A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?
Dietary salt restriction
Absence of symptoms
Addition of a new medication
A detailed plan of care
The Correct Answer is B
Rationale:
A. Dietary salt restriction is challenging but is a specific intervention that can be managed with education and support.
B. The absence of symptoms can significantly hinder compliance because clients may not perceive the need to adhere to a treatment plan if they do not feel unwell. This perception can lead to underestimating the importance of managing their blood pressure.
C. The addition of a new medication may pose some challenges, but clients often adapt to new medications with proper guidance.
D. A detailed plan of care can enhance understanding and compliance, making it less likely to be a barrier compared to the lack of symptomatic cues indicating a need for treatment.
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Correct Answer is A
Explanation
Rationale:
A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.
B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.
C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.
D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.
Correct Answer is B
Explanation
Rationale:
A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.
B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.
C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.
D. While 0.9% sodium chloride is isotonic and can be used for irrigation, it is not typically the solution used for gastric lavage; water or a specific lavage solution is more appropriate.