Help On Take Home Quiz - Activity Intolerance

[guest337992]

Hey there,

I was wondering if I could get some quick help from some of you on one question for a take home quiz we got. Here it is...

A client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. Which if the following nursing interventions will most likely have the greatest impact on this diagnosis?

A. Ambulating him to the bathroom before returning to bed

B. Encouraging him to change position every 2 hours while in bed

C. Including active range-of-motion exercises in both AM and PM care

D. Planning a rest period after AM care but before walking to the dining room for lunch

Right now I am torn between B and C, but I think I would have to go with C because it is specifically asking what would have the greatest impact on the diagnosis of activity intolerance and even though changing position every two hours would protect him from developing pressure ulcers on his heels and coccyx I feel that measure would only indirectly affect his activity intolerance, though it would directly affect a diagnosis for risk of impaired skin integrity. However, the active range of motion seems to have a more direct impact on the activity intolerance than the 2 hour position change.

You thoughts???

[Daytonite, BSN, RN]

a client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. which if the following nursing interventions will most likely have the greatest impact on this diagnosis?

a. ambulating him to the bathroom before returning to bed

b. encouraging him to change position every 2 hours while in bed

c. including active range-of-motion exercises in both am and pm care

d. planning a rest period after am care but before walking to the dining room for lunch

the question is giving you assessment information about a nursing problem (step #1 of the nursing process) and skipping to step #3 and asking what nursing interventions will have an impact (work together to cause some reaction) on this problem. just to throw you off, they mention another nursing diagnosis (diagnosis is done in step #2 of the nursing process) that has little relationship to this problem. activity intolerance is insufficient physiological or psychological energy to endure or complete required or desired daily activities. answer choices a and d would be appropriate for someone with activity intolerance, but that is not what the question is asking you if you read it closely. reddened areas on both heels and his coccyx would be symptoms (defining characteristics) of impaired skin integrity. reddened areas on both heels and his coccyx are stage i pressure ulcers, or the beginning of pressure sores. the etiology (related factor) for pressure sores in this case is inactivity and remaining in the same position for long periods of time. you want to do things to get pressure off those heels and coccyx to stop this process so the skin doesn't continue to break down. the best answer choice you have that is going to accomplish that is b. encouraging him to change position every 2 hours while in bed because it gets pressure off those two areas of the body. choice c would be the next best thing to do because it promotes circulation in the feet.

[guest337992]

They said the answer was D because like you said, activity intolerance has to do with insufficient energy and a rest would get him that energy. I thought active range of motion would help him develop that energy, but I guess not. Got to love these tricky ones. Thanks for the help though.

[Daytonite, BSN, RN]

I see. I totally overlooked the part in the stem of the question that said "greatest impact on this diagnosis" meaning the Activity Intolerance. Which is why it is important to read the stem of the question carefully! Right? Of course, with Activity Intolerance you would plan a rest period. The walking, I guess just sort of related it back to the red heels. Ha! Ha! Oh! Would I give the instructors such flak over that answer choice. They could have come up with something better.

[guest337992]

Ya, pretty much no one got that right and she said that she might drop that question from the quiz. I'm amazed by how many questions there are like that. We spend half of our time arguing about our wrong answers and justifying why we think they are probably just as right as the right one. On the upside, at least no one would have died from getting this one wrong!

[Daytonite, BSN, RN]

this is the problem when one person is writing test questions. it is hard for them to see any unfairness in it. i have no doubt that your instructor was trying to work some distraction into the question, but the actual answer was kind of odd and it seems like she was trying to merge the two nursing problems and that really isn't appropriate + is confusing even for those who are experienced with nursing diagnosis. take reassurance in knowing that the nclex questions are reviewed by many, many people so these kinds of incongruencies found and the question either re-written or deleted before it ever gets to a person taking the test.