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Observing the cardiac monitor for increased heart rate may indicate pain indirectly, but it is not the priority. Heart rate changes can result from various factors (e.g., anxiety, hypovolemia). Directly assessing the patient’s pain level provides specific, subjective data to guide interventions, making this choice less immediate.

Assessing body language can provide nonverbal pain cues, but it is less precise than verbal pain rating. Subjective pain assessment via patient report is the gold standard, as body language may be misinterpreted or influenced by cultural factors, making this a secondary action.

Inspecting the incision site is important to rule out complications (e.g., infection, dehiscence), but pain assessment takes precedence to address the patient’s immediate complaint. Pain rating informs whether inspection or other interventions are urgent, making this a follow-up rather than priority action.

Sanguineous drainage is bright red and consists primarily of blood, indicating active bleeding. Watery red drainage suggests a mix of blood and serous fluid, not pure blood, making this choice incorrect for the described wound drainage.

Serous drainage is clear or slightly yellow, watery fluid without blood. The presence of red in the described watery drainage indicates a combination with blood, ruling out pure serous drainage, making this choice incorrect for the observed characteristics.

Purulent drainage is thick, opaque, and often yellow, green, or white, indicating infection. Watery red drainage does not fit this description, as it lacks the viscosity and color of pus, making this an incorrect choice for the wound’s drainage.

Complete bed rest increases stasis, a risk factor for thrombus formation per Virchow’s triad. Immobility slows venous return, promoting clot development, making this choice counterproductive and incorrect for preventing postoperative thrombi.

Light wrapping may provide comfort but does not effectively prevent thrombus formation. Compression stockings are preferred for venous return, and wrapping alone is insufficient, making this choice less effective than ambulation.

Pillows under the knees cause venous pooling by flexing joints, increasing thrombus risk. This contradicts measures to enhance circulation, such as ambulation, making it an incorrect choice for thrombus prevention.

Blood pressure of 148/92 mmHg indicates hypertension, not directly related to prolonged diarrhea. Diarrhea causes fluid loss, leading to hypotension or normal blood pressure, not elevated readings, making this an unlikely finding for a patient with dehydration from diarrhea.

Abdominal distention is less likely with diarrhea, which typically reduces bowel contents. Distention may occur in conditions like bowel obstruction, not fluid loss from diarrhea, making this an incorrect expected finding for this patient’s condition.

A heart rate of 62 beats/min is normal and not expected in diarrhea, which causes tachycardia due to dehydration and compensatory sympathetic activation. A low or normal heart rate is inconsistent with fluid loss, making this an incorrect finding.

Chronic alcohol abuse may cause hypomagnesemia, which can mimic hypocalcemia symptoms, but a positive Chvostek sign is specific to low calcium. Alcoholism alone is less likely to cause this sign without concurrent hypocalcemia, making this choice incorrect.

Osteoporosis in a 75-year-old involves bone density loss but does not typically cause hypocalcemia or a positive Chvostek sign. Calcium levels are usually normal unless other conditions exist, making this choice incorrect for the expected finding.

Severe burns cause fluid shifts and potential electrolyte imbalances, but hypocalcemia is not a primary feature. A positive Chvostek sign is less likely without specific calcium depletion, making this choice incorrect for the expected finding.

Stopping smoking is beneficial for lung health but does not directly address immediate fatigue from ineffective breathing during sleep. Elevating the head improves airway patency overnight, providing faster relief for sleep-related breathing issues, making this less effective.

Running 30 minutes daily is inappropriate for an obese patient with fatigue and ineffective breathing, as it may exacerbate respiratory strain. Elevating the head during sleep directly improves oxygenation, making exercise a long-term rather than immediate solution for sleep promotion.

Limiting diet to 1500 calories addresses obesity but not acute fatigue from ineffective breathing during sleep. Sleeping with pillows elevates the head, reducing airway obstruction and improving rest, making dietary changes a secondary intervention for this specific issue.

A bowel movement two days ago suggests mild constipation, not a contraindication for ibuprofen. While NSAIDs can cause gastrointestinal issues, constipation is not an immediate concern, making this choice incorrect for holding the medication.

Joint pain rated 2/10 and intermittent may not warrant ibuprofen if pain is mild, but it is not a contraindication. The decision to hold is based on risks like ulcers, not pain severity, making this choice incorrect.

Respiratory depression from opioids is unrelated to ibuprofen administration. While concerning, it does not contraindicate ibuprofen, which lacks respiratory effects, making this choice incorrect for holding the NSAID in this scenario.

Increased muscle strength is not expected in an 84-year-old, as aging leads to sarcopenia, reducing muscle mass and strength. This causes weakness and mobility issues, making this an incorrect finding for an elderly patient’s typical presentation.

Enhanced night vision is not typical in aging; older adults often experience reduced night vision due to retinal changes and slower pupil adaptation. This makes night vision an incorrect expected finding for an 84-year-old patient.

Improved short-term memory is not expected, as aging often impairs short-term memory due to neuronal loss and slower cognitive processing. Memory decline is common in the elderly, making this an incorrect finding for an 84-year-old.

Doing nothing is inappropriate, as a fall risks injury (e.g., fractures, head trauma), even if no harm is immediately apparent. Notifying the provider ensures further evaluation and intervention, making this choice unsafe and negligent for patient safety.

Further assessment is important, but the initial assessment has been done. Notifying the provider takes precedence to ensure medical oversight for hidden injuries, as falls in healthcare settings require professional evaluation, making this a secondary action.

Completing an incident report is necessary for documentation and quality improvement but is not the priority over clinical care. Notifying the provider ensures immediate medical attention for potential injuries, making reporting a follow-up action.

Imagery involves visualizing specific scenes or outcomes to reduce stress, not focusing on physical sensations like breathing or muscle relaxation. The group’s focus on body awareness and sequential relaxation aligns with progressive relaxation, making this an incorrect description.

Meditation typically involves mindfulness or mental focus, not systematic physical relaxation of body parts. The group’s structured progression through breathing and muscle groups is specific to progressive relaxation training, making meditation an incorrect term.

Group biofeedback uses devices to monitor physiological signals (e.g., heart rate), not verbal guidance to focus on relaxation. The described activity relies on mental focus without equipment, aligning with progressive relaxation, making biofeedback incorrect.