother in the decision-making process can help reduce caregiver stress by sharing the responsibility and ensuring that the client's preferences and needs are considered. This collaborative approach can lead to better outcomes and improved communication.
Choice B rationale: It is important to acknowledge that caregiving can be challenging and can affect emotions. Recognizing that it is okay to have complex feelings, including not always loving or liking the person being cared for, helps normalize these emotions and reduces guilt and stress.
Choice C rationale: Moving a loved one into a care facility can be a difficult decision, but it does not necessarily mean a lack of love. However, this statement is not appropriate as it may reinforce negative emotions and guilt.
Choice D rationale: Avoiding the discussion of negative situations that may occur in the future is not helpful. It is important to plan for potential challenges to be prepared and reduce stress.
Choice E rationale: Saying "no" to things involving the care of a loved one is not selfish. It is important to set boundaries and prioritize self-care to prevent caregiver burnout. However, this statement suggests the opposite and is not appropriate.
Choice F rationale: Taking time for oneself and maintaining other important relationships is essential for a caregiver's well-being. Self-care and social support can help reduce stress and improve the ability to provide care effectively.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Noting the date and time of the behavior is the first step in addressing the issue, providing a record for future reference and ensuring accuracy in documentation.
Choice C rationale
Planning for scheduled break times helps address potential reasons for the behavior, offering a structured solution to prevent recurrence and improve overall workflow.
Choice B rationale
Evaluating the UAP for signs of improvement is the final step, assessing whether the implemented interventions have been effective and if further actions are needed.
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