A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?

Loosen the client's bed linens.

Provide bright lights in the client's room.

Massage the client's sacrum.

Offer to play music in the client's room.

Answer and Explanation

The Correct Answer is D

A. Loosen the client's bed linens:

For support surfaces to be effective, there must be minimal layering in between the device and the person. A single sheet that can be kept dry and crease free is optimal. Loosening linens can help make the client more comfortable by reducing pressure and friction on the skin, but it does not directly address the client's acute pain from a pressure injury.

B. Provide bright lights in the client's room:

Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.

C. Massage the client's sacrum:

Massaging the client's sacrum is not recommended when there is a pressure injury, as this could further damage the tissue and exacerbate the injury.

D. Offer to play music in the client's room:

Music therapy is a widely recognized nonpharmacological intervention for pain management. Listening to music can reduce the perception of pain by distracting the client, promoting relaxation, and triggering the release of endorphins. This approach is safe, inexpensive, and can be tailored to the client’s preferences.

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Correct Answer is B

Explanation

A. Whisper a series of words softly into one ear.

Explanation: Whispering words into one ear is not part of Weber's test. This action is more relevant to the assessment of hearing acuity and not the lateralization of sound. Weber's test focuses on the perception of sound in relation to both ears, not the ability to hear whispered words.

B. Place an activated tuning fork in the middle of the client's forehead.

Explanation: In Weber's test, a tuning fork is placed in the middle of the client's forehead. The test is designed to assess whether sound lateralizes (moves) to one ear or is heard equally in both ears. If the client perceives the sound more in one ear than the other, it may indicate a hearing imbalance or issue.

C. Deliver a series of high-pitched sounds at random intervals.

Explanation: Delivering high-pitched sounds at random intervals is not part of Weber's test. Weber's test involves a single action – placing an activated tuning fork in the middle of the client's forehead. The purpose is to determine if the client perceives the sound equally in both ears or if there is lateralization. Random intervals and high-pitched sounds are not specified components of this test.

D. Hold an activated tuning fork against the client's mastoid process.

Explanation: While holding a tuning fork against the mastoid process is part of another hearing test called the Rinne test, it is not the appropriate action for the Weber's test. The Rinne test compares air conduction (using the tuning fork near the ear) to bone conduction (using the tuning fork against the mastoid process) to evaluate hearing in each ear. In Weber's test, we are specifically interested in lateralization of sound, not comparing air and bone conduction.

Solved] In Weber's test, lateralization of sound to diseased ear

A. Lactose intolerant, B. Alcohol use C. Smoking history D. Phosphorous level E. Activity level F. Vitamin D level

Correct Answer is ["A","B","C","F"]

Explanation

Correct responses

A. Lactose intolerant: Lactose intolerance can lead to lower dairy intake, which may reduce calcium intake, increasing the risk of osteoporosis.

B. Alcohol use: Excessive alcohol consumption can interfere with calcium absorption and bone health, increasing the risk of osteoporosis.

C. Smoking history: Smoking is associated with decreased bone density and increased risk of osteoporosis due to its negative effects on bone metabolism.

F. Vitamin D level: The client's vitamin D levels are below the recommended range. Vitamin D is crucial for calcium absorption and bone health, so insufficient levels can increase the risk of osteoporosis.

The other factors are less directly related to osteoporosis risk in this client:

D. Phosphorous level: The phosphorous level is within the normal range and is not directly linked to osteoporosis risk.

E. Activity level: The activity level is not provided in the information; however, physical activity is generally important for bone health. If the client is sedentary, it could be a risk factor, but it's not specified here.

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A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?

Nursing Test Bank

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A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Correct Answer is B

Explanation

A nurse in a provider's office is caring for a client. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)

Correct Answer is ["A","B","C","F"]

Explanation

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