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Rigid abdomen:A rigid abdomen could indicate peritonitis or a serious abdominal condition such as bowel perforation, which is a medical emergency. This would not be expected in a patient with uncomplicated diarrhea. Rigid abdominal muscles are typically associated with acute abdominal emergencies rather than simple diarrhea.

Hypothermia:Hypothermia is generally not associated with diarrhea. Diarrhea is more likely to cause fever or a normal body temperature due to the body's inflammatory response to infection or irritation. Hypothermia typically occurs in cases of prolonged exposure to cold or in critically ill patients, but it is not a typical response to diarrhea alone.

Decreased bowel sounds:While decreased or absent bowel sounds can be seen in bowel obstruction or paralytic ileus, it is not typically a finding associated with diarrhea. In fact, in the early stages of diarrhea, increased bowel sounds (hyperactive bowel sounds) are often noted due to the rapid peristalsis and gastrointestinal irritation.

Place the client on a low-fiber diet:A low-fiber diet is not recommended for patients experiencing constipation. Fiber plays a key role in bowel regularity by absorbing water and adding bulk to stool, which promotes movement through the intestines. In fact, a high-fiber diet (from fruits, vegetables, whole grains, and legumes) is usually recommended for clients with constipation. Reducing fiber intake can worsen constipation and should be avoided unless otherwise directed by a healthcare provider for specific conditions (e.g., during acute exacerbations of inflammatory bowel disease).

Request a prescription for a mineral oil for the client:Mineral oil is a laxative that is sometimes used to relieve constipation, but it is typically used only for short-term relief and under specific circumstances. Long-term use of mineral oil can interfere with the absorption of fat-soluble vitamins (A, D, E, and K) and can also lead to a lipid pneumonia if aspirated. It is not the first-line intervention for a patient on bed rest with constipation and should not be used indiscriminately without a provider's recommendation.

Encourage the client to drink cold fluids:
While fluid intake is essential for managing constipation, it is not specifically the temperature of the fluid that makes a difference. Both cold and room temperature fluids are effective, but encouraging the client to increase fluid intake overall is the most important action. Water is particularly helpful, as it helps soften stool and aids in the movement through the colon.

Implementation:Implementation refers to the actual carrying out of the nursing interventions and care plan that were developed during the planning phase. This is when the nurse takes action based on the goals set earlier, such as administering medications, teaching the patient, or performing specific procedures. While this phase is crucial for the success of the care plan, it does not involve the creation of goals, which is the focus of the planning phase.

Assessment:
Assessment is the first step in the nursing process. It involves gathering comprehensive information about the patient’s physical, psychological, social, and emotional status. The assessment phase is focused on identifying the patient’s needs, strengths, and problems. While it provides the foundation for formulating goals, it is not the phase where goals are set. Instead, the assessment phase is about collecting data to inform the planning process.

Evaluation:Evaluation occurs after the implementation of interventions. During this phase, the nurse evaluates whether the patient’s goals have been met, partially met, or not met at all. The nurse examines the effectiveness of the care plan and determines if adjustments need to be made. This is not the phase where goals are set; rather, it is a reflective stage where the nurse assesses progress toward achieving the goals established in the planning phase.

Describe the steps of walking with crutches for the client:Describing the steps of walking with crutches involves cognitive learning, where the focus is on understanding and acquiring knowledge. In this case, the nurse is providing verbal information to the client about how to use crutches, but this does not engage the psychomotor domain, which involves the physical performance of tasks or skills.

Encourage the client to ask questions about walking with crutches:Encouraging questions is part of the affective domain of learning, which focuses on attitudes, feelings, and the ability to value or appreciate information. By encouraging the client to ask questions, the nurse is promoting understanding and engagement, but this is not related to the psychomotor domain, which requires physical action or skill development.

Show the client a video on walking with crutches:
Showing a video involves cognitive learning as it provides the client with visual information and demonstrations. While this helps with understanding how to walk with crutches, it is still a passive form of learning where the client is watching but not physically engaging with the task.

The client reports having trouble sleeping the previous night:While difficulty sleeping could be a concern, it is not directly related to the administration of an antihypertensive medication unless the client reports other symptoms, such as palpitations, chest pain, or anxiety, which may indicate an underlying issue. It is not a priority to delay or further assess medication administration based solely on sleep disturbances unless other significant factors are present.

The client ate 60% of their breakfast:
Eating 60% of the meal is not typically a reason to withhold or delay antihypertensive medication unless the client is showing signs of severe nausea, vomiting, or gastrointestinal distress. Many antihypertensive medications can be taken with food to reduce gastric irritation, and this percentage of food intake does not pose an immediate concern.

The client has a urine output of 400 mL for the past 8 hours:Urine output of 400 mL over 8 hours is within the normal range (approximately 50–60 mL/hr), suggesting adequate renal function and fluid balance. While a decrease in urine output can be concerning, there is no immediate indication that this level of output would interfere with the administration of an antihypertensive medication.

Prepares the sterile field 2 hours before it is needed:A sterile field should be prepared as close to the time it will be used as possible, typically within 15 to 30 minutes before the procedure, to ensure its sterility is maintained. Preparing a sterile field 2 hours in advance increases the risk of contamination, as airborne particles and bacteria can settle on the field during that time.

Places the sterile field against a wall in the client's room:
Placing the sterile field against a wall is not advisable, as it may increase the likelihood of contamination. A wall is not a sterile surface, and anything in close proximity to the wall (e.g., furniture, equipment) could inadvertently contaminate the sterile field. A sterile field should be placed on a clean, flat surface that is free from any potential contaminants, away from traffic or other surfaces that could compromise sterility.

Opens the first flap of the sterile package towards the nurse's body:When opening a sterile package, the first flap should always be opened away from the body, not towards it. This action ensures that the nurse does not risk contaminating the sterile field by inadvertently touching it with their body or clothing. The nurse should open each flap of the sterile package away from themselves, then discard it, continuing to open the remaining flaps in a way that maintains the sterility of the items within.

Role-play:Role-playing is a teaching strategy where the client or learner acts out a scenario or situation to practice certain behaviors, such as interacting with others in a social or clinical setting. In this case, the nurse is not asking the client to simulate a scenario or interact with others, but instead, to physically perform a specific task (walking with a walker).

Question-and-answer:The question-and-answer method involves the nurse asking the client questions to assess understanding or clarify information. This method typically involves verbal interaction rather than performing a physical skill. In this scenario, the nurse is not simply asking questions, but rather observing the client as they perform the physical task of walking with a walker.

Discussion:
Discussion is a method of teaching where ideas or concepts are shared and discussed, often in a conversational format. While the nurse might use discussion as part of the overall teaching, the act of having the client physically demonstrate walking with a walker is a separate and more focused teaching strategy.

Clean the skin near the drain in a circular motion from the outside to the inside:When cleaning around a drain, the nurse should use a circular motion, but it is important to clean from the inside (near the drain) outward to prevent introducing bacteria into the drain site. Cleaning from the outside to the inside increases the risk of contaminating the wound and could cause infection.

Empty the drainage device when it is half full:For a Penrose drain, the drainage is typically absorbed by a dressing rather than being collected in a drainage device. In general, for drains like Jackson-Pratt or Hemovac, emptying the device when it is half full is correct, but this is not applicable to a Penrose drain. A Penrose drain relies on passive drainage, and there is no reservoir that requires emptying.

Connect the drain to continuous low-pressure suction:A Penrose drain does not require suction. It is a passive drain, relying on gravity to facilitate the drainage of fluid. Suction is typically used for other types of drains, such as Jackson-Pratt or Hemovac drains, which require a suction mechanism to actively draw out fluid.

Improved sexual function:While ACE inhibitors like lisinopril may have a beneficial impact on overall health, improved sexual function is not a direct therapeutic effect of this medication. In fact, ACE inhibitors can sometimes cause side effects like sexual dysfunction in some individuals. Therefore, improved sexual function is not considered a therapeutic outcome for lisinopril.

Increase of HDL cholesterol:
Lisinopril does not have a direct effect on increasing HDL (high-density lipoprotein) cholesterol. While ACE inhibitors may have some indirect cardiovascular benefits, such as improving endothelial function or reducing risk factors for heart disease, raising HDL cholesterol is not one of their specific effects. This outcome would not indicate a therapeutic effect of lisinopril.

Prevention of bipolar manic episodes:Lisinopril is not used for the treatment or prevention of bipolar disorder or its manic episodes. While certain medications, such as mood stabilizers or antipsychotics, may be used in the management of bipolar disorder, lisinopril is not effective for this purpose. Therefore, preventing bipolar manic episodes is not a therapeutic outcome of lisinopril.