Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

Pallor

Right-sided paralysis

2+ pitting edema of the feet

Orthopnea .

Answer and Explanation

The Correct Answer is D

Choice A rationale
While pallor can indicate various health issues such as anemia or low blood flow, it is not the most crucial finding when planning to provide a complete bed bath to a bedfast client.
Choice B rationale
Right-sided paralysis could affect the client’s ability to assist with the bath and could require special care or positioning. However, it is not the most crucial finding in this context.
Choice C rationale
2+ pitting edema of the feet could indicate fluid overload or poor circulation, but it is not the most crucial finding when planning to provide a complete bed bath.
Choice D rationale
This is the correct answer. Orthopnea, or difficulty breathing while lying flat, is the most crucial finding in this context. If a client has orthopnea, they may need to be positioned in a way that allows them to breathe comfortably during the bath.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale

Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.

A. Orange juice. B. Hot chocolate. C. Apple juice. D. Chicken broth.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale
Orange juice is a clear liquid and is allowed in the Mormon faith.

Choice B rationale
Hot chocolate is not a clear liquid and is not typically consumed by individuals who follow Mormon beliefs due to its caffeine content.
Choice C rationale
Apple juice is a clear liquid and is allowed in the Mormon faith.
Choice D rationale
Chicken broth is a clear liquid and is allowed in the Mormon faith.
Choice E rationale
Black coffee is not a clear liquid and is not typically consumed by individuals who follow Mormon beliefs due to its caffeine content.

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Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A client with influenza requires assistance in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

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The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma. The adolescent reports experiencing phantom limb pain. Which non-pharmacological intervention should the nurse provide?