Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?
Raise the head of the bed 30 degrees
Measure blood pressure and pulse rate
Flex legs and place blanket between legs
Place pillows to maintain alignment.
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Sinus tachycardia may occur in response to various stressors or physiological conditions but is not directly related to anorexia nervosa or severe malnutrition. It is not the primary pathological process resulting from this condition.
Choice B rationale:
Menstrual cramps are not a pathological process but rather a symptom that may result from hormonal changes or other factors. While amenorrhea (absence of menstrual periods) is a common feature of anorexia nervosa, menstrual cramps are not a primary concern in this context.
Choice C rationale:
Hypertension is not typically associated with anorexia nervosa or severe malnutrition. In fact, individuals with anorexia nervosa often experience hypotension (low blood pressure) due to dehydration and nutritional deficiencies.
Choice D rationale:
Amenorrhea is the primary pathological process resulting from the adolescent's consistent maladaptive behavior of anorexia nervosa. Severe malnutrition and low body weight can disrupt the normal menstrual cycle and lead to amenorrhea. This is a significant concern for individuals with anorexia nervosa and can have long-term health implications.
Correct Answer is B
Explanation
Choice A rationale:
Notifying the healthcare provider that the client is having difficulty using the spirometer may be necessary if the client is unable to use the device correctly despite encouragement and education. However, the initial action should be to encourage the client and provide support.
Choice B rationale:
Encouraging the client to continue inhaling slowly into the spirometer until the goal is met is the correct action. Incentive spirometry is used to improve lung function, and it is essential for the client to use it correctly and meet their goals to achieve the desired outcomes.
Choice C rationale:
Offering to demonstrate the correct use of the incentive spirometer to the client may be helpful if the client is struggling to use it properly. However, the initial response should be to encourage the client and provide guidance.
Choice D rationale:
Reminding the client to cough after each use of the spirometer to help clear the lungs is not the most appropriate action in this situation. While coughing may be beneficial, the primary focus should be on achieving the goals of the incentive spirometry.
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