A nurse is supervising an assistive personnel (AP. who is applying anti-embolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?
Applying the stockings before the client gets out of bed
Turning the stockings inside out before applying them
Asking the client to point their toes before applying the stockings
Ensuring that creases in the stockings are on the front of the client's legs
The Correct Answer is D
The nurse must intervene if the AP leaves creases or folds in the stockings because wrinkles and creases create uneven pressure points that can restrict blood flow and irritate the skin. Anti-embolic stockings are designed to provide smooth, graduated compression to promote venous return; any bunching or folding defeats this purpose and increases the risk of skin breakdown or thrombus formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
The correct answer is Choices B and D.
Choice A rationale: Using confrontation to manage a client’s behavior is not recommended, especially for clients with Alzheimer’s disease. Confrontation can lead to increased agitation, confusion, and distress in these clients. It’s important to approach clients with Alzheimer’s disease in a calm, reassuring manner and to validate their feelings and experiences.
Choice B rationale: Limiting the number of choices for the client is a beneficial strategy when caring for clients with Alzheimer’s disease. Too many choices can overwhelm these clients and lead to increased confusion and frustration. By simplifying decisions, caregivers can help to reduce the client’s stress and improve their ability to function.
Choice C rationale: While it’s important to keep clients with Alzheimer’s disease engaged and stimulated, providing a stimulating environment can be counterproductive. Too much stimulation can overwhelm these clients and lead to increased confusion and agitation. It’s more beneficial to provide a calm, quiet, and familiar environment for these clients.
Choice D rationale: Using written signs to assist the client with locating the bathroom can be very helpful for clients with Alzheimer’s disease. As the disease progresses, these clients often struggle with memory loss and disorientation. Clear, simple signs can help them navigate their environment and maintain a level of independence.
Correct Answer is C
Explanation
A. Tonicclonic seizures might be part of the electroconvulsive therapy procedure itself, but they would typically occur during the treatment, not 15 minutes after.
B. Paresthesias (tingling or numbness. are not a common expected finding following electroconvulsive therapy?
C. Correct. Disorientation is a common side effect after electroconvulsive therapy and usually resolves over time.
D. Sleep apnea is not an expected finding following electroconvulsive therapy.
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