D
rationale
the nurse should ensure that the client is not experiencing diarrhea (answer
Before administering a laxative to a choice D) before administering a laxative, which will increase the frequency of
bedfast client, it is most important for bowel movements. answer choices A,B,C R4 and assessments for the provision
the nurse to perform what assessment? of care when the client experience is a valve, but are of less priority then answer
choice D which provides data about the possible need to hold medication
a-Observe the skin integrity of the
client's rectal and sacral areas
b-assess the client strength in moving
and turning in the bed
c-evaluate the client's ability to
recognize the urge to defecate
d-determine the frequency and
consistency of bowel movements
Rationale
jaw tightness and a stiff neck are signs of tardive dyskinesia, a serious side
effect of health all that can be reversed with Benadryl answer choice A. the
Client being treated with Haldol for client complaints are not considered hallucinations b. Massaging the neck does
schizophrenia is complaining of jaw not eliminate the symptoms. A 12 lead EKG is not indicated because the pain is
tightness & a stiff neck. Which not cardiac in origin.
interventions should the nurse
impliment?
-give PRN those of diphenhydramine
Benadryl
-assess client other sensory
hallucinations
-massage neck until muscles begin to
relax
-obtain a 12 lead EKG
, rationale
the client is at risk for gastrointestinal bleeding duty history of NSAID a .new
onset anemia indicates bleeding may be present. NSAIDS May impact liver
function b, but this is of less immediacy than a. C is a basic core measure but
Client takes nonsteroidal anti- not one of high priority for this client. D often useful for persons with anemia
inflammatory drugs every day for but is of less priority than a
rheumatoid arthritis is being treated for
anemia which intervention is most
important for the nurse to include any
plan of care
observe for gastrointestinal bleeding
monitor liver function test results
protect skin from bruising
offered dietary selections rich in iron
rationale
rationale
the nurse should ensure that the client is not experiencing diarrhea (answer
Before administering a laxative to a choice D) before administering a laxative, which will increase the frequency of
bedfast client, it is most important for bowel movements. answer choices A,B,C R4 and assessments for the provision
the nurse to perform what assessment? of care when the client experience is a valve, but are of less priority then answer
choice D which provides data about the possible need to hold medication
a-Observe the skin integrity of the
client's rectal and sacral areas
b-assess the client strength in moving
and turning in the bed
c-evaluate the client's ability to
recognize the urge to defecate
d-determine the frequency and
consistency of bowel movements
Rationale
jaw tightness and a stiff neck are signs of tardive dyskinesia, a serious side
effect of health all that can be reversed with Benadryl answer choice A. the
Client being treated with Haldol for client complaints are not considered hallucinations b. Massaging the neck does
schizophrenia is complaining of jaw not eliminate the symptoms. A 12 lead EKG is not indicated because the pain is
tightness & a stiff neck. Which not cardiac in origin.
interventions should the nurse
impliment?
-give PRN those of diphenhydramine
Benadryl
-assess client other sensory
hallucinations
-massage neck until muscles begin to
relax
-obtain a 12 lead EKG
, rationale
the client is at risk for gastrointestinal bleeding duty history of NSAID a .new
onset anemia indicates bleeding may be present. NSAIDS May impact liver
function b, but this is of less immediacy than a. C is a basic core measure but
Client takes nonsteroidal anti- not one of high priority for this client. D often useful for persons with anemia
inflammatory drugs every day for but is of less priority than a
rheumatoid arthritis is being treated for
anemia which intervention is most
important for the nurse to include any
plan of care
observe for gastrointestinal bleeding
monitor liver function test results
protect skin from bruising
offered dietary selections rich in iron
rationale
