125 Basic care and comfort Monday 1-3

A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device?

"The splint immobilizes the body part in a functional position."

Which nursing intervention should be included in the care of an unconscious child with Reye's syndrome?

Place the child on a sheepskin.

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?

intermittent urethral catheter

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response"

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse?

"I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication."

The nurse is providing teaching for the parents of an 8-year-old girl who has undergone surgery. The nurse emphasizes the importance of maintaining adequate hydration. Which response by the mother would indicate a need for further teaching?

"I will remind her that she will need an IV if she does not drink."

A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate

"Keep your fluid intake to fewer than 2 liters per day."

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?

"No, it can initiate premature uterine contractions."

A client has an initial visit with a chiropractor and states to the nurse, "I am already in pain and am so afraid that the doctor may cause even more." What are therapeutic responses from the nurse? Select all that apply.

"We may use heat or ice on the affected area." "The chiropractor may use painless electrical stimulation." "The chiropractor may recommend dietary supplements."

What is the length of time a client undergoes a complete sleep cycle?

90-110 minutes

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A client who has leg strength and can cooperate with the movement

A nurse is performing pain assessments on clients in a physician's office. Which clients would the nurse document as having acute pain? Select all that apply.

A client who presents with the signs and symptoms of appendicitis A client who fell and broke an ankle a client who is having a myocardial infarction

"Get the stuff from him" is an example of which type of message?

Abstract

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally.

An adolescent has skeletal traction for a fractured femur. Which is the most appropriate nursing intervention for this client?

Assess pin sites every shift and as needed.

You are caring for a client with CAD. What is an appropriate nursing action when evaluating a client with coronary artery disease (CAD)?

Assess the characteristics of chest pain.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes

A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber.

Understanding one's dosha, or basic constitution, is central to which type of whole medical system?

Ayurveda

Clients often do not mention the use of alternative therapies to the health care provider. Which is a likely reason they do not discuss alternative therapies? Select all that apply.

Clients fear that the health care provider will not approve of any alternative therapies. Clients think that if a product is "natural," including it in a list of medications does not make

A 78-year-old woman is on a nurse's rehabilitation unit status post a cerebrovascular accident (CVA). As the nurse assess her gait, the nurse notices that the client's left foot is dragging and she is not bending her left knee nor swinging her left arm. How would the nurse best describe the client's gait

Hemiparesis

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress?

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?

Hyperactive bowel sounds

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds.

Which of the following nursing interventions should a nurse perform to promote the dignity and self-esteem of a dying client?

Keep the client clean and well groomed.

A nurse is assessing an older adult with reports of constipation, for which the client often takes over-the-counter medications. What assessment should the nurse perform to address the etiology of the client's problem?

Medication regimen for drugs like anticholinergic agents or calcium

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

A patient is undergoing a perineal surgical procedure. Which of the following actions by the nurse is appropriate?

Place the patient in lithotomy position.

A 71-year-old client reports to the nurse that he often notices a pink tinge to his urine. Upon further questioning, he states that he experiences no pain when voiding and has not noticed any change in the frequency of his voiding. Which response by the nurse is best?

Promptly report this finding to the client's health care provider.

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair?

Protein

The client who has experienced third-degree burns is susceptible to which specific type of gastrointestinal (GI) ulceration?

Stress

The nursing students have learned in class that causes of urinary obstruction and urinary incontinence include which of the following? Select all that apply.

Structural changes in the bladder Structural changes in the urethra Impairment of neurologic control of bladder function

The nurse is caring for a client with dysrhythmia. What would be an important procedure to teach a client with dysrhythmia to perform to evaluate his or her response to treatment?

Technique for palpating and counting the radial pulse

The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy?

Tension

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

The birth can cause perineal swelling.

The nurse is working with school-aged children who are having enuresis or encopresis. What will most likely be the first step in this child's treatment?

The child will have a complete physical exam.

For a client with anorexia nervosa, which goal takes the highest priority?

The client will establish adequate daily nutritional intake.

A client with impaired hearing communicates through sign language and has been admitted to the unit before scheduled surgery. The interpreter that the hospital employs is at the bedside. The nurse needs to take what actions into consideration prior to doing preoperative teaching with this client?

The interpreter may lag a few words behind--especially if names or technical terms are to be finger spelled

The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence?

Total incontinence

When caring for a postoperative client, in order to promote wound healing, which of these nutrients does the nurse encourage the client to consume?

Vitamin C

A patient has been admitted to the intensive care unit with a diagnosis of acute pancreatitis. Which of the following laboratory values will the nurse prioritize when gauging the course of his disease? Select all that apply.

White blood cells (WBCs) Amylase Lipase

A nurse is educating the family of a small child with phenylketonuria about meal choices. Which meal choice by the parents indicates to the nurse that they understand the dietary management of this disease?

a bowl of dry cereal with strawberries and apple juice

A nurse is performing pain assessments on clients in a physician's office. Which clients would the nurse document as having acute pain? Select all that apply.

a client who is having a myocardial infarction A client who fell and broke an ankle A client who presents with the signs and symptoms of appendicitis

A major physiologic function of the gastrointestinal system is to:

absorb nutrients into the bloodstream

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to:

divide daily food intake into five or six meals.

A nurse is assessing a client's nutritional intake during pregnancy. What is the best method for accomplishing this?

enacting a 24-hour nutrition recall

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

high-protein

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends

increasing the amount of bran and fresh fruits and vegetables

A laboring client, 2 cm dilated and 50% effaced, is screaming in pain. The nurse caring for this client recognizes this woman's response to pain should be documented using which label?

low pain threshold

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet?

maintenance of normal bowel elimination

The nurse visits the home of a client with a newly applied leg cast. On which area should the nurse focus when assessing this client's neurovascular functioning? Select all that apply.

motion sensation capillary refill

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of

organ meats

A client has a stage III pressure injury in the sacral area. What factor(s) can contribute to the development of pressure injuries? Select all that apply.

pressure shearing force friction

Sudoriferous glands secrete which type of substance?

sweat

A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping the client cope with these cramps?

teaching her to dorsiflex her foot during the cramp

hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is most appropriate?

Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath.

A preschool-age child who is receiving gastrostomy feedings occasionally vomits following a feeding. When the parent describes the feeding process, what does the nurse note as the likely cause of the vomiting?

The mother does not check gastric residual prior to feedings.