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The patient complains of fatigue and joint pain and reports that they are unable to walk due to pain in the knees. What is the most appropriate statement by the nurse?
"You should avoid walking. This might be osteoporosis."
"You just have arthritis and should take some ibuprofen."
"Please tell me more about when your pain started."
"You need to lose weight or the pain won't go away."
The Correct Answer is C
Choice A reason: This is an incorrect statement because it is not based on any assessment or diagnosis. Osteoporosis is a condition that affects the bones, not the joints. It also does not cause fatigue. The nurse should not make assumptions or give advice without proper evaluation.
Choice B reason: This is an incorrect statement because it is dismissive and insensitive. Arthritis is a general term that covers many types of joint inflammation and pain. It is not a simple condition that can be treated with just ibuprofen. The nurse should not minimize the patient's concerns or prescribe medication without a doctor's order.
Choice C reason: This is the correct statement because it shows empathy and interest in the patient's situation. It also helps the nurse gather more information about the onset, duration, frequency, and severity of the pain. This can help the nurse identify possible causes and plan appropriate interventions.
Choice D reason: This is an incorrect statement because it is rude and judgmental. Weight loss may or may not help with joint pain, depending on the underlying cause. The nurse should not blame the patient or make them feel guilty. The nurse should focus on the patient's current symptoms and needs, not their appearance or lifestyle.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Allowing the client to sleep to build up stamina is not the priority intervention, because it does not address the psychosocial needs of the client. Sleeping is a physiological need, not a psychosocial need. Sleeping may help the client recover physically, but it does not help the client cope emotionally or socially with the isolation.
Choice B reason: Maintaining a sixfoot distance from the client is not the priority intervention, because it does not enhance the psychosocial needs of the client. Maintaining a sixfoot distance from the client is a safety measure, not a psychosocial intervention. Maintaining a sixfoot distance from the client may help prevent the transmission of infection, but it does not help the client feel less lonely or isolated.
Choice C reason: Providing a timeframe for the isolation is not the priority intervention, because it does not enhance the psychosocial needs of the client. Providing a timeframe for the isolation is an informational intervention, not a psychosocial intervention. Providing a timeframe for the isolation may help the client understand the rationale and duration of the precautions, but it does not help the client feel more engaged or supported.
Choice D reason: Providing the client with diversional activities is the priority intervention, because it enhances the psychosocial needs of the client. Providing the client with diversional activities is a psychosocial intervention, not a physiological, safety, or informational intervention. Providing the client with diversional activities may help the client feel more entertained, stimulated, and connected with others, which can reduce the negative effects of isolation.
Correct Answer is C
Explanation
Choice A reason: The client is in a private room is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should be in a private room, as it can reduce the exposure to pathogens or allergens that may cause infection or inflammation. The client with reduced immunity has a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection. The private room can also provide privacy, comfort, and security for the client.
Choice B reason: The client has a dedicated vital signs machine is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have a dedicated vital signs machine, as it can prevent the crosscontamination or transmission of pathogens or allergens that may cause infection or inflammation. The vital signs machine is a device that measures the blood pressure, pulse, temperature, and oxygen saturation of the client. The vital signs machine can be contaminated by the blood, body fluids, or secretions of the client or other clients, and can harbor bacteria, viruses, or fungi. The dedicated vital signs machine can also ensure the accuracy, consistency, and availability of the measurements for the client.
Choice C reason: The client has a vase of fresh flowers on the table is an observation that requires further action by the nurse, because it is inappropriate and undesirable. The client with reduced immunity should not have a vase of fresh flowers on the table, as it can increase the exposure to pathogens or allergens that may cause infection or inflammation. The fresh flowers are a source of mold, pollen, or insects, which can trigger allergic reactions, respiratory distress, or skin irritation. The fresh flowers can also contain bacteria, viruses, or fungi, which can infect the client through inhalation, ingestion, or contact. The vase of fresh flowers should be removed from the room and replaced with artificial flowers, pictures, or cards.
Choice D reason: There is hand sanitizer by the door is not an observation that requires further action by the nurse, because it is appropriate and desirable. The client with reduced immunity should have hand sanitizer by the door, as it can promote the hand hygiene and infection prevention of the client and others. Hand sanitizer is a product that contains alcohol or other agents that can kill or reduce the number of pathogens or allergens that may cause infection or inflammation. Hand sanitizer should be used by the client, the staff, and the visitors before and after entering or leaving the room, or after touching any objects or surfaces in the room.
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