The client is at risk for impaired skin integrity related to the need for several weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best action?

Correct Answer: D

Rationale: In this scenario, the nurse should choose option D, which is to keep the nursing diagnosis in the plan of care the same since the risk factors are still present. This is the best action because even though the skin integrity has not been impaired after one week, the client is still at risk due to the continued need for bedrest. Choosing option A to remove the nursing diagnosis is incorrect because the risk factors that led to the initial diagnosis are still present, so vigilance is necessary. Option B, changing the diagnosis to impaired mobility, is not appropriate as the primary concern is the risk of impaired skin integrity due to prolonged bedrest. Option C, modifying the diagnosis to impaired skin integrity, is unnecessary since the skin integrity has not been compromised yet, but the risk remains. Educationally, this scenario highlights the importance of ongoing assessment and evaluation in nursing care. It emphasizes the need to consider the underlying risk factors that led to the initial diagnosis and to continue monitoring the client's condition to provide proactive care and prevent potential complications. It also underscores the significance of critical thinking and clinical judgment in nursing practice.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: a client that recently traveled and developed a fever with cough. This client should be placed in isolation for airborne precautions due to the potential risk of carrying an airborne infectious disease such as tuberculosis or influenza. Option A, a high school wrestling champion with a rash, does not indicate a need for airborne precautions as rashes are typically not transmitted through the air. Option C, a client with an unknown skin infection, would not require airborne precautions unless the skin infection is associated with an airborne pathogen, which is not mentioned in the scenario. Option D, a client with heart palpitations, does not require airborne precautions as heart palpitations are not indicative of an airborne infectious disease. In an educational context, understanding the different types of precautions in healthcare settings is crucial for preventing the spread of infections. Airborne precautions are specifically used for diseases that are transmitted through the air via droplet nuclei. It is important for healthcare providers to correctly identify which clients require airborne precautions to ensure the safety of both patients and healthcare workers.

Correct Answer: D

Rationale: In caring for a client with Rheumatoid Arthritis (RA), the best goal for pain control is for the client to have pain less than 8/10 throughout the day (Option D). This goal is considered appropriate because RA is a chronic condition characterized by persistent pain and inflammation. Achieving pain levels below 8/10 can significantly improve the client's quality of life, mobility, and overall well-being. Option A, focusing on healthy meals and hydration, although important for overall health and managing RA symptoms, does not directly address the immediate goal of pain control. Option B, having pain throughout the entire day, is not a suitable goal as it does not aim for pain reduction. Option C, having pain less than 3/10 for most of the day, may be too ambitious for some clients with RA and may not be realistic or sustainable in the long term. In an educational context, understanding the importance of setting realistic and achievable goals for pain management in clients with RA is crucial. Educators should emphasize the individualized nature of pain management goals and the need to balance aspirations for pain reduction with the client's unique circumstances and limitations. By focusing on realistic and attainable goals, healthcare providers can better support clients in managing their pain effectively and improving their overall quality of life.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Nociceptive pain. Nociceptive pain occurs due to tissue damage or inflammation, which is typically the case after an amputation surgery. The client's complaint of pain distal to the amputation site indicates that the pain is originating from the remaining tissues and nerves around the amputated area. Option B) Neuropathic pain is characterized by nerve damage or dysfunction. While it can occur after an amputation, in this case, the pain is more likely nociceptive in nature as it is directly related to the tissue trauma from the surgery. Option C) Visceral pain originates from internal organs, which is not relevant in the context of an amputation scenario. Option D) Cutaneous pain is related to the skin, which is not the primary source of pain in this case as the client is experiencing pain distal to the amputation site. Educationally, understanding different types of pain is crucial for healthcare professionals to accurately assess and manage their patients' pain. Recognizing the type of pain a client is experiencing helps in determining appropriate treatment strategies, such as medication choices or physical therapy interventions, to provide effective pain relief and improve the client's overall well-being.

Correct Answer: D

Rationale: The correct answer is D) Perform neurovascular assessments per protocol. In the context of a post-operative client after a total hip arthroplasty, monitoring neurovascular status is crucial to assess for any signs of compromised circulation or nerve function. This intervention is a priority as it helps in early detection of complications such as compartment syndrome, deep vein thrombosis, or nerve damage, which can have serious implications if not addressed promptly. Option A) Observing client for changes in mental status, while important, is not the priority in this scenario as neurovascular compromise poses a more immediate threat to the client's physical well-being. Option B) Using aseptic technique for wound care and emptying of drains is important for infection prevention, but it is not the priority over monitoring neurovascular status. Option C) Keeping the client's heels off the bed is aimed at preventing pressure ulcers and maintaining skin integrity, which is also important but not the priority when compared to assessing neurovascular status. Educationally, this question highlights the critical thinking skills required in prioritizing nursing interventions based on the client's condition and the potential risks involved. It underscores the importance of timely and accurate assessments in post-operative care to ensure optimal patient outcomes.