A nurse is caring for a patient with a BMI of.
Appropriate nursing interventions include:
Hourly vital signs.
Implementing all fall risk precautions.
Utilizing bariatric bed and trapeze bar.
Supine positioning.
The Correct Answer is C
A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.
These interventions can promote comfort, safety, and independence for the patient.
Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.
Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.
Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.
The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.
Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.
Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.
Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.
Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.
Correct Answer is D
Explanation
This is because fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia often co-exists with other conditions, such as irritable bowel syndrome, chronic fatigue syndrome, migraine and other types of headaches. One of the main symptoms of fibromyalgia is widespread pain that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist. The pain could also be felt in specific areas called tender points. These are places on the body where even light pressure causes pain. There are 18 possible tender points on the body. Having pain in at least 11 of these points is one way to help diagnose fibromyalgia.
Choice A is wrong because chronic ocular pain related to stress, fatigue, and certain triggers is not a typical symptom of fibromyalgia.
Ocular pain is more likely to be caused by other conditions, such as dry eye syndrome, glaucoma, or eye infections.
Choice B is wrong because pain and sensitivity in the upper extremities and neck are not enough to indicate fibromyalgia. The pain must be widespread and affect both sides of the body and above and below the waist. Choice C is wrong because dull joint pain that accompanies physical exertion and which is relieved with rest is not a characteristic of fibromyalgia. The pain associated with fibromyalgia is often described as a constant dull ache that does not improve with rest. It may also be accompanied by other symptoms, such as fatigue, cognitive difficulties, and sleep problems.
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