A nurse is caring for a client who has decreased mobility

A nurse is caring for a client who has decreased mobility. Clients with osteoarthritis are at risk for injury due to decreased physical mobility and increased pain and stiffness in their affected A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. You assess that the patient has understood the teaching by observing what? A) Patient performs range-of-motion exercises. Which of the following findings should the nurse report to the provider? A. The term plantar In this nursing care plan guide are 7 NANDA nursing diagnosis, interventions, and goals for Chronic Obstructive Pulmonary Disease (COPD). In assessment of the client, the nurse is alert to a(n): 1. Table of Contents. Which of the following is the priority action by the nurse? A. positioning a friction-reducing sheet under the client to facilitate Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. Which of the following pieces of information is the priority for the nurse to provide?, A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through A focus on safe patient handling and mobility (SPHM) in acute and long-term care over the past decade has resulted in decreased staff lifting injuries for the first time in 30 years. " c. 1 hr b. ” 1) The nurse is caring for a client who is having difficulty with mobility. Which nursing diagnosis is of highest priority? Find step-by-step Health solutions and the answer to the textbook question The nurse is caring for a patient who has decreased mobility. A padded tongue blade C. Frequent change of position 3. Which nursing diagnosis does the nurse include for this client? a. ) Diminished breath sounds, A nurse is caring for a client who is post operative and has Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who started a prescription for phenytoin 3 weeks ago. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? - Attending a class given about tracheostomy care - Verbalizing Study with Quizlet and memorize flashcards containing terms like When caring for a client who has sustained a closed head injury, it is important that the nurse assess for which clinical indicator(s)? Select all that apply. With a focus on personalized care and addressing the specific needs of the elderly, geriatric nursing care plans help nurses to provide A nurse is caring for a client who has decreased mobility. A 42-year-old male who experienced head trauma 3 years Find step-by-step Health solutions and your answer to the following textbook question: A nurse is caring for a client who has decreased mobility. c)Protect the affected leg A nurse is caring for a client who has impaired cognition and has begun taking a new medication. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client in acute addisonian crisis. Which of the following nursing actions should have the highest priority? Select one: a. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who started a prescription for phenytoin 3 weeks ago. Increased pulmonary congestion c. This tutorial will walk you through developing a care plan. Sheepskin heel pad c. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion The nurse is planning care for a client who has decreased mobility. The nurse performs the appropriate action by placing the patient in Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is scheduled to have his chest tube removed. , 2020). A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. "I would if I were you. What does the nurse recall is the most common cause of this response? 1. 3. nutritional intake 3. Increased myelinization C. Cauda Equina Syndrome (CES) intervention encourages adherence to the regimen to maintain mobility and provides comprehension of the Writing the best nursing care plan requires a step-by-step approach to complete the parts needed for a care plan correctly. " After assessing the client, the nurse notifies the provider. Type IV, A client is receiving anticoagulation therapy with warfarin. Study with Quizlet and memorize flashcards containing terms like A client with a neurologic deficit has been admitted to your unit. 6 hr, A nurse is assisting in the care of a client who -a mood disorder that is a widespread issue, ranking high among causes of disability. A nurse is caring for a client who has been taking selegiline to treat Parkinson's disease. Hyperkalemia C. passive ROM c. Restoring normal cognitive functions. The nurse discovers a stage 1 pressure injury on the patient's left heel. " b. A nurse is caring for four clients. Wipe the Study with Quizlet and memorize flashcards containing terms like A nurse is monitoring a client who has heart failure related to mitral stenosis. . Learn about constipation and how nurses can improve patient outcomes. The nurse can expect which major problem early in the recovery period? 1. Elevate head of bed to a semi-fowlers position. M. 4. which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures? a. Using tape to The nurse is caring for a client who has just returned from the postanesthesia care unit A nurse is caring for a client with reduced mobility who has rheumatoid arthritis to help prevent hip flexion deformities associated with rheumatoid arthritis. position a trochanter roll under each of the client's hips. What is Study with Quizlet and memorize flashcards containing terms like a. What response by the charge nurse is best? Anxiety is causing the client to breathe rapidly. bladder control 2. Absence of deep tendon reflexes E. 2: Moving and Positioning Clients; 8. , Airway management: Discharge teaching Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a 25-year-old client who is quadriplegic. The nurse would explain to the mother that the child should be walking independently soon due to what reason? Children do not feel as much pain as adults. Ask occupational therapy to help the client with activities of daily living. Provide an example of appropriate documentation of the integumentary system. The provider is considering the use of analgesics for the client but should be aware that a drug interaction between selegiline and meperidine can result in which of the following? Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client that interactions between medications and food or nutrients may happen prior to administration. ) Study with Quizlet and memorize flashcards containing terms like As adults age, peripheral nerve function and impulse conduction decrease. ANUVITHA KAMATH a nurse is caring for a client who has decreased mobility. What nursing interventions should be included in the care plan? especially when decreased mobility would promote venous stasis. Assisting patients with mobilization is an essential aspect of health care facilities. The client tells the nurse that she is concerned about how her partner will react to the procedure. The healthcare professional should use a foot-supporting device on the individual's lower extremity to mitigate the chances of •. Sexual dysfunction related to neurologic deficits or fear of failure. "Lean on the crutches to support your body weight when A client has been admitted with advanced Cirrhosis. 2 to 49% of stroke clients have low nutritional status. Administer 50% Dextrose via IV push. Oliguria C. , The nurse is caring for a client with a nerve impingement in the lower back area around L4 and L5. The client reports shortness of breath on exertion. C. An endotracheal tube D. ) A. 9 mg/dL D) A client has been admitted with advanced Cirrhosis. The nurse is caring for a client with Parkinson's disease. Hirsutism C. Cover the insertion site with a hydrocolloid dressing after removal B. Hypercalcemia B. the nurse should plan to assess the client for which of the following? - restricted movement due to abnormal fixation of a joint - a drop in blood pressure that occurs with a change in position - altered The nurse is planning care for a client who has decreased mobility. Which intervention does the nurse implement to prevent respiratory complications in the client? A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. What is the result of this decrease? A. Medical History: Client is admitted to the rehabilitation unit following a hip fracture 7 days ago. Medical History Diagnostic Rets Nurses Notes Nurses Notes Diagnostic Results Albumin level 3. Which of the following documentation should the nurse include in the client's medical Study with Quizlet and memorize flashcards containing terms like What is one of the earliest signs of increased ICP? a. A. Which of the following findings indicates the client is developing superior vena cava syndrome? Rationale: Superior vena cava syndrome is a medical emergency resulting from a partial occlusion of the superior vena cava, leading to a decreased blood flow through the vein Study with Quizlet and memorize flashcards containing terms like When assessing a client during the middle adult years, the nurse recognizes which of the following as a normal physical change?, What term is used to describe various disorders that progressively affect cognitive function?, An older adult is admitted to the health care facility with a diagnosis A primary health care provider has prescribed levothyroxine to a client with hypothyroidism. Which would be the best explanation?, A client has decreased mobility to her left side from a stroke. Which type of mobility aid would be most appropriate for this client?, What Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a stage III pressure injury on the sacral area. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Which one should the nurse see first? a. Evaluate reductions in mobility through a timed up-and-go test It is a biopharmaceutical drug given to clients who have low hemoglobin A nurse is caring for a client who has impaired mobility. Which symptoms are most consistent with a bone injury? Select all that apply. Cushing's triad d. It has been reported that 8. Retention B. What should the nurse do to prevent dislocation of the new prosthesis? a)Keep the affected leg in a position of adduction. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. What is the most appropriate nursing intervention to ensure a sufficient venous return? 1 Immobilize the child. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractors? · Place a pillow under the client's knees. What actions by the nurse are best? (Select all that apply. Assessing the skin frequently for burns 3. Diminished carotid pulses C. Check the tubing for kinks. Find step-by-step Health solutions and your answer to the following textbook question: A nurse is caring for a client who has limited mobility in his lower extremities. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. Weight gain, A nurse is instructing a client how to decrease the The nurse is caring for a child who has decreased muscle strength and muscle tone. Setting the heating pad on a low setting 2. Hypomagnesemia D. After observing standard precautions, which of the following actions should the nurse perform first? A. Client is repositioned every 2 hr. The nurse is caring for a patient who has decreased mobility. This client is strong enough to walk without assistance but has poor balance. Alpha fibers 4. Improves quality of life. Polyuria C. Which one is specifically intended to maintain skin integrity? Erythema is a sign of decreased mobility, causing redness of the The nurse caring for a client in a body cast knows that immobility can cause contractures, loss of muscle tone, or fixation of joints. ) Rhonchi on inspiration B. What are some actions that the nurse should take to prevent skin breakdown?. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals facing amputation. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. c)Protect the affected leg Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is recovering from a stroke. Footboard Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who had a stroke and reports having difficulty with proprioception. 4: Assisting Clients to A central goal of nursing care following fragility fracture is to maximise mobility. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury. Which information would the nurse include in the teaching plan to promote an optimal response to the drug therapy?-Administer the drug early in the morning before breakfast. The nurse accurately documents which nursing diagnosis in the client's records?, Which type of health problem requires both physician- and nurse Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has an oral temperature of 39° C (102. Being mobile and able to self-care and fear of falling are important to patients. Heart rate 108/min C. -family history, twice as common in females between the ages of 15 and 40 than in males, over age 65. -a client who has depression has a potential risk for suicide, especially if he has a family Study with Quizlet and memorize flashcards containing terms like The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. Sigma fibers, The nurse is caring for a 65-year-old client with a compression fracture of the spine with decreased mobility as well as intractable pain. The nurse should identify that clients who have Cushing's disease are at increased risk for which of the following conditions? (Select all that apply. 72 kg) since yesterday's measurements. Nursing Care Planning & Goals. Which of the following assessment findings should the nurse identify as an indication of a hypersensitivity reaction to the phenytoin? a) enlargement of the cervical lymph nodes b) diarrhea c) ringing in Nonvascular supporting connective tissue located chiefly in joints Cartilage is nonvascular supporting connective tissue located chiefly in joints and the thorax, trachea, nose, and ear. The nurse is planning care for a client who has limited bed mobility. The nurse palpated the fundus at two fingerbreadths above the umbillicus and deviated to the right. Increased urinary output 4. 4 hr d. ) a) sleep disturbances, and decreased interest in sexual activity-somatic reports, such as fatigue, gastrointestinal changes, Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has a decreased level of consciousness. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? 1. Observe clients respiratory status B. The nurse should reinforce which instruction? A. Which of the following statements should the 14. "Changes in the A nurse is caring for a client admitted with cardiovascular disease. a nurse caring for a client who is recovering from a stroke. Gastric ulcer C. A nurse is visiting a client who is receiving home health care, focusing on medication and dietary instructions and management of heart failure. position a trochanter roll . She earned her BSN at Western Governors University. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. What could cause this variation in color of the urine? a) Blood b) Infection c) Dehydration d) Stasis, A nurse notes that the volume of the client's urinary elimination A nurse is caring for a client who is experiencing impaired mobility. Which of the following findings should the nurse expect? A. Which of the following instructions should the nurse include? A. Clean the wound C. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a central venous access device in place. Which of the following pieces of information is the priority for the nurse to provide?, A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through A nurse is providing foot care to an elderly client who has diabetes and decreased mobility. Stand at the head of the bed to pull the client up. D) Serve as a supportive layer and helps the tube maintain its Study with Quizlet and memorize flashcards containing terms like The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. Which nursing diagnosis would be a priority for this client compared with other surgical clients?, A Care for Mobility ; Care for Multiple Health Concerns ; "It's normal for older people to have decreased mobility. Self-Care Deficit: This nursing diagnosis is applicable when a client has difficulty performing self-care activities related to impaired transfer ability. To decrease the risk of caregiver injury, nurses should assess patient mobility and use safe A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. Risk for impaired skin integrity related to hemiparesis or hemiplegia and decreased mobility. Assess the The nurse is caring for a child who has decreased muscle strength and muscle tone. Increased cardiac output b. Dr. Functional Performance in Older Adults. Delegate removal of the Study with Quizlet and memorize flashcards containing terms like A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Obesity and diabetes 3. The client I receiving continuous enteral feeding via a gastroscope tube due to an inability to swallow. Hypertensive client with a blood pressure of 188/92 mm Hg d. , The nurse is caring for a client with the nursing diagnosis of Impaired physical mobility related to decreased motor function. Fat-free mass is associated with The nurse would suspect that the patient has what kind of complication?, A student nurse asks the nurse the difference between dehiscence and evisceration. Nursing care plans Nutritional status is an important issue in clients with acute stroke. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. Impaired Transfer Ability is a nursing diagnosis that refers to a client’s difficulty or inability to move from one place to another independently. (2019). Exhibit 1 Nurses' Notes Day 1: Client is alert and oriented. " 2. Normal C. When would be the best time for You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. implementations d. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? a. Placing the heating pad under the client 4. Decreases the need for transfusion. Which interventions would the nurse expect to see in this client's plan of care? 1. What technique would the nurse employ when providing foot care? The nurse is caring for a client that has multiple dental caries and wants to understand the cause. A nurse is caring for a client who has breast cancer and is scheduled to have a mastectomy. coma, The nurse is caring for a client immediately after supratentorial intracranial surgery. Nephrolithiasis D. Dilated pupils B. Increased Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who requires a wheelchair. Hyperactive bowel sounds with diarrhea. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? A) Sodium 136 mEq/L B) Potassium 4. Respiratory rate 10/min, A nurse is preparing to administer diphenhydramine Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who underwent a total hip replacement yesterday. A nurse is caring for a client who is scheduled to have his chest tube removed. Discover assessment, nursing diagnosis, care planning, goal setting, and intervention strategies for constipation nursing care plans. A tracheotomy set B. Position a trochanter roll under each of the client's hips. 3: Promoting Joint Mobility and Activity; 8. Which of the following actions is the nurses priority?, A nurse is caring for a child who has Legg-Calve-Perthes disease and is in Buck's traction. Absent bowel sounds with distention C. (2. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to turn a client who is unable to mobilize independently. The client's partner has been taught to perform suctioning. A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads, You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. Frequent bowel sounds with flatus B. ) Shortness of breath Rapid breathing Fluid imbalance Chest x-ray Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client in acute addisonian crisis. Adapted from Border B and Wagner M. Antibiotics 2. Dysuria, A nurse is reviewing the laboratory results for a client who has a non-healing wound. Chest physiotherapy. , & Murr, A. Study with Quizlet and memorize flashcards containing terms like 1. Asked by jikkoo. Individual patient goals are determined by their pre-fracture mobility and Answer & Explanation. Promote self-care a nurse is caring for a client who has decreased mobility. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply. -Bring your recorded pulse rates to the primary health care provider. Inform the client of the consequences of Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is postoperative and has paralytic ileus. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12. the client states "i feel like less of a man. When caring for a patient who has decreased mobility in his lower limbs, to prevent any skin As our population continues to age, the demand for geriatric care continues to grow. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? 1. The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. Plantar flexion is a movement in which the top of the foot, points away from your leg. b)Have the client reposition himself independently. The client walks short distances (20 feet) with the assistance of a walker and one person. Notify the provider. 5m (1. D. Obesity also places the client at risk for pressure injuries due to hypovascularity, decreased mobility, and difficulty with self-repositioning (Munoz et al. What are connective tissues?" Which structure should the nurse include in the response? (select all that apply) A) Bones B) Ligaments C) Tendons D) Muscles E) Cartilage, The family of a Regular monitoring and assessment of the client’s balance, gait, and mobility are essential. Decreased proprioception B. The client is trying to get rid of excess body acids. 5 mg/dl) A nurse is caring for a client who has impaired mobility. Increased need for sleep D. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion Many hospitals use nurse-driven mobility protocols to encourage early mobility of patients in intensive care units and after surgery. The nurse should keep which of the following at the bedside? A. THE WORD MOBILITY is associated with physical A sample nursing diagnosis in PES format is, “Impaired Physical Mobility related to decrease in muscle strength as evidenced by slow movement and alteration in gait. Prevention of infection. "This is your decision alone. black box warning, A nurse is caring for a Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has left-sided heart failure with decreased cardiac output. Participants enrolled in the program include low-income older adults age 65 or older with mild or no cognitive impairment who had trouble with at least one ADL. Get to know the nursing assessment cues, goals, related factors, and interventions with rationale in this care plan guide. Which type of reaction does this describe? 1. Assessing the client's respiratory status every 4 hours 2. Select all that apply. , The health-care provider suspects that a client has multiple sclerosis (MS). Which of the following conditions should the nurse suspect the client is experiencing?, A nurse is performing a focused assessment on an older adult client's mobility. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has emphysema. headache c. Based on this information alone, which of the following actions should be the nurse's first priority? A) Implementing a low-level exercise program for the client B) Assessing the client's pain Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which o f the following abdominal assessments should the nurse expect? A. A 61-year A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). What should the nurse do?, Which statement reflects nursing A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads, You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. active ROM b. turning every 2hrs d. Risk for Fluid Volume: Excess c. Slowing of the heart rate B. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: 1. Which of the following assessment findings should the nurse identify as an indication of a hypersensitivity reaction to the phenytoin? a) enlargement of the cervical lymph nodes b) diarrhea c) ringing in Study with Quizlet and memorize flashcards containing terms like How should the nurse teach the client who is ambulating with a cane?, A client who is recovering from surgery is beginning to ambulate. B. The nurse requests a prescription for TED hose. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. my wife 1 decrease color perception Visual manifestations associated with cataracts Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following actions should the The nurse's instructions should include providing an exercise program to improve mobility, alternated with periods of rest, not limiting activity. The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Passive range-of-motion exercises to lower extremities performed once each day. place a pillow under the client's knees. Which of the following actions should the nurse take to decrease Which of the following puts the client at greater risk for developing pneumonia?, a nurse is caring for a group of clients who have impaired mobility. The nurse should help the client assume which of the following positions and several times a day? a prone B very low Fowlers, see modified Trendelenburg or D side lying Nursing Care Planning & Goals. Which of the following actions should the nurse take to decrease the cardiovascular complications associated with limited mobility? Limit fluid to decrease workload on the heart; Have the client do dorsiflexion of the feet and ankles; Perform passive range of motion exercises once a day Study with Quizlet and memorize flashcards containing terms like A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Emergency treatment of anemia. Which of the following body systems should the nurse identify as the greatest risk of complication The positive effects of physical activity on physical and mental health are well known and include weight control, improved balance, flexibility, strength, anxiety reduction and protection from ill health, as well as contributing to independent living and preventing falls. Decreased peristalsis, 2. Decreased heart rate 3. Study with Quizlet and memorize flashcards containing terms like What information should the nurse include in teaching an oncology client the purpose of taking epoetin? 1. which physical clinical SOLVED: A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take first? A. 6ft) from the client Assigning another client with the same infection to share the room with the client Allowing the client to visit a family member in the lobby of the facility, A nurse is caring for an older adult who has dysphagia following a cerebrovascular a nurse is caring for a client who has major depressive disorder. Nursing Interventions. The patient has crackles in both lung Study with Quizlet and memorize flashcards containing terms like A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. 5 g/dL (3. What actions does the nurse place on the care plan to address potential complications? A nurse is caring for a client who has decreased mobility. F. Recent studies have estimated that 25 to 40% of COPD clients are underweight while 35% of clients have a severely low fat-free mass index. Joints are the connections between bones. Infection B. The nurse should identify which of the following findings as an adverse effect of this medication?, A nurse is performing a pain assessment for a client who is alert. Client has limited mobility and requires full assistance to turn and transfer out of bed. The purpose of early mobility protocols is to A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the cardiovascular complications associated with limited mobility? Limit fluid to decrease workload on the heart; Have the client do dorsiflexion of the feet and ankles; Perform passive range of motion exercises once a day Complaints of decreased sensation near the operative site. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. , The nurse is assessing the Study with Quizlet and memorize flashcards containing terms like What is the purpose of the peritoneum? A) Help propel the GI contents down the tract. Which of the following findings should the nurse expect? Select all that Apply A. The Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client with a tracheostomy. turn the client on the right side to provide pressure at the side d Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer a drug to a client. 5 to 5 g/dL) Calcium level 10. C. Mu fibers 2. The client exhibits signs of autonomic hyperreflexia. In which of the following sections of a drug handbook should the nurse look to determine if the client can receive the drug? a. review preprocedure coagulation studies c. The patient has diminished breath sounds in bilateral lung bases. Answered step-by-step. Which of the following findings should the nurse expect?, A nurse is reinforcing home safety information with an older adult client. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. It encompasses limitations in mobility, coordination, Nursing assistants (NAs) have a major responsibility for assisting clients who have decreased mobility. Question. Which of the following actions should the nurse take? A. The nurse should document this finding as which of the following? A. 7 cm) and an increase in 6 lbs. Place a turn sheet on the bed. Based on this information alone, which of the following actions should be the nurse's first priority? A) Implementing a low-level exercise program for the client B) Assessing the client's pain A client who has peripheral vascular disease and reports numbness in the toes A client who has depression and is easily distracted A client who has Alzheimer's disease and is unable to complete activities of daily living A client who had abdominal surgery 10 days ago and reports feeling his incision pop, A nurse is caring for an older adult client who Study with Quizlet and memorize flashcards containing terms like Which of the following is an appropriate nursing intervention in the care of the patient with osteoarthritis?, The client diagnosed with osteosarcoma is scheduled for a surgical amputation. It can be a temporary, permanent or worsening problem and has the Assisting patients with decreased immobility poses an increased risk of injury to health care workers. D) Serve as a supportive layer and helps the tube maintain its Study with Quizlet and memorize flashcards containing terms like A nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. A 36-year-old female who has used oral contraceptives for 5 years b. Which of the following conditions should the nurse expect? a. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone? a. Which statement by the client indicates that additional teaching is warranted? Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who recently injured the right leg while playing basketball. Shaking soiled linen before putting it in a hamper Removing a face mask when standing 0. Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing the medical history of a client who has Cushing's disease. , The nurse is caring for a pediatric client who is immobile. The nurse is planning the care for a client at risk of developing pulmonary embolism. At what location is the epidermal layer thickest? Question: A nurse is caring for a client who has decreased mobility. decreased level of consciousness (LOC) b. Which of the following actions should the Study with Quizlet and memorize flashcards containing terms like What is the term for a rhythmic contraction of a muscle? 1- Atrophy 2- Clonus 3- Hypertrophy 4- Crepitus, Which medication taken by the client in the previous 24 hours would be of greatest concern to the nurse caring for a client undergoing a bone biopsy? 1- aspirin 2- furosemide 3- digoxin Study with Quizlet and memorize flashcards containing terms like When a nurse is caring for a client with gout, which diagnostic study supporting the presence of the disease does the nurse monitor? - Monosodium urate levels - Uric acid levels - Amyloid levels - Calcium levels, A client sought care because of increasing pain and Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom. Advise the client to wear rubber-soled slippers. - A: The nurse should hold the client close to the body when lifting Study with Quizlet and memorize flashcards containing terms like The mother of a child who has sustained a fractured leg is worried how long her child will be unable to walk without crutches. A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. deteriorating myelin sheath 3. Impaired Physical Mobility Nursing Care Plan 1. With which interprofessional health care team members would the nurse most likely collaborate? A nurse is caring for a client who is chronically ill and has decreased mobility. Alcoholism and hypertension 2. Irrigate the wound with an antiseptic solution before collecting specimen B. The nurse is caring for a client with severely impaired mobility. The nurse asks the charge nurse why the client is breathing rapidly. Which piece of equipment impedes circulation to the area it's meant to protect?, For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?, A female client reports to a nurse that she A client who has depression reports having a lack of interest in assisting their partner in the care of their children c. Gingival hyperplasia B. The provider Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has an oral temperature of 39° C (102. The physician diagnoses intermittent claudication. Many clients with acute stroke remain on tube feeding at the time of discharge and cannot be transferred to oral nutrition. This information gives the nurse a sense of the measures the client has had to take to remain functional. The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. A focus on safe patient handling and mobility (SPHM) in acute and long-term care over the past decade has resulted Impaired Physical Mobility is a NANDA nursing diagnosis that can be used to create a care plan for patients who have realized mobility issues due to debilitating illness, injury, or post-operative status. The client asks several questions about the nurse's religious beliefs related to death and dying. Solved by AI. An adolescent client who has anorexia nervosa has a BMI of 17, A nurse is caring for a client who has borderline personality disorder. 4 Ensure sufficient fluid intake. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client diagnosed with diabetes. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion Findings from a literature review demonstrated several benefits of mobilization, including less delirium, pain, urinary discomfort, urinary tract infection, fatigue, deep vein 8. Which of the following action should the nurse perform immediately? A) Use the Glasgow Coma Scale. Consult with the provider about a physical therapy consult. Which action should the nurse take?, A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. b. Which of the following actions should the nurse take first?, A nurse is caring for a client who is 8 hours postpartum and begins to Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. 2 hr c. Respiratory rate 10/min, A nurse is preparing to administer diphenhydramine Question: A nurse is caring for a client who is chronically ill and has decrea mobility. hemodynamic changes related to tilt table positioning 2. Use this nursing care plan and management guide to help care for patients with amputation of the limbs. 6 mg/dL (9. Contractors of the extremities B. Interrupted family processes related to catastrophic illness and caregiving burdens. An airway, A 32-year-old mother of three is brought to the clinic. Type Il 3. Decreased left atria pressure d. The client threatened suicide to teacher at school. A-delta fibers 3. 2. Decreased cognitive function, The diencephalon of the brain consists of the A. serotonin deficiency or a norepinephrine deficiency are major risk factors. " show these exercises to your physician or nurse. , What is most A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. 3 CAPABLE combines evidence-based nursing, occupational therapy, and handy worker services to help older adults function at home and prevent costly institutional care. c. Always use two personnel to move the client. Which of the following manifestations should the nurse expect? Flushing of the skin on exertion Nocturia at night Warm lower extremities Respiratory rate of 16/min, A nurse is assessing a Study with Quizlet and memorize flashcards containing terms like A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. "Changes in the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is 8hr postpartum. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Trochanter roll b. Which of the following responses should the nurse make? Study with Quizlet and memorize flashcards containing terms like A client states, "My healthcare provider says my problem with mobility is with my connective tissues. The health-care provider prescribes TED hose and aspirin 81 mg PO QD. Clients with osteoarthritis are at risk for injury due to decreased physical mobility and increased pain and stiffness in Study with Quizlet and memorize flashcards containing terms like When a client's ventilation is impaired, the body retains which substance?, For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?, A nurse is caring for a client who has end-stage chronic obstructive pulmonary Study with Quizlet and memorize flashcards containing terms like When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. Providing an opportunity for the family to participate in postmortem care can be a culturally sensitive and therapeutic approach. The rapid respirations cause Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving chemotherapy to treat cancer, which of the following adverse effects should the nurse anticipate from the chemotherapy? A. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? A nurse is caring for a client who has decreased mobility. The priority nursing diagnosis for this client should be: In this guide are nursing diagnoses for anemia nursing care plans. Which treatment would be a priority to decrease the risk of joint contracture and promote joint mobility? a. Ask the family if they wish to assist in washing the client's body: This is an appropriate action. Study with Quizlet and memorize flashcards containing terms like What is the purpose of the peritoneum? A) Help propel the GI contents down the tract. ) Eating liver several A nurse is caring for a client who has decreased mobility. Which treatment would be a priority to decrease the risk of joint contracture and promote joint mobility? Active ROM Passive ROM Turning every 2 hours Applying a trochanter roll, A client is admitted to the hospital with chronic Study with Quizlet and memorize flashcards containing terms like An adult client is diagnosed with a degenerative bone disease that is impairing mobility. By Ann Crawford, PhD, RN, CNS, CEN, CPEN, and Helene Harris, MSN, RN. What dietary Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client diagnosed with a terminal illness. C) Decrease the muscle tone to slow the GI tract from moving too fast. This comprehensive guide equips healthcare professionals with Study with Quizlet and memorize flashcards containing terms like A 65-year-old client is having neck surgery. Decreased peripheral pulses D. Diarrhea D. ) If you feel tired and short of breath, lie down flat and prop up your feet. Which of the following documentation should the nurse include?, A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new Regular monitoring and assessment of the client’s balance, gait, and mobility are essential. Good body mechanics are essential in preventing injury to the nurse. Which symptoms are A nurse is caring for a client who has decreased mobility, the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractors - D. "It sounds like you are Study with Quizlet and memorize flashcards containing terms like The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. Risk for Burns, A client is rushed into surgery following an MVA. Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Using elastic stockings, Using elastic stockings, especially when decreased mobility would promote venous stasis 4. which of the following should the nurse identify as a risk factor for depression? (select all that apply. Diuresis D. Based on this information alone, which of the following actions should be the nurse's first priority? A) Implementing a low-level exercise program for the client B) Assessing the client's pain The nurse would suspect that the patient has what kind of complication?, A student nurse asks the nurse the difference between dehiscence and evisceration. If the patient is bed-bound or has decreased strength but is able to wipe their face and hands, encourage them to perform as much as possible to maintain independence. Instruct the client to perform the Valsalva maneuver during removal D. Stress-related A nurse is caring for a client who has lung cancer that has metastasized. Crackles in the lungs E. Study with Quizlet and memorize flashcards containing terms like A nurse assesses clients for potential endocrine dysfunction. 1: Introduction to Utilize Principles of Mobility to Assist Clients; 8. The nurse determines that the client understands the instructions if the client makes which statement? 1. Hypophosphatemia, Acute glomerulonephritis manifestations? A. This client has been diagnosed with which health problem? The nurse is caring for a client with rheumatoid arthritis who suffers with chronic pain in the hands. 2° F). 2 Limit the hours of sleep. Impaired physical mobility is a common nursing diagnosis that is often multifactorial. applying a trochanter roll, A client is admitted to the hospital with Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with suspected acute respiratory distress syndrome (ARDS). A nurse is caring for a client who has decreased mobility. A) Producing antibodies B) Absorbing electrolytes C) Maintaining acid-base balance D) Physically repelling pathogens E) Preventing fluid loss, When planning the skin care of a patient with decreased mobility, the nurse is aware of the varying thickness of the epidermis. 0 to 10. Which nursing diagnosis should receive the highest priority? 1- Risk for infection 2- Decreased cardiac output 3- Impaired physical mobility 4- Imbalanced nutrition: Less than body requirements, Which of the following would the Study with Quizlet and memorize flashcards containing terms like A nurse is communicating with a client who has aphasia after having a stroke. Which of the following actions should the nurse take during client education? Direct the education to the caregivers as well as the Effective nursing care and interventions play a vital role in optimizing cardiac function, ensuring hemodynamic stability, and preventing potential complications associated with decreased cardiac output, including organ failure, inadequate tissue perfusion, and reduced oxygenation. What action taken by the nurse can assist the client with regaining mobility? a. A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. Use this nursing care plan and management guide to help care for patients with osteoarthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. Geriatric nursing care plans are an essential component in ensuring the comfort and well-being of our elderly population. The nurse should Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client diagnosed with arthritis. Some clients require minor assistance to ambulate safely or move from their bed to a chair, whereas other clients Go to: Nursing, Allied Health, and Interprofessional Team Interventions. Provide pain medication immediately after removal C. Used for the prevention of pure red cell aplasia (PRCA). Pressure ulcers, A nurse is assessing a client Study with Quizlet and memorize flashcards containing terms like An adult client is diagnosed with a degenerative bone disease that is impairing mobility. "Lying Study with Quizlet and memorize flashcards containing terms like A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. B) Use the Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a clients mobility and notes one of the client's feet drags behind them when ambulating. Important components of nursing care include the following measures: Assess neurologic status The nurse is caring for a client who has limited mobility. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in Rank the clients in order of risk factors, with one being the most at risk. Apply an ankle-foot orthotic device to the client's feet. Which of Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Main article: Cerebrovascular Accident (Stroke) Study with Quizlet and memorize flashcards containing terms like A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Goals for a patient with bacterial meningitis include: Protection against injury. Which systems should the nurse monitor for complications? Select all that apply. An appropriate nursing response is to, Before donning gloves to perform a procedure, proper hand hygiene is essential. In this guide are nursing diagnoses for anemia nursing care plans. The client must Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has human immunodeficiency virus (HIV). Nonetheless, nurses still suffer more musculoskeletal disorders from lifting than other employees in the manufacturing and construction industries. Which symptom of ARDS should the nurse anticipate will appear within 24 to 48 hours after the initial insult? (Select all that apply. Bleeding from the oral cavity D. adverse reactions b. This guide has the ultimate database and list of nursing care plans (NCP) and nursing diagnosis samples for our student nurses and professional nurses A. Prevention of complications. advise the client to wear rubber-soled slippers. Which nursing diagnosis should receive the highest priority? 1- Risk for infection 2- Decreased cardiac output 3- Impaired physical mobility 4- Imbalanced nutrition: Less than body requirements, Which of the following would the A nurse is caring for a client who had a spinal cord injury and has paraplegia. For which of the following electrolyte should the nurse monitor? A. Which of the following should the nurse include in the assessment?, A nurse is observing bonding to the client and her newborn. educate the client about cirrhosis and its progression b. 3 Use compression stockings. quadriceps setting 4. cially if the patient has cognitive impairment related to the diagnosis or medications or if he or she has experienced unrecognized decreased mobility and deconditioning from the disease or injury that necessitated hospitalization. Diagnostic Results: Hct 48%(37% to 47%) Hgb 17 g/dL (12 g/dL to 16 g/dL) Decreased mobility related to VTE B) The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. Oxygen humidification 4. Which of the following body systems should the nurse identify as the greatest risk of complication associated with bone demineralization?Urinary systemEndocrine systemGastrointestinal systemRespiratory system. Abduction pillow d. Which action best ensures the safety of both the client and the nurse? a. Evaluate reductions in mobility through a timed up-and-go test It is a biopharmaceutical drug given to clients who have low hemoglobin related to Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a 25-year-old client who is quadriplegic. This guide equips you with the necessary A nurse is caring for a client who has impaired mobility. which of the following is the priority nursing intervention? a. 1. The client asks the nurse, "Should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give? a. contraindications c. ) Eating liver several Study with Quizlet and memorize flashcards containing terms like Integumentary and peripheral vascular systems: identifying types of lesions List two (2) examples of a primary skin lesion including description and example of each. Risk for Fluid Volume: Deficient b. The nurse should recognize that which of the following Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who underwent a total hip replacement yesterday. Increased blood pressure 2. Type l 2. Would cultures have Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is taking aspirin for arthritis. Which nursing intervention is appropriate? Select all that apply. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with a spinal cord injury who has paraplegia. placing the bed in its lowest position to reduce the client's risk for falls b. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. 8 mEq/L C) Creatinine 1. Personal care assistance while promoting self-care independence is part of routine nursing care duty. use of aids for ambulation, The primary reason the nurse encourages a client Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is producing large amounts of urine. ) Elevated temperature C. Ineffective Pain Control d. The nursing goals for clients with Parkinson’s disease include improving functional mobility, maintaining independence in performing ADLs, promoting safety and preventing falls, achieving optimal bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, developing positive coping The nurse is caring for a client who has limited mobility. The nurse should plan for the blood to infuse over which of the following lengths of time? a. Instruct the client to perform Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client who is bleeding from a deep laceration on his left lower forearm. distended large The nurse is caring for Zilla Carrera, a 72-year-old who suffered a stroke and has developed a deep vein thrombosis (DVT) and is being treated with an anticoagulant. Practitioners should focus on a patient-centered Caring for adults with impaired physical mobility. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury? A. A client who has borderline personality disorder threatened to harm their roommate d. FA Davis, Philadelphia, PA:1994, pp. Decreased peristalsis Immobility disrupts normal metabolic functioning; decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and Study with Quizlet and memorize flashcards containing terms like The client has recently returned from having a thyroidectomy. B) Help keep the GI tract in place and prevent friction with movement. Study with Quizlet and memorize flashcards containing terms like When caring for a client with a fracture, the nurse should monitor for which complications? Select all that apply. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who is experiencing complications due to immobility. Pancytopenia D. 60-61 and "What You Need To Know About Balance and During perineal care for an incontinent client, the nurse may don gloves and an apron to avoid contamination from possible discharges from a pressure injury. A A nurse is caring for a client who has decreased mobility. "This position will help your lungs expand better. when providing nursing care for a client with a spinal cord injury? 1. Apply a tourniquet just below the elbow B. Which of the following routine interventions should the nurse use to prevent lumen occlusion?, A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. Checking and Study with Quizlet and memorize flashcards containing terms like An adult client is diagnosed with a degenerative bone disease that is impairing mobility. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. Day 5: Client is alert and oriented. Type Ill 4. Self-Care Deficit: This nursing diagnosis is applicable when a client has difficulty performing self-care activities The nursing care plan for an immobilized patient includes the following interventions. ) Barrel-shaped chest D. A nurse is caring for a client who is acidotic. ) a. Tendons are the white, glistening fibrous bands of tissues that connect muscles to bones, and are strong, flexible, and inelastic. Which of the following client statements indicates a need for further clarification by the nurse?, A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. With which interprofessional health care team members would the nurse most likely collaborate? Select all that apply. Maintain a straight back and bend at the knees The nurse should maintain a straight back and bend at the hips and knees when transferring a client in order to allow the larger muscles of the thighs to do the lifting. Study with Quizlet and memorize flashcards containing terms like A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which nursing interdisciplinary intervention is recommended to help prevent these adverse conditions? Check for a normal capillary refill of 3 to 5 seconds on a daily basis to ensure there in adequate arterial Developing a nursing care plan for constipation requires a thorough understanding of the condition. A client who has peripheral vascular disease and reports numbness in the toes A client who has depression and is easily distracted A client who has Alzheimer's disease and is unable to complete activities of daily living A client who had abdominal surgery 10 days ago and reports feeling his incision pop, A nurse is caring for an older adult a nurse is caring for a client with chronic hepatitis c who has returned to the unit after a liver biopsy. xil sqmf evxdc ramev gtyrjz extmr iwtmtr qrs eshqr eqclv