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 D
Explanation
Choice D
This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
Choice A is not the correct answer because it assumes that the client is feeling lonely without giving them the opportunity to express their own feelings.
Choice B is not the correct answer because it confronts the client about their behavior in an accusatory manner.
Choice C is not the correct answer because it suggests a solution without first exploring the client’s feelings and needs.
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.
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