A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

Ask the client's closest kin to convince him to stop fasting due to his injuries.

Encourage the client to stop fasting, as it will delay the wound healing process.

Call dietary to reschedule the client's meals.

Start enteral tube feedings if the client refuses to take food orally.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Asking the client's closest kin to convince him to stop fasting due to his injuries is not an appropriate action. Respecting the client's religious beliefs and practices is crucial, and attempting to persuade the client to stop fasting would infringe upon their autonomy and cultural values.

Choice B rationale:

Encouraging the client to stop fasting goes against respecting the client's religious observance and autonomy. The nurse should prioritize culturally competent care and support the client in their religious practices, while also ensuring their nutritional needs are met.

Choice C rationale:

Calling dietary to reschedule the client's meals might seem like a reasonable action, but it does not address the client's religious needs or their wound healing process. Ramadan fasting is an important religious practice, and the nurse should find a way to accommodate the client's fasting while also ensuring appropriate nutritional support.

Choice D rationale:

Starting enteral tube feedings if the client refuses to take food orally is the correct action. Beneficence, a principle of ethical nursing care, emphasizes promoting the well-being of the patient. In this case, the nurse should prioritize the client's wound healing by ensuring they receive necessary nutrition through enteral feeding while still respecting their fasting during Ramadan.

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Correct Answer is D

Explanation

Choice A rationale:

A macular rash on the chest and back is not indicative of a paradoxical drug reaction to lorazepam, a benzodiazepine. Paradoxical reactions involve unexpected and opposite responses to a medication, such as increased agitation and excitement instead of the intended calming effect. A rash is not consistent with this type of reaction.

Choice B rationale:

Increased appetite is not associated with a paradoxical drug reaction to lorazepam. Paradoxical reactions involve behavioral and physiological responses that are contrary to the expected effects of the medication. Increased appetite does not fit this pattern.

Choice C rationale:

Drowsiness and mild sedation are the intended effects of lorazepam, a benzodiazepine. Paradoxical reactions are characterized by unexpected and opposite responses. Drowsiness and mild sedation align with the expected pharmacological actions of benzodiazepines, making this choice incorrect for a paradoxical reaction.

Choice D rationale:

Increased agitation and insomnia are indicative of a paradoxical drug reaction to lorazepam. Benzodiazepines like lorazepam are central nervous system depressants and are commonly used to treat anxiety and promote sedation. However, in some cases, paradoxical reactions can occur, leading to increased agitation, excitement, and even insomnia. These reactions are thought to be more common in children and older adults. This choice is correct because it aligns with the characteristics of a paradoxical reaction.

A. Clean the wound by scrubbing the site with gauze. B. Massage reddened areas with dressing changes. C. Reposition the client at least every 2 hours. D. Apply a heat lamp twice a day.

Correct Answer is C

Explanation

Choice A rationale:

Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.

Choice B rationale:

Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.

Choice C rationale:

(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.

Choice D rationale:

Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.

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A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

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Naxlex Comprehensive Predictor Exams

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

Correct Answer is D

Explanation

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Correct Answer is C

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