Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed.
The nurse establishes a problem of 'Activity intolerance related to pain'. Based on this problem, which outcome statement is best for the nurse to include in his care plan?
To ambulate without discomfort.
To take analgesics as prescribed.
To show evidence of incision healing.
To avoid pain-causing activity.
The Correct Answer is A
The goal of the care plan should be to help the client overcome his activity intolerance related to pain.
This can be achieved by helping him to ambulate without discomfort.
Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.
Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.
Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
Correct Answer is C
Explanation
This response shows that the nurse is willing to listen and provide support to the client.
It also allows the client to decide if they want to talk and share their feelings.
Choice A is not correct because it is not the most therapeutic response.
While it does encourage the client to talk about their visit with their significant other, it does not show that the nurse is willing to listen and provide support.
Choice B is not correct because it is not the most therapeutic response.
While it does acknowledge that the client may be feeling lonely, it does not show that the nurse is willing to listen and provide support.
Choice D is not correct because it is not the most therapeutic response.
While it does encourage the client to talk about their visit, it does not show that the nurse is willing to listen and provide support.
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