Basic Care and Comfort

123 A blood pressure of 180/95 mm Hg is an MAP of 123, calculated by (systolic blood pressure + 2 x diastolic pressure) / 3. An MAP of >60 is needed to adequately perfuse and sustain the vital organs of an average person under most conditions.

The mean arterial pressure (MAP) for a client who has a blood pressure of 180/95 mm Hg is

Banana A medium banana contains only 1 mg of sodium. All the other choices are higher than a banana. Carrots are low in sodium, but ¼ cup contains 10 mg. An 8 oz. yogurt contains more than 100 mg, and tomato juice has approximately 24 mg per cup.

The nurse has taught a client about a low-sodium diet. Which food choice by the client indicates successful learning? Banana Carrots Yogurt Tomato juice

Exposing the casted extremity Exposing the casted extremity is the safest way to dry the cast evenly. With a blow dryer, the cast may dry on the outside but remain damp within; it also presents the danger of burning the child. Opening the window may create a draft and be uncomfortable for the child. Covering the cast with a light sheet will impede the circulation of air and delay drying.

Which intervention would the nurse provide to facilitate the drying of a cast recently applied to a child with clubfoot? Using a blow dryer Opening the window Exposing the casted extremity Covering the cast with a light sheet

"They are easy to please with food." "They are growing at an increased rate." Toddlers exhibit strong food preferences and become picky eaters. The growth rate slows during the toddler years (i.e., from 1 to 3 years of age). Toddlers need fewer kilocalories than infants; however, they require an increased amount of protein in relation to body weight. The toddler's appetite often decreases at 18 months of age. Calcium and phosphorus are important for healthy bone growth in toddlers.

The nursing instructor asks the nursing student to explain the developmental needs of toddlers. Which statement by the nursing student indicates a need for further teaching? Select all that apply. "They need fewer calories." "They have a decreased appetite." "They are easy to please with food." "They are growing at an increased rate." "They need calcium for healthy bone growth."

Level I Level I trauma centers provide a full continuum of trauma services for all clients. Level II trauma centers provide care for most injured clients. Level III centers are able to stabilize clients with major injuries. Transport clients if needs exceed resource capabilities. Level IV trauma centers are usually involved in providing basic trauma client stabilization and advanced life support within the resource capabilities. Transfer of clients if need exceeds the resource competencies.

Which functional level of trauma center is involved in providing a full continuum of trauma services? Level I Level II Level III Level IV

Eating a high-fiber diet Immediately after this type of surgery, pain is associated with bearing down; the client should be instructed to increase fluid, fiber, and activity to prevent constipation. Exercise is encouraged. The anterior/posterior colporrhaphy is expected to reduce incontinence; urine retention is not expected. The colporrhaphy involves only the vaginal wall; the rectum should not be involved.

Which instruction would the nurse include in discharge teaching for a client who has had an anterior posterior colporrhaphy? Eating a high-fiber diet Limiting daily activities Reporting signs of urine retention Being alert to signs of a rectovaginal fistula

Tic douloureux is also called trigeminal neuralgia and has a characteristically severe stabbing pain to one or both sides of the face. The nurse should avoid walking swiftly past the client because drafts or even slight air currents can initiate pain. Pressure on the face while in the prone position may trigger an attack. Oral hygiene is not discontinued. The client should avoid massaging the face because the massage may trigger an attack.

Which intervention would the nurse implement to prevent precipitating a painful attack in a client with tic douloureux? Avoid walking swiftly past the client. Keep the client in the prone position. Your answer is incorrect Discontinue oral hygiene temporarily. Massage both sides of the face frequently.

Warmed socks Reflective blanket A reflective blanket and warm socks are passive warming measures that can be used to promote the warmth and comfort of the client experiencing hypothermia. The use of a radiant warmer, forced warm air, and humidified oxygen are active warming measures.

Which passive warming measures would the nurse use to promote the warmth and comfort of a client experiencing hypothermia? Select all that apply. One, some, or all responses may be correct. Warmed socks Radiant warmer Warm forced air Reflective blanket Humidified oxygen

Rest the affected joint. Use a compression splint. Take nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain. Bursitis is an inflammation of the bursal sac surrounding the joint. Rest, use of a compression splint, and taking NSAIDs can help relieve bursitis. Use of an ice pack (not a heat pack) can also help with pain. Gentle range-of-motion exercises are not indicated for bursitis.

Which would the nurse recommend to a client with bursitis of the left knee? Select all that apply. One, some, or all responses may be correct. Rest the affected joint. Apply a heat pack. Use a compression splint. Do gentle range-of-motion exercises. Take nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain.