A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?
Tolerates physical discomforts
Performs self-care independently
Begins reconnecting with their partner
Is eager to review the birth experience
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I might have occasional seizures for several days after the procedure." This statement is not accurate. ECT does induce a controlled seizure during the procedure, but clients typically do not experience seizures after the treatment. This statement does not indicate an understanding of the procedure.
Choice B Reason:
"I might have short-term memory loss after the procedure. “This statement is accurate. Memory loss is a common side effect of ECT, particularly short-term memory loss. It's important for the client to be aware of this potential side effect.
Choice C Reason:
"I will have a urinary catheter in place during the procedure." This statement is not accurate. A urinary catheter is not typically used during ECT. It's important for the client to have accurate information about the procedure.
Choice D Reason:
"I will need to follow a full-liquid diet for 24 hours after the procedure." This statement is not accurate. Clients undergoing ECT do not usually require a full-liquid diet afterward. The dietary restrictions may vary depending on the facility's policies, but it is not typically a full-liquid diet.
Correct Answer is A
Explanation
Choice A Reason:
Planning to remove the restraints as soon as the client is calm is a correct action. Restraints should be used for the shortest duration necessary to ensure safety. Once the client is calm and no longer poses a risk to themselves or others, the restraints should be removed promptly.
Choice B Reason:
Ensuring that the provider has signed a prescription for restraints within 48 hr is incorrect. Restraints should never be applied without a proper prescription or order from a qualified healthcare provider. The provider's order should be obtained before applying restraints, not within 48 hours afterward.
Choice C Reason:
Offering the client, a nutritious snack every 4 hr is unrelated to the use of physical restraints and should not be the nurse's priority in this situation. The focus should be on ensuring the client's safety and addressing their behavior.
Choice D Reason:
Monitoring the client's range of motion every 60 min is a correct action. When a client is restrained, it's essential to monitor their physical well-being regularly. Monitoring range of motion helps ensure that the restraints are not causing harm or discomfort to the client. The specific time interval for monitoring may vary by facility policy but should be frequent enough to assess the client's condition effectively.
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