Two days after surgery, a client experiences incisional pain while dangling at the bedside and refuses to ambulate as prescribed. The nurse establishes a problem of "Activity intolerance related to pain." Based on this problem, which outcome statement is best for the nurse to include in this client's plan of care?
Avoid pain-causing activity.
Ambulate without discomfort.
Show evidence of incision healing.
Take analgesics as prescribed.
The Correct Answer is B
Rationale:
A. Avoiding pain-causing activities would not address the problem of activity intolerance, nor would it promote recovery.
B. The goal is for the client to ambulate with minimal or no discomfort, which would indicate successful pain management and adherence to the postoperative plan.
C. Incision healing is important but does not directly relate to the problem of activity intolerance due to pain.
D. Taking analgesics as prescribed is a component of managing pain, but the outcome should focus on the result of this intervention, which is pain-free ambulation.
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Correct Answer is C
Explanation
Rationale:
A. Baclofen should not be stopped abruptly as it can cause withdrawal symptoms. The client should consult their healthcare provider before using other antispasmodic.
B. Monitoring intake and output every 8 hours is not specific to baclofen administration.
C. Baclofen can cause dizziness, drowsiness, and hypotension. Advising the client to move slowly and cautiously when rising and walking helps prevent falls or injury due to these side effects.
D. While muscle strength assessment is important, it is not required every 4 hours and does not specifically address the common side effects of baclofen.
Correct Answer is D
Explanation
Rationale:
A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.