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• Pros:Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
• Cons:While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.

• Cons:Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.

• Cons:While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.

Apply the skin sealant on damp skin. Rationale: Applying skin sealant on damp skin is not the recommended approach for securing an ostomy appliance. It's important to ensure that the skin is clean and dry before applying the sealant or the skin barrier. Moisture can compromise adhesion and lead to skin irritation or appliance detachment.

Remove the appliance before emptying the pouch. Rationale: Removing the appliance before emptying the pouch is not a necessary step when changing an ostomy appliance. Typically, the pouch can be emptied without removing the entire appliance, which helps maintain the seal and reduces unnecessary skin exposure.

Ensure that the skin is slightly damp for better adhesion of the pouch. Rationale: Ensuring that the skin is slightly damp is not advisable for better adhesion of the pouch. The skin should be completely dry before applying the pouch to ensure proper adhesion. Moisture on the skin can lead to leakage or detachment of the appliance.

Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.

Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.

Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.

Instructing the client's loved ones that the client should not have fresh flowers in their room (Choice A) is not a necessary action for rubella isolation. Rubella is transmitted through respiratory droplets, and the prohibition of fresh flowers is not a relevant precaution.

Placing the client in a room with negative-airflow pressure (Choice C) is not specifically indicated for rubella isolation. Negative-airflow pressure rooms are typically used for diseases that require strict airborne precautions, such as tuberculosis.

Instructing the client that visitors will not be allowed while they are in isolation (Choice D) is not entirely accurate for rubella isolation. While isolation precautions are necessary, visitors can enter the room if they are properly protected, including wearing masks and following infection control protocols.

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

Peer pressure (Choice A) is an external stressor, as it involves the influence of others on an individual's thoughts or actions. It originates from outside the individual and is not directly related to an internal psychological response.

Death of a family member (Choice B) is an external stressor, as it is an event that occurs externally to the individual. While it can cause significant emotional distress, it is not considered an internal stressor.

Job transfer to another city (Choice D) is an external stressor, as it involves a change in the individual's external environment. It is not an internal psychological factor causing stress.

Suggestions for the provider regarding client care are typically included in the "assessment" or "recommendation" portions of the SBAR communication tool, rather than the "background" portion. The "background" portion is focused on providing information about the current situation and the client's present condition, setting the stage for the rest of the communication.

Physical findings are part of the assessment and observation of the client's current condition. While important, these findings are better suited for the "assessment" portion of the SBAR communication. The nurse should summarize the physical findings in the "assessment" section after providing the context in the "background" section.

Previous treatments are also relevant information, but they belong in the "assessment" or "background" portions of the SBAR communication tool. The nurse should provide the provider with information about the client's current condition before discussing previous treatments, as the provider needs to know the current situation before considering the relevance of past interventions.

1 cup of shredded lettuce is low in potassium and is not the best source of potassium for a client with heart failure. While vegetables like lettuce are generally healthy, they do not provide a significant amount of potassium.

1 oz of tuna is a source of protein but is not particularly rich in potassium. While protein intake is important for overall health, other choices on the list provide more potassium, which is specifically needed for clients with heart failure.

1 cup of raspberries is a good source of fiber and antioxidants, but it is not as rich in potassium as cantaloupe. While raspberries can be a healthy addition to the diet, they are not the best choice for addressing potassium needs in this scenario.

Elevating the head of the bed when caring for a deceased client (post-mortem care) is an appropriate action. This helps prevent blood pooling and discoloration in the dependent areas of the body, promoting a more natural appearance during the viewing. This action ensures respectful and dignified care of the deceased.

Using a clean washcloth, soap, and water for indwelling catheter care is incorrect. The appropriate method for catheter care involves cleaning the area around the insertion site with antiseptic solution or the solution provided by the facility. Using soap and water can introduce contaminants and increase the risk of infection.

Using scissors to remove tape securing a peripheral IV catheter is an appropriate action. It helps prevent accidental pulling of the catheter during removal and minimizes patient discomfort. Scissors are a safe tool to detach tape, ensuring a smooth and painless removal process.

Assuming that learners have no prior knowledge of first aid might not be the best approach. Adult learners often come with varying levels of knowledge and experience. It's important to assess the learners' prior knowledge and adjust the content accordingly to avoid redundancy or information that is too basic for them.

Repetition of procedures and techniques is a valuable teaching strategy. Repetition aids in retention and comprehension. Reiterating important points reinforces learning and helps participants remember critical steps in first aid procedures. Avoiding repetition can lead to incomplete understanding and retention.

Dividing the planned program into several sessions held about 1 week apart might not be the most effective strategy for community education. Spacing the sessions too far apart could result in learners forgetting the content or losing interest. It's better to maintain a consistent schedule to ensure continuity and engagement.

Placing a sterile kit on the overbed table above waist level is incorrect. Sterile fields need to be set up at or below waist level to ensure that they remain within the nurse's line of sight and control. This minimizes the risk of contamination and maintains the sterility of the field.

Turning their back to the sterile field when coughing during the procedure is incorrect. Proper aseptic technique involves turning away from the sterile field and coughing or sneezing into a tissue or elbow while maintaining a distance from the sterile area. This prevents the dispersal of microorganisms onto the field.

Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is incorrect. The appropriate technique is to hold the gauze slightly above the sterile field to allow it to fall onto the field without direct contact. Holding it 12 inches above is unnecessary and might increase the risk of dropping it from too high, potentially contaminating the field. The height should be minimal to avoid unnecessary air currents.

The walking gait test is used to assess a client's walking pattern and balance, particularly for identifying abnormalities in gait. However, it doesn't specifically evaluate sensory functions, making it an inappropriate choice for this scenario.

The plantar reflex test, also known as the Babinski reflex test, assesses the neurological integrity of the corticospinal tract. It involves stimulating the sole of the foot to elicit specific reflex movements. While this test is important in assessing neurological function, it doesn't directly evaluate sensory functions as requested in the question.

The Romberg test evaluates a client's balance and proprioception. It involves having the client stand with their feet together and their eyes closed to assess their ability to maintain balance without visual input. While this test is relevant to sensory functions, it primarily assesses proprioception and balance rather than coordination, which the question is specifically targeting.

Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.

Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.

Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.

Cleaning reusable equipment with isopropyl alcohol before removing it from the client's room is not the appropriate approach for preventing Clostridium difficile infection transmission. While cleaning equipment is important, this choice does not address the primary mode of transmission, which is through contaminated hands.

Wearing a mask when within 3 feet of the client is not a specific measure for preventing the transmission of Clostridium difficile infection. This infection is primarily transmitted through the fecal-oral route, and mask usage does not directly address this mode of transmission.

Wearing gloves when changing the client's hospital gown is an important infection control measure, but it does not specifically address the prevention of Clostridium difficile transmission. Gloves are essential to prevent contact with bodily fluids and contaminated surfaces, but hand hygiene is the primary focus for C. difficile prevention.

Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.

Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.

Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.

Verifying the client's gastric pH to be at least 7 prior to feeding is not necessary for administering intermittent enteral feedings. Gastric pH varies widely among individuals and is not a standard requirement before every feeding.

Pouring the client's formula into the syringe and adjusting the syringe's height to control the rate of flow is not recommended. Controlling the rate of flow in this manner is imprecise and can lead to inconsistent delivery of the formula, potentially causing discomfort or complications.

Applying sterile gloves before accessing the client's gastrostomy tube is an important step in infection control, but it is not specifically related to administering intermittent enteral feedings. Sterile gloves are essential to prevent contamination and infection during tube maintenance and insertion, not during the feeding process itself.

The client's statement about scheduling an electrophysiologic study is unrelated to the teaching about kyphosis and osteoporosis. Electrophysiologic studies are used to evaluate the electrical activity of the heart, and they are not directly relevant to the client's bone health or the management of kyphosis and osteoporosis.

The client's statement about wearing a neck brace while sleeping to prevent injury is incorrect and indicates a misunderstanding of the teaching. Kyphosis primarily affects the thoracic (upper/mid-back) spine and is not typically associated with wearing a neck brace. Neck braces are more commonly used for cervical spine issues.

The client's statement about avoiding weight-bearing exercise to minimize trauma is incorrect and demonstrates a misunderstanding of the teaching. Weight-bearing exercise, such as walking and strength training, is important for maintaining bone density and muscle strength, which are critical for individuals with kyphosis and osteoporosis. Avoiding weight-bearing exercise could actually lead to further bone loss and weakness.

Chronic grief is characterized by a prolonged and ongoing sense of loss that doesn't seem to improve with time. It doesn't directly relate to maladaptive coping, which the client in the scenario is exhibiting. Chronic grief may involve a persistent yearning or sadness for the deceased, but it doesn't necessarily involve maladaptive coping strategies.

Delayed grief refers to a situation where the emotional response to a loss is significantly postponed, often resulting in a delayed and intense reaction later on. It doesn't necessarily involve maladaptive coping, as seen in the client's case.

Masked grief occurs when the grieving person's behavior and emotional responses are influenced by the loss but not recognized as being related to it. This can lead to various physical or psychological symptoms that mask the true underlying cause, the grief. While maladaptive coping can sometimes be seen in masked grief, it doesn't directly correlate with the client's substance use in this scenario.

0.8 mL is not the correct amount of diazepam to administer. As mentioned earlier, the correct calculation for a 2 mg dose of diazepam using the available oral solution (5 mg/1 mL) is 0.4 mL.

The correct answer is 1 mL. The client is prescribed 2 mg of diazepam, and the oral solution is 5 mg/1 mL. To administer a 2 mg dose, the nurse should give 2 mg / 5 mg/mL = 0.4 mL. Since the available solution concentration is 5 mg/1 mL, the nurse should administer 0.4 mL to deliver the prescribed dose of 2 mg.

1.6 mL is not the correct amount of diazepam to administer. To achieve a 2 mg dose of diazepam using the available oral solution (5 mg/1 mL), the nurse should administer 0.4 mL, as calculated in the previous explanations.

Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.

The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.

Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.

Emergency contact information is important, but it is usually found in a separate section of the medical record, not specifically in the discharge summary. It is critical information, especially in case of emergencies, but it's not a standard component of the discharge summary.

The intake and output summary is generally more relevant during the client's stay in the healthcare facility. It provides information about the fluids the client has taken in and eliminated, which is crucial for monitoring their hydration status and renal function. However, it is not typically included in the discharge summary.

The list of community resources can be helpful for a client's transition to home care, but it is not a standard component of a discharge summary. This information might be provided separately to the client to facilitate their access to appropriate community resources after discharge.

Breathing normally while performing relaxation techniques is not accurate. Progressive relaxation involves a systematic tensing and relaxing of muscle groups while controlling your breath. Slowing down the breath and focusing on relaxation techniques can enhance the effectiveness of the exercise.

Comparing sensations while tensing and relaxing muscles is not a step in progressive relaxation. The technique involves focusing on each muscle group, tensing it, and then releasing the tension while paying attention to the contrast between tension and relaxation. This comparison aids in increasing body awareness and promoting relaxation.

Using a series of stretches is not characteristic of progressive relaxation techniques. Progressive relaxation primarily involves muscle tensing and relaxing, rather than stretches. Stretching can be a separate technique for relaxation, but it is not typically combined with progressive muscle relaxation

Justice refers to the fair distribution of resources and benefits. It pertains to treating individuals equitably and ensuring that their rights are respected. However, in this scenario, the nurse is specifically addressing the client's right to refuse treatment, which aligns more with the concept of autonomy.

Veracity is the principle of truthfulness and honesty in communication between healthcare professionals and clients. While it is an important ethical principle, it does not directly relate to the client's right to refuse treatment. This right falls under the principle of autonomy, where individuals have the right to make decisions about their own healthcare, including the decision to refuse treatment.

Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and being dedicated to the well-being of the client. While respecting the client's autonomy is part of being faithful to their needs and preferences, the specific right to refuse treatment is better categorized under the principle of autonomy.

Planning to insert an oral airway if seizure activity begins is not a suitable intervention for a client with a history of seizures. During a seizure, it's essential to protect the client from injury by preventing them from aspirating secretions or foreign objects. However, inserting an oral airway during an active seizure can be dangerous and lead to injury.

Administering pain medication after the seizure is not a priority intervention. While some clients may experience muscle soreness or discomfort following a seizure, the primary focus during and immediately after a seizure is ensuring the client's safety and preventing injury. Pain medication can be considered later if necessary.

Placing the client in a supine position during a seizure is not recommended. It's important to position the client on their side (lateral recumbent position) during a seizure to allow any oral secretions or vomit to drain from the mouth, reducing the risk of aspiration. Placing the client supine could obstruct the airway and increase the risk of aspiration.

Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.

Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.

Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.