A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

Apply cold compress to the client's flank area

Restrict protein intake to 2 servings per day.

Encourage intake of at least 3 L of fluids per day

Discourage ambulation

Answer and Explanation

The Correct Answer is C

A. Apply cold compress to the client's flank area - Applying a warm compress, not a cold one, to the flank area can help alleviate pain associated with urolithiasis. Heat can promote muscle relaxation and increase blood flow to the area, potentially easing discomfort.

B. Restrict protein intake to 2 servings per day - There is no direct connection between protein intake and urolithiasis. However, specific dietary recommendations may vary based on the type of kidney stones a person has. For example, individuals with certain types of stones might be advised to limit oxalate-rich foods. It's essential to tailor dietary advice based on the composition of the stones.

C. Encourage intake of at least 3 L of fluids per day - Adequate fluid intake, particularly water, is crucial for preventing the formation of kidney stones. Increased fluid intake can help dilute substances in the urine that contribute to stone formation, reducing the risk of stone recurrence.

D. Discourage ambulation - Encouraging ambulation and movement is generally beneficial for patients with urolithiasis. Movement can help alleviate discomfort, prevent complications such as blood clots, and promote overall well-being. Restricting movement unnecessarily is not advisable.

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

Explanation

A. Applying ice intermittently - Ice application helps reduce swelling and inflammation by constricting blood vessels. It is effective in managing pain and preventing further tissue damage in contusions, strains, and sprains.

B. Elevating the injured limb - Elevating the injured limb above the level of the heart helps reduce swelling by allowing fluids to drain away from the injured area. This is particularly important in managing contusions, strains, and sprains where swelling is a common symptom. Elevation supports the body's natural healing processes.

C. Resting the affected extremity - Rest is essential to allow the injured tissue to heal. Avoiding movement and stress on the affected area prevents further damage and promotes the healing process. Resting the extremity prevents additional strain on the injured muscles, ligaments, or tendons, allowing the body to repair the damaged tissues effectively.

D. Massaging the affected limb - Massaging the affected limb is generally not recommended in the acute phase of musculoskeletal injuries, especially contusions, strains, or sprains. Massaging can potentially worsen the injury, increase swelling, and cause further tissue damage. It is important to wait until the initial acute phase has passed and consult a healthcare professional before considering massage therapy.

E. Compression dressings - Compression helps control swelling by applying pressure to the injured area. Compression dressings or bandages provide support to the injured limb, minimize swelling, and reduce the risk of further injury. However, it's essential to apply compression correctly to avoid cutting off circulation, and it's usually best done under the guidance of a healthcare provider.

A. Remove heel boots B. Reposition every 3 hours C. Apply cornstarch to keep the skin dry D. Provide high protein diet

Correct Answer is A

Explanation

A. Remove heel boots:
Heel boots are often used to protect the heels from pressure ulcers. However, it's important to assess the skin regularly and remove heel boots periodically to inspect the skin underneath. Leaving them on continuously without proper inspection can cause moisture buildup, leading to skin breakdown.

B. Reposition every 3 hours
Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown, especially in individuals at risk, such as older adults. Prolonged pressure on specific areas of the body can lead to pressure ulcers or bedsores. Regular repositioning helps relieve pressure on vulnerable areas, improving circulation and reducing the risk of skin breakdown.

C. Apply cornstarch to keep the skin dry:
While it's essential to keep the skin clean and dry, using cornstarch can sometimes lead to moisture retention, especially in skin folds. Excess moisture can contribute to skin breakdown and fungal infections. Instead, proper hygiene practices and the use of moisture-wicking products are recommended.

D. Provide high protein diet:
Adequate nutrition, including a high-protein diet, is essential for overall skin health and healing. Protein is necessary for tissue repair and regeneration. While a balanced diet is crucial for overall health, it is not a specific intervention solely focused on maintaining skin integrity.

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A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

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