A nurse is making a follow-up call to client who has a new prescription for ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

A) You should avoid exercising for the next 6 weeks:
This statement is not accurate. The client is encouraged to gradually increase activity and participate in physical therapy as prescribed to improve mobility and strength following a total hip arthroplasty. While some rest and limited activity may be necessary immediately after surgery, complete avoidance of exercise for six weeks is generally not advised unless there are complications. Physical therapy exercises are often a key component in the recovery process after hip replacement surgery.

B) You should avoid lying on your right side:
This recommendation is incorrect unless specifically contraindicated due to complications. After a right total hip arthroplasty, the client can typically lie on either side once they are comfortable, unless instructed otherwise by the healthcare provider. It is important to follow the surgical instructions regarding positioning, especially avoiding positions that might place stress on the new joint

C) You should avoid putting a pillow between your legs when in bed:
This statement is incorrect. After a total hip arthroplasty, placing a pillow between the legs when lying on either side is recommended to maintain proper alignment of the hip joint and prevent dislocation. The pillow helps keep the legs slightly apart, preventing the hip from rotating inward, which can put the new joint at risk for dislocation.

D) You should avoid crossing your legs formonths:
This is correct. Following a total hip arthroplasty, it is essential to avoid crossing the legs, especially for the first several months. Crossing the legs can lead to hip dislocation or improper alignment of the joint. The nurse should reinforce the importance of avoiding crossing the legs both while sitting and lying down to ensure proper healing and to avoid complications such as dislocation of the new hip joint.

A) "Request the client’s caregivers to remain with the client.": While having caregivers present can provide some emotional support, this is not a sufficient or appropriate intervention when a client is actively expressing intent to self-harm. Caregivers may not be trained to recognize subtle changes in the client’s condition, and they might not be able to provide the level of safety required. It is essential that a trained nurse or professional provides direct observation.

B) "Notify the supervisor that the client requires one-to-one nursing observation.": This is the most appropriate and immediate action when a client verbalizes a clear intent to self-harm. One-to-one nursing observation ensures that the client is under constant surveillance, which is crucial for preventing harm and providing immediate intervention if the client attempts to act on their suicidal thoughts.

C) "Assign the client to a private room.": Assigning the client to a private room is not a recommended action when the client is expressing intent to self-harm. In fact, isolation in a private room could increase the risk of harm. The priority is to ensure the client is closely monitored, and being placed in a private room may reduce the ability for staff to observe and intervene as needed.

D) "Increase the frequency of client assessment to hourly.": While increasing the frequency of assessments is important, it is not sufficient to prevent self-harm in a client who is at immediate risk. The client needs continuous observation to ensure their safety. One-to-one nursing observation is more effective than periodic assessments for clients with active suicidal ideation or intent.