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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?

A.

Avoid pain-causing activity.

B.

Ambulate without discomfort.

C.

Show evidence of incision healing.

D.

Take analgesics as prescribed.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

Rationale:

A. Erythromycin does not require the client to avoid sunlight, unlike some other antibiotics.

B. The timing of medication intake does not affect the interaction between erythromycin and oral contraceptives.

C. Erythromycin can reduce the effectiveness of oral contraceptives. It is essential to use an additional contraceptive method to prevent unintended pregnancy.

D. Stopping the oral contraceptive is not necessary but using an additional form of contraception is important.

Correct Answer is A

Explanation

Rationale:

A. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.

B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.

C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.

D. Background music may be distracting rather than helpful during the provision of important instructions.

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