A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?
Patient will increase activity level this shift.
Patient will turn side to back to side with assistance every 2 hours.
Patient will use the walker correctly to ambulate to the bathroom as needed.
Patient will use a sliding board correctly to transfer to the bedside commode as needed.
The Correct Answer is B
A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Multipersonal connectedness involves relationships with multiple people, which is not the focus of the nurse-patient connection in spiritual care.
B. Transpersonal connectedness refers to a connection that goes beyond the physical and mental levels, fostering a deeper spiritual relationship between the nurse and the patient, often characterized by empathy and understanding.
C. Interpersonal connectedness describes the relationship between individuals, focusing on social and emotional interactions, but does not encompass the spiritual dimension.
D. Intrapersonal connectedness relates to an individual's self-awareness and inner thoughts, not the connection with another person in a spiritual context.
Correct Answer is C
Explanation
A. Weak quadriceps muscles can occur with electrolyte imbalances, but the provided values do not indicate hypokalemia or other issues causing muscle weakness.
B. Decreased deep tendon reflexes are generally associated with elevated calcium levels or other electrolyte disturbances but are not specifically indicated by the given lab values.
C. A calcium level of 4.5 mg/dL is significantly low (normal range is typically around 8.5-10.5 mg/dL), which can lead to hypocalcemia symptoms such as tingling of the extremities and tetany due to increased neuromuscular excitability.
D. Light-headedness when standing up (orthostatic hypotension) is more related to fluid volume status or dehydration rather than directly related to the given electrolyte levels.
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