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 A
Explanation
Rationale:
A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.
B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.
C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.
D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.
Correct Answer is D
Explanation
Rationale:
A. The presence of a supernumerary breast nipple is not related to the onset of menarche and is not a common assessment in determining sexual maturity.
B. Temporary gynecomastia is more commonly observed in adolescent boys rather than preteen girls.
C. While age can provide a rough estimate, it is not as accurate as a physical assessment of sexual maturity.
D. The Tanner staging is a reliable method used to assess sexual maturity in adolescents. It includes evaluating the development of breasts, pubic hair, and other secondary sexual characteristics, which can help determine if the client has likely reached menarche.