A client with a nursing diagnosis of activity intolerance has ...

[lracut11]

A client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. Which of the following nursing interventions will most likely have the greatest impact on this diagnosis?
 
  1. Ambulating him to the bathroom before returning to bed
  2. Encouraging him to change position every 2 hours while in bed
  3. Including active range-of-motion exercises in both AM and PM care
  4. Planning a rest period after AM care but before walking to the dining room for lunch

Question 2

The nurse has delegated the task of ambulating a client who is experiencing activity intolerance.
 
  Which of the following statements made by the nurse best reflects an understanding of the nurse's role to properly instruct the ancillary personnel regarding this task?
  1. Stop the walking if the client complains of pain or weakness.
  2. Please be sure she has proper footwear on before starting out.
  3. Be sure to document the time spent and the distance she walked.
  4. Take her blood pressure and pulse both before and after walking.

[Ahnyah]

Answer to Question 1

ANS: 4
Rest periods will allow for the client to recuperate before expending additional energy. The re-maining options are more directed towards the skin breakdown problem.

Answer to Question 2

ANS: 1
The assigned staff must be instructed to notify the nurse of client reports of pain or any other condition that might result in physical harm. While the other options are not incorrect, they do not have the priority that the answer has.