Page 2602 - Saunders Comprehensive Review For NCLEX-RN

appropriate interventions.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Planning
Content Area: Health Assessment/Physical Exam: Health History
Health Problem: N/A
Priority Concepts: Communication; Health Promotion
Reference: Jarvis (2016), pp. 29–30.

906. Answer: 3

Rationale: An inactive older adult may become disoriented because of lack of
sensory stimulation. The most appropriate nursing intervention would be to reorient
the client frequently and to place objects such as a clock and a calendar in the client’s
room to maintain orientation. Restraints may cause further disorientation and
should not be applied unless specifically prescribed; agency policies and procedures
should be followed before the application of restraints. The family can assist with
orientation of the client, but it is inappropriate to ask the family to stay with the
client. It is not within the scope of nursing practice to prescribe laboratory studies.
Test-Taking Strategy: Note the strategic word, best, and eliminate option 4 first
because it is not within the realm of nursing practice to prescribe laboratory studies.
Next, eliminate option 1 because restraints may add to the disorientation that the
client is experiencing. It is inappropriate to place the responsibility of the client on
the family, so eliminate option 2. Also, note the relationship between the words
disoriented in the question and the implications of reorientation in the correct option.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Musculoskeletal
Health Problem: Adult Health: Musculoskeletal: Skeletal injury
Priority Concepts: Cognition; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), pp. 26, 864-865.

907. Answer: 2

Rationale: Skin traction is achieved by Ace wraps, boots, or slings that apply a
direct force on the client’s skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of
weight, and this type of traction can cause skin breakdown. Urinary incontinence is
not related to the use of skin traction. Although constipation can occur as a result of
immobility and monitoring bowel sounds may be a component of the assessment,
this intervention is not the priority assessment. There are no pin sites with skin
traction.
Test-Taking Strategy: Note the strategic word, priority. Eliminate option 4 first
because there are no pin sites with skin traction. Visualizing the traction setup and
knowledge of the complications associated with this type of traction will direct you
to the correct option.
Level of Cognitive Ability: Creating

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