A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?
Patient will increase activity level this shift.
Patient will turn side to back to side with assistance every 2 hours.
Patient will use the walker correctly to ambulate to the bathroom as needed.
Patient will use a sliding board correctly to transfer to the bedside commode as needed.
The Correct Answer is B
A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.
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Correct Answer is B
Explanation
A. The definition of spirituality does not typically include concepts of fire or giving life; this option does not accurately capture the essence of spirituality.
B. Awareness of one's inner self encompasses the essence of spirituality, focusing on personal beliefs, values, and the search for meaning, which is widely recognized in health care.
C. Spirituality is often considered equally essential to physical needs, especially in holistic approaches to health and well-being, making this statement misleading.
D. Spirituality can have a significant impact on health, influencing coping mechanisms and overall well-being; therefore, labeling it as having a minor effect is not accurate.
Correct Answer is ["A","D"]
Explanation
A. Turning the clean pillowcase inside out over the hand holding it helps avoid contamination and allows easy application.
B. Soiled linens should be kept away from the nurse's uniform to prevent cross-contamination; hence, this is incorrect.
C. Sterile gloves are not required for bed-making; clean gloves may be used when handling soiled linens.
D. A modified mitered corner keeps the bed neat and helps secure the sheet, blanket, and spread.
E. Advising the patient of a lump when rolling over is not necessary for bed making, as the goal is to provide comfort without lumps.