The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?
"There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."
"My grandfather always had problems with his arthritis, and he would tell me that it's better to be more stoic and not let pain interrupt your life."
"Place throw rugs throughout your home. You'll enjoy how pretty they are, and you can use them to cover up power cords, so you don't trip on them."
"Lack of home safety may be an issue of compliance. Are you being compliant with your medications?"
The Correct Answer is A
Choice A reason: This statement is correct and should be included in the nurse's teaching. It informs the client about the availability and benefits of adaptive devices that can enhance their home safety and independence. It also shows the nurse's empathy and respect for the client's needs and preferences.
Choice B reason: This statement is incorrect and should not be included in the nurse's teaching. It reflects the nurse's personal opinion and bias, and it may discourage the client from seeking help or expressing their pain. It also shows the nurse's lack of understanding and compassion for the client's condition and challenges.
Choice C reason: This statement is incorrect and should not be included in the nurse's teaching. It suggests an unsafe and hazardous practice that can increase the risk of falls and injuries for the client. It also shows the nurse's negligence and irresponsibility for the client's home safety.
Choice D reason: This statement is incorrect and should not be included in the nurse's teaching. It implies that the client is noncompliant and blames them for their home safety issues. It also shows the nurse's judgmental and accusatory attitude towards the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Include many fresh fruits and vegetables in your diet is not a correct answer, because it may increase the risk of infection for the client with AIDS. Fresh fruits and vegetables may contain bacteria, parasites, or pesticides that can cause gastrointestinal or systemic infections in immunocompromised clients. The nurse should advise the client to wash, peel, or cook fruits and vegetables before eating them, or to avoid them altogether if they have diarrhea or low white blood cell counts.
Choice B reason: Drink at least 2 to 3 L of fluids per day is a correct answer, because it helps prevent dehydration, maintain electrolyte balance, and flush out toxins and waste products. Fluid intake is especially important for clients with AIDS who may experience fever, sweating, vomiting, diarrhea, or oral lesions that can cause fluid loss.
Choice C reason: Eat highcalorie foods is a correct answer, because it helps prevent weight loss, muscle wasting, and malnutrition. Clients with AIDS may have increased caloric needs due to increased metabolic rate, infection, inflammation, or medication side effects. Highcalorie foods can provide energy and support immune function.
Choice D reason: Lower your caloric intake is not a correct answer, because it can worsen the nutritional status and health outcomes of the client with AIDS. Lowering caloric intake can lead to weight loss, muscle wasting, malnutrition, and increased susceptibility to infections and complications. The nurse should encourage the client to meet or exceed their caloric needs based on their weight, activity level, and disease stage.
Choice E reason: Choose foods high in protein is a correct answer, because it helps maintain muscle mass, tissue repair, and immune function. Clients with AIDS may have increased protein needs due to increased protein breakdown, infection, inflammation, or medication side effects. Highprotein foods can provide amino acids and antibodies that are essential for immune response.
Correct Answer is B
Explanation
Choice A reason: Removing the nursing diagnosis in the plan of care since it has not occurred is not a good action, because it does not account for the possibility of future impairment. The client is still at risk for impaired skin integrity due to the prolonged bed rest, and the nurse should continue to monitor and prevent any skin breakdown.
Choice B reason: Keeping the nursing diagnosis in the plan of care the same since the risk factors are still present is the best action, because it reflects the current situation and the potential problem. The client has not developed impaired skin integrity, but the risk factors have not changed. The nurse should maintain the interventions that have been effective in preventing skin impairment, such as turning, repositioning, moisturizing, and inspecting the skin.
Choice C reason: Modifying the nursing diagnosis in the plan of care to impaired skin integrity is not a good action, because it does not match the data. The client has not shown any signs of impaired skin integrity, such as redness, blanching, breakdown, or ulceration. The nurse should not change the diagnosis based on assumptions or predictions, but on evidence.
Choice D reason: Changing the nursing diagnosis in the plan of care to impaired mobility is not a good action, because it does not address the original problem. The client may have impaired mobility due to the bed rest, but that is not the focus of the question. The question is about the risk for impaired skin integrity, which is a different issue that requires different interventions. The nurse should not ignore or replace the existing diagnosis without justification.
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