Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

Correct Answer: D

Rationale: The most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery is option D) Client will remain free from falls throughout their hospital stay. Rationale: 1. Correct Answer: Option D is the most appropriate goal because preventing falls is crucial for an elderly client post-hip surgery. Falls can lead to serious complications such as fractures, delayed healing, and increased pain, which can further exacerbate the client's condition. 2. Incorrect Options: - Option A: Increasing mobility by discharge may not be realistic or safe for an elderly client immediately post-hip surgery as it can increase the risk of falls. - Option B: Demonstrating effective breathing patterns while ambulating is important, but it does not directly address the risk for injury post-hip surgery. - Option C: Increasing activity tolerance is important for rehabilitation, but the immediate focus should be on preventing falls to ensure the client's safety. Educational Context: Understanding the specific needs of elderly clients post-hip surgery is crucial for nursing practice. Emphasizing fall prevention as a priority goal aligns with best practices in geriatric care and patient safety. By setting realistic and targeted goals, healthcare providers can ensure optimal outcomes and promote the well-being of elderly clients during their recovery process.

Correct Answer: C

Rationale: In the context of rheumatoid arthritis, a positive rheumatoid factor (RF) is typically seen in clients experiencing a flare-up of the disease. The presence of RF indicates the production of autoantibodies against the individual's own healthy tissues, which is a hallmark characteristic of rheumatoid arthritis. This autoimmune response leads to inflammation, joint damage, and other symptoms associated with the condition. Option A, stating that the factor does not change, is incorrect because in active rheumatoid arthritis, there is often an increase in RF levels due to the heightened immune response. Option B, suggesting a decreased level of rheumatoid arthritis, is incorrect as RF levels are not expected to decrease during a flare-up. Option D, a negative rheumatoid factor, is also incorrect as a negative RF result is not typically associated with rheumatoid arthritis. From an educational standpoint, understanding the significance of rheumatoid factor in the diagnosis and monitoring of rheumatoid arthritis is crucial for healthcare providers involved in the care of patients with this condition. Recognizing the relationship between RF levels and disease activity can help guide treatment decisions and improve patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take when suspecting a 3-year-old has aspirated a small object and is coughing vigorously is option D: Encourage the child to continue coughing. This is the correct choice because during choking incidents, coughing is the body's natural way of trying to dislodge the obstructing object. Encouraging the child to cough can help expel the object without the need for intervention that could potentially worsen the situation. Option A, delivering upward abdominal thrusts with a fisted hand (Heimlich maneuver), is not recommended for children under 1 year of age and may not be effective or safe for a 3-year-old. Option B, performing a blind finger sweep of the child's mouth, is also not recommended as it can push the object further down the airway. Option C, completing five rapid back blows between the shoulder blades, is indicated for conscious choking victims who are unable to cough, but in this case, encouraging the child to cough is the initial appropriate action. Educationally, it is crucial for healthcare providers to have a good understanding of first aid interventions for choking in pediatric patients. Training in pediatric basic life support (BLS) equips nurses with the knowledge and skills to respond effectively in emergency situations involving airway obstruction. By knowing the appropriate actions to take based on the age and condition of the child, nurses can provide timely and lifesaving care.

Correct Answer: B

Rationale: In this scenario, option B, "I will shower every day in hot water," indicates a need for further teaching about preventing dry skin. Hot water can actually strip the skin of its natural oils, leading to further dryness and exacerbating xerosis. Option A, "I will drink at least 3000 mL of water daily," is a good practice as adequate hydration is important for skin health. Option C, "I will avoid tight belts," is relevant as tight clothing can exacerbate dry skin by restricting airflow. Option D, "I will use a humidifier during the winter months," is also a good strategy as it helps to add moisture to the air, preventing dry skin. Educationally, this question highlights the importance of understanding the impact of daily habits on skin health. It emphasizes the need for proper skin care practices to prevent dryness and itching, underscoring the significance of gentle skincare routines and avoiding triggers that can worsen skin conditions. Students can learn how to educate clients on effective strategies for maintaining healthy skin and preventing common skin issues like xerosis.

Correct Answer: B

Rationale: The correct answer is B) Use a bath sponge to cleanse the skin. This is not appropriate client education for preventing the spread of MRSA because bath sponges can harbor bacteria and spread infections. Option A is correct as avoiding contact sports can prevent the spread of MRSA to others. Option C is also correct as hand hygiene is crucial in preventing the transmission of MRSA. Option D, using an antibacterial soap when showering, is also appropriate as it can help reduce the bacterial load on the skin. Educationally, it is important to emphasize the proper hygiene practices to prevent the spread of MRSA, such as proper handwashing, avoiding sharing personal items, and keeping wounds covered. Teaching patients about these measures is crucial in preventing the spread of MRSA in healthcare settings and the community. Patients should be encouraged to follow evidence-based practices to protect themselves and others from infections like MRSA.