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Fresh vegetables: While fresh vegetables are generally considered healthy and nutritious, they do not have specific associations with yin or yang energies in TCM. Therefore, the client may not necessarily choose fresh vegetables to address a headache based on the yin-yang concept.

Chicken: Chicken is a neutral food in TCM and is not specifically associated with either yin or yang energies. Therefore, the client may not necessarily choose chicken to address a headache based on the yin-yang concept.

Chili peppers: Chili peppers are considered yang-warming foods in TCM due to their spicy nature. They are believed to increase yang energy in the body. Therefore, the client who believes in the concept of yin and yang may not choose chili peppers to treat their headache, as it may exacerbate yang energy rather than balance it.

The client adjusts the head of their bed to 90°: Adjusting the head of the bed to 90° is a correct action for clients with dysphagia as it helps facilitate swallowing by promoting an upright position, reducing the risk of aspiration.

The client tucks their chin when they swallow: Tucking the chin when swallowing is a recommended technique for clients with dysphagia, as it helps close off the airway and directs the food or liquid toward the esophagus, reducing the risk of aspiration.

The client takes frequent breaks while eating: Taking frequent breaks while eating is a beneficial strategy for clients with dysphagia, as it allows them to rest and swallow safely without feeling rushed or overwhelmed by large amounts of food or liquid.

"Perform water aerobics three times each week": While water aerobics is a beneficial form of exercise for overall health and fitness, it may not be as effective as weight-bearing exercises like walking for preventing osteoporosis. Water-based activities do not provide the same impact on bone density as weight-bearing exercises.

"Maintain a lean body mass": While maintaining a healthy body weight is important for overall health, particularly for reducing the risk of conditions like heart disease and diabetes, it may not specifically prevent osteoporosis. In fact, having a low body weight or being underweight can increase the risk of osteoporosis.

"Increase intake of vitamin B12": Vitamin B12 is important for various bodily functions, including nerve function and the formation of red blood cells, but it is not directly linked to the prevention of osteoporosis. Adequate calcium and vitamin D intake, along with weight-bearing exercise, are key factors in preventing osteoporosis.

Cut a 4 inch x 4 inch (10 cm x 10 cm) gauze pad to place under the flanges of the tracheostomy tube: Placing gauze pads under the flanges of the tracheostomy tube is not a standard practice for tracheostomy care. Instead, the nurse should use pre-cut tracheostomy dressings designed specifically for this purpose.

Cleanse the skin around the stoma with full-strength hydrogen peroxide: Full-strength hydrogen peroxide is too harsh for cleansing the skin around the tracheostomy stoma. It can cause irritation and damage to the skin. Instead, the nurse should use a prescribed solution, such as normal saline or mild soap and water, to clean the skin gently.

Secure the tracheostomy in place with a collar that has hook-and-loop fasteners: While securing the tracheostomy tube in place is important, using a collar with hook-and-loop fasteners is not the only option. Tracheostomy ties or Velcro straps specifically designed for securing tracheostomy tubes are commonly used for this purpose, providing a secure and adjustable fit.

"I will remove my antiembolic stockings while I am in bed": Antiembolic stockings, also known as compression stockings, are worn to prevent deep vein thrombosis (DVT) by promoting venous return. Removing them while in bed would compromise their effectiveness in preventing blood clots.

"I will hold my breath when rising from a sitting position": Holding one's breath while rising from a sitting position can increase intra-abdominal pressure and potentially cause dizziness or fainting. It is not a recommended practice and may lead to orthostatic hypotension.

"I will have my partner help me change positions every 4 hours": Changing positions every 4 hours is important for preventing pressure ulcers and promoting comfort, but it may not be frequent enough to prevent other adverse effects of immobility, such as joint stiffness and muscle weakness. Frequent position changes, at least every 2 hours, are recommended to maintain circulation and prevent complications.

Grab bars are installed in the shower: Installing grab bars in the shower is a safety measure that helps prevent falls and assists the client in safely maneuvering in the bathroom. This finding indicates a safe environment and does not require intervention.

The hot water heater is set to 47°C (117°F): The hot water heater set at 47°C (117°F) poses a scalding risk, especially for older adults with decreased sensation or mobility issues. The recommended safe temperature for hot water heaters is typically below 49°C (120°F) to prevent burns. Therefore, the nurse should intervene to adjust the temperature to a safer level.

Prescriptions are stored in a medication organizer: Storing prescriptions in a medication organizer promotes medication adherence and organization, which is beneficial for older adults managing multiple medications. This finding indicates good medication management and does not require intervention.

The client leans to the left side while sitting: While leaning to one side may indicate weakness or impaired balance, it is not as immediately concerning as the risk of aspiration. Addressing issues related to positioning and balance is important but may not pose an immediate threat to the client's safety.

The client is consuming 25% of their meals: Poor oral intake and difficulty eating are concerning but do not pose an immediate threat to the client's safety compared to the risk of aspiration. However, addressing inadequate nutrition and hydration is essential for the client's overall health and recovery.

The client's blood pressure is 142/94 mm Hg: While monitoring blood pressure is important, especially in stroke patients who may have hypertension, the blood pressure reading provided does not indicate a hypertensive crisis or immediate risk to the client's safety. Therefore, it is not the priority finding compared to the risk of aspiration.

Apply the pouch while the skin barrier is still damp.Applying the pouch while the skin barrier is damp can lead to poor adhesion and potential leaks. It’s essential to ensure the skin is completely dry before attaching the pouch.

Change the pouch once every 24 hr.: The frequency of pouch changes depends on individual client needs, stoma output, and the type of pouching system used. Changing the pouch every 24 hours may be unnecessary for some clients and could potentially cause skin irritation or damage.

Rub the peristomal skin dry after cleaning: Rubbing the peristomal skin dry after cleaning can cause irritation and damage to the skin. Instead, the nurse should gently pat the skin dry using a soft cloth or towel to avoid causing friction or trauma to the delicate skin surrounding the stoma.

Hypertension in a parent: While a family history of hypertension may increase the risk of developing high blood pressure, it is considered a non-modifiable risk factor because individuals cannot change their genetic predisposition. However, individuals can take steps to manage hypertension through lifestyle modifications and medication.

Cultural beliefs: Cultural beliefs may influence health behaviors and attitudes toward health care, but they are not directly modifiable risk factors for heart disease. However, healthcare providers can work with individuals to address cultural barriers and develop culturally sensitive strategies for promoting heart-healthy behaviors.

Air quality: Environmental factors such as air pollution can contribute to cardiovascular disease risk, but air quality is not a modifiable risk factor for individuals on an individual level. However, efforts to improve air quality through environmental policies and regulations can help reduce population-level risk of heart disease.

Supine in low-Fowler's position: This position is not ideal for postural drainage of the left lower lobe as it does not facilitate drainage of secretions from the affected area.

Prone with pillows under the lower extremities: Placing the client in a prone position with pillows under the lower extremities may facilitate drainage of secretions from the posterior segments of the lungs but is not specifically targeted for postural drainage of the left lower lobe.

Right lateral in Trendelenburg position: Placing the client in a right lateral position in Trendelenburg position would not effectively target drainage of secretions from the left lower lobe. Additionally, Trendelenburg position may not be indicated for postural drainage and may pose risks for certain clients, such as those with cardiovascular compromise.

Defamation: Defamation involves making false statements that harm a person's reputation. There is no indication of defamation in this scenario.

Battery: Battery involves the intentional and unauthorized touching of another person. While administering medication by injection without consent could be considered battery, the nurse has only made a threat at this point, not carried out the action.

Invasion of privacy: Invasion of privacy involves intruding into someone's private affairs without permission. There is no indication of invasion of privacy in this scenario.

Use an 18-gauge, 1-inch needle to administer the medication: This instruction is incorrect because heparin is typically administered using a smaller gauge needle (e.g., 25- or 26-gauge) due to its subcutaneous route of administration. Using an 18-gauge needle would be unnecessarily large and may cause discomfort or tissue damage.

Inject 5.1 cm (2 in) away from the umbilicus: This instruction is incorrect because there is no specific recommendation to inject heparin at a distance from the umbilicus. The injection site for heparin administration is typically rotated between the left and right anterolateral and posterolateral abdominal wall, avoiding the umbilicus.

Massage the injection site after withdrawing the needle: This instruction is incorrect because massaging the injection site after withdrawing the needle is not recommended for heparin administration. Massaging the site can increase the risk of bruising and hematoma formation. Instead, the nurse should instruct the client to apply gentle pressure to the site with a clean gauze pad if bleeding occurs.

Extend the client's neck while securing the ties: This action can compromise the client's airway and is not recommended during tracheostomy tie changes. The client's neck should be in a comfortable, neutral position during the procedure.

Use a quick-release knot to secure the ties: Quick-release knots are not typically used for securing tracheostomy ties. Instead, a secure knot that can be easily tied and untied is preferred to ensure the stability of the tracheostomy tube.

Cut the old ties after the new ties are secured: Cutting the old ties before ensuring that the new ties are securely in place can pose a risk of accidental decannulation of the tracheostomy tube. It is essential to secure the new ties before removing the old ones to maintain the airway's patency.

Place the client's arms at their side when turning them: Placing the client's arms at their side during turning may limit movement and comfort. Instead, the nurse should support the client's arms in a position that promotes comfort and maintains proper alignment.

Cross the client's ankles when lying supine: Crossing the client's ankles can lead to compromised circulation and pressure on the bony prominences of the ankles, increasing the risk of pressure injuries. It is not recommended to cross the client's ankles in the supine position.

Logroll the client every 4 hr: Logrolling is a technique used to move clients with suspected spinal cord injuries while maintaining spinal alignment. However, it is not necessary to logroll an immobile client every 4 hours unless there are specific indications, such as suspicion of a spinal injury. Frequent repositioning, including the use of trochanter rolls, is essential to prevent pressure injuries and maintain skin integrity but should be individualized based on the client's needs and condition.

A feeling of swelling in the feet: Swelling in the feet can be caused by various factors such as fluid retention, circulatory issues, or certain medical conditions like venous insufficiency. It is not a typical symptom of anaphylaxis, which usually involves more generalized symptoms such as hives, itching, swelling of the face or throat, difficulty breathing, and a drop in blood pressure.

Pain at the injection site: Pain at the injection site is a common side effect of receiving an injection or medication. It occurs due to tissue irritation or trauma from the needle. While allergic reactions can cause localized redness, swelling, or itching at the injection site, severe pain alone is not a hallmark symptom of anaphylaxis.

A sudden decrease in heart rate: Anaphylaxis typically leads to an increase in heart rate (tachycardia) rather than a decrease. This increase in heart rate is a response to the body's attempt to compensate for the drop in blood pressure caused by anaphylaxis. Bradycardia (a decrease in heart rate) is not a typical feature of anaphylaxis unless it occurs very late in a severe reaction due to profound circulatory collapse.

"I will avoid exposure to the sun." - Exposure to sunlight is essential for vitamin D synthesis, which helps the body absorb calcium and maintain bone health. Therefore, avoiding sunlight would not be beneficial for reducing the risk of osteoporosis.

"I will decrease my intake of dairy products." - Dairy products are a rich source of calcium, which is crucial for bone health. Decreasing intake of dairy products may lead to inadequate calcium intake, increasing the risk of osteoporosis.

"I will take 250 milligrams of calcium once per day." - While calcium supplementation is important for maintaining bone health, the recommended daily intake for older adults is higher than 250 milligrams. The client's statement suggests an inadequate understanding of calcium supplementation for osteoporosis prevention.

"Tell me more about your partner." - While exploring the client's feelings about their partner may be relevant to understanding their current emotional state, it does not directly address the statement indicating suicidal ideation. The priority in this situation is to assess the client's risk of self-harm or suicide.

"You should discuss these feelings with your provider." - While encouraging the client to communicate with their healthcare provider is important, it does not address the immediate concern of potential self-harm or suicide. The nurse should assess the client's safety and provide support before encouraging further discussion with the provider.

"Why did you stop taking your medication?" - While medication non-adherence may contribute to worsening symptoms of depression, it is not the immediate concern in this situation. The client's statement expressing thoughts of dying requires immediate assessment of suicidal ideation and intervention to ensure their safety.

Peppermint oil: Peppermint oil is not typically used as a complementary therapy for hypertension. While it may have some health benefits, such as relieving indigestion and nausea, there is limited evidence to suggest that it has a significant impact on blood pressure.

Licorice root: Licorice root has been associated with raising blood pressure in some individuals due to its effect on cortisol levels. It contains glycyrrhizin, which can cause sodium retention and potassium loss, potentially leading to increased blood pressure. Therefore, it is not recommended for individuals with hypertension.

Chamomile: Chamomile is often used for its calming properties and may help promote relaxation and reduce stress, but there is limited evidence to suggest that it has a significant effect on blood pressure. It is not typically recommended as a primary complementary therapy for hypertension.

Placing wet towels along the base of the door: While this action may help prevent smoke from entering or exiting the room, it is not the immediate priority. Activating the fire alarm takes precedence to alert others to the fire and initiate the appropriate response.

Turning off any electrical equipment: While turning off electrical equipment can reduce the risk of electrical fires, it is not the immediate priority. Activating the fire alarm is the first step to ensure the safety of everyone in the facility.

Directing a fire extinguisher at the fire: While using a fire extinguisher may be necessary to extinguish the fire, it should only be done after activating the fire alarm to ensure that emergency personnel are alerted and responding to the situation.

Asking the family if they wish to assist in washing the client's body:While involving the family in postmortem care can be part of a culturally sensitive practice, it is not the first step. First, the nurse must ensure adequate lighting and appropriate preparation of the environment.

Removing the client's dentures for their family to keep:This action may be appropriate but is not the first step. Prioritizing the removal of dentures over other essential tasks such as adjusting the lighting is not necessary.

Leaving the client's eyes open until the family views the body:
Leaving the client's eyes open may be culturally appropriate in some cases, but it is not the initial step in postmortem care. Adjusting the lighting and preparing the environment take precedence.

Administer the client's insulin dose using a tuberculin syringe:While using an appropriate syringe for insulin administration is important, ensuring the accuracy of the dosage precedes the actual administration. Therefore, verifying the dose takes precedence over selecting the syringe.

Use a filter needle when withdrawing medication from the multidose vial:While using a filter needle can be beneficial to prevent contamination, ensuring the correct dosage is more critical in preventing adverse effects associated with incorrect insulin administration.

Mix the client's long-acting and rapid-acting insulin dose in one syringe:Mixing different types of insulin in one syringe is not standard practice unless specifically instructed by a healthcare provider. This step should be performed only if explicitly ordered an

Urinary catheter care:While urinary catheter care is important for maintaining urinary hygiene and preventing urinary tract infections, it is not as urgent as addressing respiratory needs. If the client is stable and not experiencing acute urinary retention or other urinary complications requiring immediate intervention, urinary catheter care can be performed after addressing respiratory concerns.

Wound irrigation:Wound irrigation is typically performed to clean and debride wounds, promoting healing and preventing infection. While wound care is essential for preventing complications, it is not as urgent as ensuring adequate respiratory function, particularly in a client with an artificial airway requiring suctioning.

Enteral feeding:
Enteral feeding is crucial for providing nutrition to clients who cannot consume adequate nutrients orally. However, initiating enteral feeding can wait until the client's respiratory needs are addressed, as the immediate priority is to ensure effective breathing and oxygenation.

Use one patient identifier prior to medication administration.Explanation: Using at least one patient identifier, such as the patient's name or date of birth, is a standard safety practice to confirm the patient's identity before administering any medication. This helps ensure that the medication is given to the right patient, reducing the risk of administering medications to the wrong individual.

Access the online drug formulary for an unfamiliar medication.
Explanation: While it's essential to be knowledgeable about medications, relying solely on an online drug formulary for unfamiliar medications may not be sufficient for safe administration. Online resources can provide valuable information, but they should supplement, not replace, comprehensive education and understanding of medications. Nurses should have a solid understanding of the medications they administer and consult additional resources as needed.

Ask the client if they have ever taken a similar medication.Explanation: While it's important to gather information from the patient about their medical history and previous experiences with medications, solely relying on the patient's response may not be sufficient for ensuring safe medication administration. Patients may not always accurately recall or provide complete information about their medication history. Nurses should verify medication orders through appropriate channels and rely on documented medical records whenever possible to confirm medication history and suitability for administration.