To promote client understanding and promote security, the nurse ...

[shofmannx20]

To promote client understanding and promote security, the nurse should:
 
  A. Restrain the client
  B. Explain all procedures
  C. Allow the client more time alone
  D. Change the schedule on a regular basis

Question 2

The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia. The patient is lying in bed but tells the nurse that she needs to go to the bathroom.
 
  The nurse tells the patient that she will stay with her and will help her get there. The patient states, That's OK. I can make it on my own. The nurse should: a. help the patient to the bathroom and stay with her.
  b. allow the patient to get up on her own and go to the bathroom.
  c. allow the patient to go to the bathroom and call for help if needed.
  d. insert a Foley catheter.

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Answer to Question 1

B
B. Orient client and family to surroundings, introduce to staff, and explain all treatments and procedures. This promotes client understanding and cooperation.
A. The use of restraints is one safety strategy that can protect clients from injury, but restraints must be used with extreme caution. Physical restraints should be the last resort and used only when reasonable alternatives have failed.
C. Encourage family and friends to stay with client. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Client anxiety is reduced and safety is increased when one person provides care and supervision is constant.
D. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so client has long uninterrupted periods throughout the day. This provides for sleep and rest periods. Constant activity may irritate client.

Answer to Question 2

A
Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., lightheadedness, dizziness) and low blood pressure when rising to an upright position. Orthostatic changes in vital signs are good indicators of blood volume depletion. In severe cases of orthostatic hypotension, loss of consciousness may occur. Foley catheters are believed to be a major source or urinary tract infection.