Share This Link

This option involves informing the healthcare provider about the client's statement regarding their lack of understanding about the surgical procedure. Notifying the provider is important because it allows the provider to assess the situation, address any misunderstandings or concerns the client may have, and ensure that informed consent is obtained appropriately. The provider may choose to personally explain the surgery to the client or provide additional educational materials to enhance the client's understanding.

Assault is defined as an intentional threat to cause bodily harm to another person, coupled with an apparent ability to cause the harm. The AP's statement "If you do not remain in bed, I will place you in restraints" constitutes a threat that instills fear of harm or unwanted physical contact in the client, even if no physical contact occurs.

The nurse should assess the pulses in the extremities to ensure that circulation is not compromised by the restraints.

Once the nurse has confirmed that the peripheral pulses are intact, they should assess the client's skin integrity. Prolonged or improperly applied restraints can cause pressure injuries or skin breakdown, so it is important to check for any signs of skin damage.

After assessing peripheral pulses and skin integrity, the nurse should evaluate the client's comfort level. The nurse should address any discomfort or pain caused by the restraints and ensure that the client's physical and emotional needs are met.

While elimination needs are important, they may not pose an immediate threat to the client's safety compared to compromised circulation or skin integrity. Once the more urgent assessments have been completed, the nurse should address the client's elimination needs.

During the alarm reaction stage of the general adaptation syndrome (GAS), the body's initial response to stress occurs. This stage is characterized by the activation of the body's

fight-or-flight response. The nurse should identify that the manifestation that occurs during the alarm reaction stage is dilated pupils.

The alarm reaction stage is the body's immediate response to a stressor, where it mobilizes its resources to cope with the perceived threat. During this stage, the sympathetic nervous system is activated, resulting in various physiological changes to prepare the body for action. Dilated pupils are one of the responses caused by the sympathetic nervous system activation. This physiological change enhances visual acuity and allows for better peripheral vision, which can be beneficial in assessing the environment for potential threats.

Motivation is influenced by various factors, including the client's perception of the benefits or rewards they will receive by engaging in a particular behavior. When the client believes that their needs will be met through education, they are more likely to be motivated to learn and actively participate in the teaching process.

The Braden scale is a commonly used tool for assessing a patient's risk of developing pressure injuries (also known as pressure ulcers or bedsores). It evaluates six specific elements to determine the patient's risk level. These elements include sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element is assessed and assigned a score, with a lower score indicating a higher risk for developing pressure injuries.

An artificial larynx is a device used for speech production after a laryngectomy. It's important for the nurse to educate the client about this option for communication post-surgery. Familiarizing the client with the use of an artificial larynx is the most crucial intervention to address their immediate communication needs after surgery.

An IVP is a radiographic procedure that involves injecting a contrast dye into the vein to visualize the urinary tract. Metal objects can interfere with the imaging process and may need to be removed or avoided during the procedure. The nurse should assess the client for any metal objects, such as jewelry or clothing accessories, and ensure they are removed before the procedure to ensure accurate imaging.