A nurse is reinforcing teaching with a client who has recurrent back injuries related to lifting. Which of the following lifting instructions should the nurse include?

Choice A Reason:

"I'll listen to my favorite music to take my mind off the pain." This statement refers to distraction techniques, like listening to music, which can help manage pain but isn't specifically guided imagery.

Choice B Reason:

"I'll think about my grandfather's farm to reduce pain." This statement indicates an understanding of this technique. Guided imagery involves creating a detailed mental image or scenario that promotes relaxation and diminishes pain perception. In this case, the client visualizing a familiar, pleasant place like their grandfather's farm can be an effective form of guided imagery to alleviate pain by diverting attention and inducing relaxation.

Choice C Reason:

"I'll use focused breathing to control my pain." This statement does not indicate an understanding of this technique.

Focused breathing, while beneficial for relaxation and pain management, is a different technique from guided imagery.

Choice D Reason:

"I'll learn to notice the sensation of muscle tension." This statement refers to progressive muscle relaxation, a technique involving systematically tensing and relaxing muscle groups, which isn't guided imagery.

Choice A Reason:

Recording the urinary output at the end of each shift is appropriate action. Furosemide is a loop diuretic that increases urine production. Monitoring urinary output is important to assess the effectiveness of the medication and to ensure that the client is not at risk for dehydration or fluid overload. Recording urinary output at the end of each shift provides a comprehensive overview of the client's renal function and fluid balance.

Choice B Reason:

Checking the urine for ketones every 12 hr is inappropriate action. Checking urine for ketones is not a routine assessment for a client with an indwelling urinary catheter and a prescription for furosemide.

Choice C Reason:

Collecting a 24-hr urine specimen to send to the laboratory is inappropriate. Collecting a 24-hour urine specimen is a more extensive test and is not typically needed for routine monitoring of a client on furosemide.

Choice D Reason:

Measuring the specific gravity of the urine during each shift is incorrect. While monitoring specific gravity can provide information about the concentration of urine, it is not usually required for routine monitoring in this specific situation. Monitoring urinary output is a more practical and clinically relevant approach.