During review of admission data, the nurse learns that the new ...

[Diane]

During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client?
 
  1. Use the clock face as a format for describing the position of food on meal trays.
  2. Provide all teaching materials in very large font.
  3. Ensure that the client has assistance when ambulating.
  4. Use only nonirritating soaps for bathing.

Question 2

The nurse is completing a preoperative assessment with a client. What should this assessment include?
 
  1. Current health status
  2. Allergies
  3. Current medications
  4. Mental status
  5. Respiratory rate

[amandanbreshears]

Answer to Question 1

Correct Answer: 3
Rationale 1: This would be appropriate for the client with an alteration in vision.
Rationale 2: This would be appropriate for the client with an alteration in vision.
Rationale 3: Kinesthetic sensation refers to the awareness of the position and movement of body parts. The client with impairment of this sensation may be prone to injury by falling and should be assisted when ambulating.
Rationale 4: This intervention would be appropriate for a client having a tactile or skin disorder.

Answer to Question 2

Correct Answer: 1, 2, 3, 4
Rationale 1: When documenting the current health status, essential information includes general health status and the presence of any chronic diseases that might affect the client's response to surgery or anesthesia.
Rationale 2: When documenting allergies, the nurse should include allergies to prescription and nonprescription drugs, food allergies, and allergies to tape, latex, soaps, or antiseptic agents.
Rationale 3: All current medications should be listed. Herbal remedies and over-the-counter preparations are also a part of this assessment.
Rationale 4: The client's current mental status is a part of this assessment.
Rationale 5: Respiratory rate is part of the physical assessment.

[Diane]

Excellent

[mcabuhat]

TYSM