PrepU chapter 47 Next Generation - NGN

An adult has been admitted to the intensive care unit following a cerebrovascular accident. The client is uncounscious and the plan of care includes passive range-of-motion exercises.

The nurse should move each joint both internally and externally, which results in relief of stasticity.

A famous actor with bipolar disorder has been admitted in the mental health unit for treatment. A well known news outlet has offered the nurse several thousand dollars to provide information or a picture of the client. The nurse knows that it is their professional duty and legal responsibility to uphold privacy and confidentiality. For each of the behaviors exhibited by the nurse, click to specify whether the behavior upholds the principle of privacy or confidentiality.

Confidentiality -sharing client information only to the caregivers directly assigned to client care -logging off the electronic health record after documenting assessment information -asking the client to sign a medical release form before providing information to the health insurance company Privacy -keeping the door closed while conducting physical assessment - obtaining the client's permission before allowing a student nurse to assist with care

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care? Select all that apply. current chemotherapy treatment dyspnea with exertion prescription for warfarin recent unwitnessed fall altered mental status prescription for carvedilol low platelet count diagnosis of periodontitis

prescription for warfarin diagnosis of periodontitis current chemotherapy treatment low platelet count

A middle-aged adult was rushed to the emergency department after sustaining a broken ankle due to a fall. The client only speaks German and the nurse only speaks English. An interpreter was asked to help. Which action(s) should be implemented? Select all that apply. Obtain the interpreter's advice when dealing with sensitive or delicate topics. Choose an interpreter of the same gender and approximate age as the client. Ask questions that are answerable by a yes or no. Allow a family member to help with the translation. Use metaphors and analogies. Allow adequate time for the interpreter to translate. Look at the interpreter when asking questions. SUBMIT ANSWER

-Ask questions that are answerable by a yes or no. -Allow adequate time for the interpreter to translate. -Choose an interpreter of the same gender and approximate age as the client. -Obtain the interpreter's advice when dealing with sensitive or delicate topics. he nurse will ask direct questions to eliminate the need for lengthy explanations. Thus, this will help to facilitate communication. The nurse will anticipate that the interpreter may take time translating information, especially if medical terms are used. When possible, it is best to choose an interpreter of the same gender and approximate age as the client to faciliate comfort. Because sensitive information is being shared, the nurse will try to select an interpreter with whom the client shares something in common with may enhance rapport. The interpreter serves as the key informant of the client's culture; therefore, it is best for the nurse to ask for the interpreter's advice when dealing with sensitive and delicate topics. The nurse will use short and simple phrases or sentences to facilitate understanding. Metaphors and analogies are difficult to translate; hence, they should be avoided. When asking questions, the nurse should look at the client, not at the interpreter. Looking at the client and maintaining eye contact facilitate interpretation and understanding of nonverbal cues. Moreover, it suggests that the focus of care is on the client. Although having a family member translate may seem like the easiest option for the nurse, it is important that to use an interpreter with an understanding of the health care system. Family members or friends of the client may feel protective of the client and choose to only relay partial information. For this reason, the guidelines discourage using family or friends as translators.

A nurse is providing care for an older adult who is unable to get out of bed. Intake and output records indicate a possible alteration in urinary elimination. Click to identify the findings that can impair the amount of urinary output. Client is alert and oriented × 4. Client is verbal, but with dysphasia , as associated with recent cerebrovascular accident . Client reports a high level of stress associated with recent social changes. Respirations even and unlabored. Continued reports of sneezing that is slightly improved with the use of antihistamines for seasonal allergies. Cardiac rhythm is regular and rate within normal limits. Edema of 2+ to bilateral feet , improved from 3+ following a.m. diuretic administration and elevation of bilateral lower extremities. Bowel sounds positive x 4, denies diarrhea or constipation.

Explanation: Impaired neurologic function caused by disorders such as cerebrovascular accidents, tumors of the brain, or spinal injury can reduce the perception of bladder fullness. A high level of stress can either cause a strong need to urinate or it could contribute to urinary retention. Anticholinergic medications such as antihistamines and tricyclic antidepressants can cause urinary retention. Anticholinergic medications such as antihistamines and tricyclic antidepressants can cause urinary retention. A cognition of alert and oriented × 4 is a positive factor and normal finding that would not alter elimination. The ability to verbally communicate effectively does not impair or alter the function of the genitourinary system. Social changes may be positive or negative and are not associated with altered urinary output. Even and unlabored respirations are normal factors that would not alter urinary function. Sneezing is a respiratory symptom associated with allergies but not with urinary function. A regular cardiac rhythm and rate are positive and normal findings not associated with urinary elimination. The presence of edema is a consequence of fluid overload, which can be reduced with elevation, but does not directly alter the production of urine. Gastrointestinal findings such as positive bowel sounds or the lack of diarrhea or constipation are normal findings that would not affect urinary output.

After caring for a pediatric client, the nurse is surprised to learn about being named in a malpractice lawsuit. Select the four actions that meet the legal requirements of malpractice. The nurse does not have a professional liability insurance. The client suffered an injury. The nurse failed to provide appropriate care. The nurse should have signed a written contract with the client or client's legal guardians. The nurse has the duty to care for the client. The nurse's lack of action directly resulted in harm. The nurse should admit being at fault.

The client suffered an injury. The nurse has the duty to care for the client. The nurse failed to provide appropriate care. The nurse's lack of action directly resulted in harm. Malpractie refers to professional negligence. It stipulates that professionals are accountable for their actions. To prove malpratice, four elements must be present, one of which is damage or injury. The client should have suffered an injury as a result of the nurse's action or inaction. Another element that needs to be established to prove malpractice is duty. The nurse is obligated to provide care for the client concern. Breach of duty, described as the failiure to provide appropriate care, is the third element needed to prove malpractice. The last element is causation, which shows that the nurse's action or inaction caused the injury. Professional liability insurance is required for nurses, because it provides legal and financial services in case of a malpractice lawsuit. Not having professional liability insurance is not, however, an element needed to prove malpractice. Admission of guilt does not establish malpractice. A written legal contract between the nurse and the client or the client's legal guardian is unnecessary. Contracts with clients are usually implied. The nurse is expected to exhibit competence in providing client care. A written contract is not an element needed to prove malpractice.

While the nurse conducts a comprehensive cultural assessment on a client with metastatic colon cancer the client states, "The pain with this cancer is God's way of punishing me for all the drinking and bad things I did in the military. I lost so many friends in the war that I look forward to having a few beers with them after I die." The nurse will use questions to explore the client's statement. Click to specify whether the nurse's question obtains information about health beliefs and practices or cultural sanctions/restrictions.

Health Beliefs/Practices How much alcohol do you use daily? How do you control your pain? Cultural Sanctions/Restrictions -Have you experienced flashbacks to your military years? -Are you part of a faith community? -How do you express emotions or feelings?

The nurse is caring for a 30-year-old dental hygienist presents to the emergency department (ED) with a throbbing headache uncontrolled by home medications. Client has a history of migraine headaches and asthma. Allergies to avocado and bananas. No other significant medical history.

Improved nausea allergic response blood pressure pulse oximetry Declined headache No change temperature

A new prescription has been noted in the medical record for an adult client with chest pain to receive a medication that comes in the form of a transdermal patch. The nurse will consider which precaution(s) to ensure safety with this form of drug use?

May cause injury with defibrillation. Fold the patch in half before disposal. Assess for fever prior to application. Remove the patch prior to magnetic resonance imaging (MRI). Monitor the client for early identification of adverse effects.

The nurse discovers during assessment that the client has an altered temperature. Select one caustive factor for each type of heat loss.

Radiation: infrared heat waves conduction: the air itself by shivering Evaporation: through sweating by uncovered body surfaces Convection: exposure to a fan

The following statements are examples of communication blocks.

Being Moralistic -"Everybody should be allowed to die if they want to." -"Why did you not use a condom? They are given at the clinic for free." Nonprofessional Involvement -"I think you should get a second opinion because your health care provider has had a lot of complaints against him." -"My ex-boyfriend did not come pick up the kids again and I did not get much sleep last night." False Reassurance -"Do not worry, this is a minor surgery. You will do great!" -"Injecting insulin is nothing for you to worry about. Even children can do it!"

A nurse has been assigned to sit overnight with a client who has been demonstrating unsafe actions. The charge nurse asks the the nurse to monitor the client closely to help identify any deficits in sleep quality. For each characteristic, click to specify if it is consistent with the Rapid Eye Movement (REM) and/or the Non-Rapid Eye Movement (NREM) stage of sleep. Each characteristic may support more than one stage.

changes in blood pressure REM/NREM decrease in muscle mobility REM increase in heart rate REM increase in body temperature REM reduction in metabolism NREM The stage of sleep classified as Rapid Eye Movment (REM) is characterized by an immobility of muscles that resembles paralysis. During REM sleep, an increase in physiologic functions such as heart rate takes place. Metabolism is also increased, which results in an increase in body temperature. During the Non-Rapid Eye Movement (NREM) stage of sleep, physiologic functions are slowed down. This includes metabolism, which results in a reduction of temperature. Both REM and NREM sleep stages include variations in blood pressure. During NREM sleep the blood pressure is reduced, whereas in REM sleep blood pressure may increase or flucturate.

A client is being discharged to home following a diagnosis of lung carcinoma and subsequent treatment with pneumectomy surgery. The client has a prescription for continuous home oxygen. Which measure(s) will the nurse include in a teaching plan aimed at increasing oxygen-related home safety? Select all that apply. Post a "no smoking" sign in a conspicious area. Keep burnable solids away from portable concentrators. Avoiding storing oxygen in cooler areas of the home. Use caution with gas or electrical appliances. Ensure tanks are stored at least 3 feet away from fire sources. Ensure concentrators are stored flush against a wall.

Post a "no smoking" sign in a conspicious area. Use caution with gas or electrical appliances. A "no smoking" sign should be posted in a conspicious area to prevent any smoking within the home or around areas where oxygen is in use. Gas or electrical appliances may produce a spark or fire that will combust more easily if in an area of high oxygen saturation. Oxygen concentrators should be stored away from walls to ensure adequate airflow around the device. Burnable liquids such as oils, greases, and alcohols, not solid items, away from portable concentrators. Oxygen tanks should be stored at least six, not three, feet away from sources of fire to reduce the possiblity of combustion. Oxygen should be stored away from direct sunlight and heat, not cool areas.

The nurse obtains a health history interview on a client with lung cancer. The client states, "I became too focused at work; I did not have time to rest. I usually work 8 hours per day but, for the past few months, I have been spending at least 12 hours per day at the office. That is probably the reason why I was diagnosed with cancer. Maybe when I try to go back to my usual schedule, the cancer will go away. I did not want to be here but my wife is insistent. I do not think medications work. My brother-in-law died of cancer. He took a lot of medicines and prayed really hard, but he died just the same."

The nurse determines that the client believes in the holistic cause of illness as manifested by believing one can be cured of cancer by limiting work hours

The charge nurse in the oncology unit is preparing the shift assignments. The unit is fully staffed: unlicensed assistive personnel (UAP), licensed practical nurse (LPN), and registered nurse (RN).

Unlicensed Assistive Personnel (UAP) -calculating the total intake and output for the entire shift -collecting a stool specimen for hemoccult Licensed Practical Nurse (LPN) -administering a pain medication intramuscularly -inserting an indwelling urinary catheter Registered Nurse (RN) -obtaining an admission assessment on a client -administering an intravesical chemotherapy

While the nurse conducts a comprehensive cultural assessment on a client with metastatic colon cancer the client states, "The pain with this cancer is God's way of punishing me for all the drinking and bad things I did in the military. I lost so many friends in the war that I look forward to having a few beers with them after I die." The nurse will use questions to explore the client's statement. Click to specify whether the nurse's question obtains information about health beliefs and practices or cultural sanctions/restrictions.

Assessment Questions Health Are you part of a faith community?Cultural Sanctions/Restriction Have you experienced flashbacks to your military years? Cultural Sanctions/Restrictions How do you express emotions or feelings?Cultural Sanctions/Restrictions How much alcohol do you use daily?Cultural Sanctions/Restrictions How do you control your pain?Health Beliefs/Practices The nurse listens to the client responses and asks more specific questions to gain understanding of the client's cultural and health beliefs and practices. Health beliefs and practices influence nursing care. These factors help the nurse recognize client's health-seeking behaviors and activities that promote, maintain, and restore health. Specific questions may be used to assess health beliefs and practices. Cultural sanctions/restrictions are a means of encouraging individuals belonging to a specific culture to conform to cultural norms. To obtain information about cultural sanctions/restrictions, the nurse may ask clients about their culture, such as military service or how they express emotions.

A nurse is caring for a client who has urinary incontinence associated with a flaccid neurogenic bladder. Drag words from the choices below to fill in each blank in the following sentence.

The nurse will implement in-and-out catheterization because the client has total urinary incontinence.

A new prescription has been noted in the medical record for an adult client with chest pain to receive a medication that comes in the form of a transdermal patch. The nurse will consider which precaution(s) to ensure safety with this form of drug use? Select all that apply. Fold the patch in half before disposal. Assess for fever prior to application. Apply patches at the same location for consistency. May cause injury with defibrillation. Dispose of transdermal patches in the trash. Monitor the client for early identification of adverse effects. Use a heating pad to increase absorption. Remove the patch prior to magnetic resonance imaging (MRI).

-May cause injury with defibrillation. -Fold the patch in half before disposal. -Assess for fever prior to application. -Remove the patch prior to magnetic resonance imaging (MRI). -Monitor the client for early identification of adverse effects. Burns to the skin and smoke may occur if a patch is in place during defibrillation. A transdermal patch should be folded in half after removal to prevent nurse making contact with the medication or inadvertently transferring the medication onto another surface. A fever higher than 102°F (39°C) may be a contraindication to use, because the heat may increase the rate of absorption. A transdermal patch may cause burning to the skin, if the patch is in place while the client is undergoing magnetic resonance imaging (MRI). The use of a transdermal patch carries the same risk as the medication given in other forms. The client should be evaluated accordingly for potential adverse effects. The nurse will follow facility protocols to dispose of a transdermal patch, often in facility-approved containers and sometimes with a second nusre as a witness. Application sites should be rotated with each application to prevent local skin irritation. Direct heat, such as that provided by a heating pad or a sun lamp, should be avoided. Local heat provided by the palm of the hand may be used initially to help facilitate adhesion

To facilitate decision-making, the nurse makes use of the ethical principles as a guide. For each nursing intervention, click to specify whether the action upholds the ethical principle of beneficence, nonmalificence or autonomy.

Nonmalificene -putting the client's scheduled furosemide on hold because of hypokalemia -informing the health care provider that the client's antipsychotic medications are causing suicidal ideations -reporting an impaired nurse to the nurse supervisor Benifience -applying an ice pack to the client's swollen ankle -administering morphine sulfate for the client's abdominal pain Autonomy -answering all of the client's questions about their care before obtaining consent to proceed -providing information in the client's primary language to ensure the client's full understanding -withholding a medication after the client has refused and notifying the health care provider

A 2-year-old child with specialized nutritional needs is receiving care in the home. The plan of care includes provision of enteral nutrition through a gastrostomy tube every 3 hours. For each nursing intervention below, click to specify the associated rationale.Note: Each nursing intervention must have at least one associated rationale.

Nursing Intervention Measure the length of the external tube. rationale: reduces the risk of aspiration Nursing Intervention Elevate the head of bed at least 30 degrees. rationale: facilitates the flow of feeding to the gut Nursing Intervention Confirm pH of aspirate is less than 5.5. rationale: useful in verifying correct placement Nursing Intervention Replace all gastric contents following measurment of aspirate. rationale to prevent electrolyte imbalance

The nurse works in a unit where the staff nurses can pick their own work schedule in exchange for being on call at least one weekend in a month. However, once the staff nurse refuses to come in when called in to work, the staff nurse loses the flexibility to choose their work schedule for the next 2 months. Complete the following sentence by choosing from the lists of options. The institution implements a______ leadership style as evidenced by the __________

The institution implements a transactional autocratic leadership style as evidenced by the task-and-reward orientation

A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity. For each activity, click to specify whether it fulfills the circulation, motor function, or sensation section of the assessment.

pallor Circulation paralysis Motor function numbness Senstation pain Motor function temperature Circulation When assessing for circulation, the nurse will check the color, temperature, pulses, and capillary refill. The nurse can assess motor function or movement of the extremity by asking the client to move the extremity. Pain with movement is a sign of neurovascular impairment. Paralysis, or the inability to move the extremity, is another sign of impairment. Assessing for sensation is an important part of a neurovascular assessment. The presence of parasthesias, such as numbness or tingling, is a sign of neurovascular damage.

A nurse is caring for a 3-year-old child that was admitted with pneumonia. The parent expresses concerns about the child's respirations. The nurse is providing education about respiratory-related developmental changes to help the parent differentiate what is normal from what is abnormal. For each assessment finding click to specify if the finding indicates the client's condition is normal or abnormal.

respiratory rate of 28/min normal thoracic breathing abnormal inspiration longer than expiration abnormal irregular respiratory pattern normal round thorax abnormal The normal respiratory rate for a 3-year-old child is between 20 and 32 breaths/min, depending on the source used. It is a normal finding for children up to 5 years of age to have an irregular respiratory pattern. It would be abnormal for a 3-year-old child to have thoracic breathing, because children up to 5 years of age demonstrate irregular breathing patterns. For these children, the parent can expect to find the expiration is longer than the inspiration. The thorax of a 3-year-old child should be eliptical, not round.

The nurse reviews the medical records of several clients scheduled for routine follow-up at the gynecology clinic. The nurse determines that a conventional Papanicolaou (Pap) test is indicated for which client(s)? 45-year-old client who had a negative Pap test 4 years ago 21-year-old client who has never had a Pap test done before sexually active 16-year-old client 30-year-old client at 29 weeks' gestation with a negative Pap test done 2 years ago 32-year-old client who has been vaccinated with human papillomavirus and has never had a Pap test done 25-year-old client who has never had sex 67-year-old client with unremarkable Pap test findings on three consecutive tests

45-year-old client who had a negative Pap test 4 years ago 21-year-old client who has never had a Pap test done before 25-year-old client who has never had sex 32-year-old client who has been vaccinated with human papillomavirus and has never had a Pap test done A conventional Pap test, also known as a liquid-based cytology test, is a test used in determining cellular cervical changes. It is helpful in detecting cervical cancer. The test is indicated for women from 30 to 65 years old; the test should be done every 3 years. Because the client is 45 years old and has had the latest Papanicolaou (Pap) test 4 years ago, the client is due for another test. Women 21 years of age and older are encouraged to have a conventional Pap test done every 3 years until age 29. Therefore, the 21-year-old client who has never had a Pap test done is due to be tested during this visit. Women 21 years of age and older are encouraged to have a conventional Pap test done every 3 years until age 29. Therefore, the 21-year-old client who has never had a Pap test done is due to be tested during this visit. A conventional Pap test is recommended to be performed every 3 years for women 21 to 29 years of age regardless of sexual history. Clients who have received a human papillomavirus vaccine should still receive a regular Pap test based on the guidelines. Because the client has not had a Pap test done before, the client is due to receive the test during this visit. Women older than 65 years of age who have had negative Pap test results on three consecutive tests are no longer required to have one. For women 30 to 65 years old, a conventional Pap test should be done every 3 years. Since the client had her Pap test done 2 years ago, she is due for another test in a year.

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system. Complete the table by selecting the intervention associated with each body system.

Cardiac Provide verbal stimulation. Respiratory Assess skin color. Neurologic Gently touch the client. Providing verbal stimulation helps to expel anesthetic gases, facilitate an increase in consciousness, and subsequently increase blood pressure. Skin color can be assessed as a determinant of efficient or deficient oxygenation of tissues. The nurse can verbally reorient the client following anesthesia using a gentle touch and addressing the client by name. Noting the response to stimulation is a means of assessing a client's neurologic status. Monitoring urinary function will help to determine renal function. The nurse can help to prevent aspiration or airway obstruction by placing lethargic or uncounscious clients in a sidelying position. Constant reorientation in the postoperative period helps to provide psychologic comfort. Pupillary response is an assessment used to determine neurologic status. Bowel sounds are an indicator of bowel motility that must be established prior to the client taking food or drink by mouth. Monitoring muscle strength is a means of assessing neurologic status. Interventions such as monitoring reflexes will help the nurse to identify when anesthetics are wearing off. Assessing the dressing for drainage can be an indicator of fluid loss which can adversly affect cardiovascular function. The performance of leg exercises helps to promote circulation. Provision of a warm blanket helps to reduce shivering, which can contribute to hemodynamic stress and cardiac disturbances. Monitoring laboratory values, for example hematocrit, to help assess circulatory status.

A middle-aged female client visits the clinic to confirm pregnancy. "I cannot believe this is happening. I cannot be pregnant. My parents will kill me. I was raised in a strict Roman Catholic home. I was not supposed to get pregnant before marriage." Complete the following sentence by choosing from the lists of options. The client is exhibiting signs of spiritual______realted to the _______

The client is exhibiting signs of spiritual guilt related to the inability to live up to devout practices disengagement from faith community The client is exhibiting spiritual guilt related to the inability to live up to devout practices. Because the Roman Catholic doctrine prohibits getting pregnant before marriage, the client feels that they have betrayed their family and their religion. Spiritual anger pertains to feelings of outrage or frustration against an ultimate or higher power. Spiritual alienation refers to feelings of separation or estrangement from a supreme power or being. Clients experiencing spiritual alienation may feel that they are detached from their faith source. Birth control and abortion are prohibited in the Roman Catholic religion. These rules may make the client feel disengaged from their faith if this situation is making the client reconsider their options related to pregnancy. The feeling of questioning their belief and value systems is characteristic of spiritual anxiety. The client's comments indicate that the client has not yet fully accepted the pregnancy. The client is displaying risk factors characteristic of spiritual pain because the client is unable to reconcile being pregnant before marriage and the religious teachings.

The nurse is caring for a 25-year-old client admitted to a medcial surgical unit after an emergency appendectomy. The newly admitted client has been assigned under the nurse's care. As part of the care plan, the nurse sets specific client goals. For each of the goals set by the nurse, click to specify whether it belongs to the orientation, working or termination phase.

Working Phase -The client states, "I know I have to get up and moving so I do not get pneumonia." Termination Phase -The client verbalizes understanding of what signs indicate infection and when to contact the health care provider. Orientation Phase -The client is able to call the nurse by name and demonstrate how to use the call light. Working Phase -The client states, "Using the pillow to splint my abdomen when I cough, really helps." The orientation phase is the initial phase of the nurse-client relationship. During this phase, specific client and nurse roles are discussed, including the duration of the therapeutic relationship. The nurse also orients the client to the room and environment as well as identify oneself by name. After the initial orientation, the client should be able to verbalize understanding of the room including being able to demonstrate how to use the call light and identify the nurse by name. The second phase of the nurse-client relationship is the working phase. Participation and cooperation between the nurse and the client are the highlights of this phase. In addiiton, verbalization of concerns and feelings also occur in the working phase. The nurse takes on the role of teacher during this phase by instructing and motivating the client to implement health-promoting activities meant to facilitate the client's ability to execute the nursing plan. The client 's statements, "I know I have to get up and moving so I do not get pneumonia," and "Using the pillow to splint my abdomen when I cough, really helps" indicates understanding of the nurse's teachings. The last phase of the nurse-client relationship is the termination phase. Evaluation of goals and termination of the therapeutic relationship occur during this phase. This can occur at the end of the nurse's shift or when the patient is discharged. The client's ability to verbalize understanding of what signs indicate infection and when to contact their physician, allows the nurse to evaluate the client's goal progression as well as assess their readiness for discharge.

The hospice nurse is caring for a client who is dying. Which intervention(s) should be included in the plan of care? Select all that apply. Provide cool foods and fluids. Routinely administer pain medications. Place in a supine position when drooling occurs. Cluster nursing activities. Obtain the blood pressure frequently. Gently massage the arms and legs. Offer normal amounts of food and fluids.

Cluster nursing activities. Provide cool foods and fluids. Gently massage the arms and legs. Routinely administer pain medications. Dying clients may exhibit sleep disturbance due to several reasons such as anxiety or environmental noise. To promote rest and sleep, the nurse should cluster nursing activities. Due to slowed peristalsis, clients who are dying may experience nausea and vomiting. Cool foods and fluids are preferred to prevent nausea. Due to diminished circulation, clients who are dying may feel cold. Gently massaging the arms and legs help promote ciriculation and transfer heat from the nurse's hands to the client. To prevent causing extreme discomfort, pain medications are administered around the clock. As the client becomes less alert, the need for pain medication continues. Allowing the client to rest is one of the most essential components of end of life care. Frequent, non-intrusive assessments may be performed. Obtaining the client's blood pressure frequently is unnecessary and disrupts rest. Small food portions of favorite foods are recommended over large or normal food amounts to prevent suppression of appetite or nausea. To prevent aspiration, the client's head should be elevated and turned to the side when drooling occurs.

A nurse on a medical-surgical unit is completing the admission assessment on a 38-year-old client. The client is feeble and unable to get out of bed and at times they slide down and require assistance for repositioning. They respond to verbal commands, but cannot accurately express discomfort and have no sensation in the left lower extremity. The client is only able to make frequent, but slight, changes in extremity position. The client has no control over their bowel or bladder and subsequently requires linen changes at least twice per shift. When fed, the client generally eats 50% or less of each meal. Using the Braden Scale, identify the appropriate score and description associated with the client's risk factors.

Risk Factor----description-Score- Sensory Perception---Slightly Limited - Moisture-----Constantly Moist - 1 Mobility----Slightly Limited - 3 he client is considered to have slighlty limited sensory perception, because the client cannot accurately express discomfort and dowa not have the ability to feel pain in one extremity, the left leg. The client is scored as constantly moist, because the client requires frequent linen changes of more than once per shift and is completely incontinent of bowel and bladder, which increases the amount of time the skin is moist. The client is considered slightly immobile, because, although slight, the client is able to frequently move extremities independently. The friction and shear of the client are a potential problem as evidenced by a feebleness and occasional sliding down in the bed. Completely limited sensory perception is described as unresponsive to or the inability to feel pain. Very limited would be scored if the client is responsive only to pain and demonstrates pain by moaning or groaning. No impairment would be assessed if the client has no sensory deficits. A description of very moist would be assessed if the client's skin was often moist and required linen changes only once per shift. The description of occasionally moist would apply if the linen needed changed once per day and was only occasionally moist. Rarely moist is associated with dry skin and routine linen changes. When assessing mobility, completely immobile is associated with the inability to make any movements or position changes independently. Very limited means the client can make slight position changes occasionally but these are infrequent and insignificant. No limitation means the client can make frequent and major position changes independently. When assessing friction and shear, the nurse would note a problem if the cilent required extensive assist with positioning and complete lifting from the bed surface is not possible. This client frequently slides down in the bed. A client with no apparent friction or shearing problem does not slide down in the bed and has sufficient strength to lift up when repositioning themselves.