NURS3209 | Holistic Nursing | Final Exam
A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the: nursing personality. past history. media. genetics.
media Ethnocentrism is a way of looking at the world through a personal lens that has been influenced by personality, genetics, family/relationships, and media. None of the remaining options play a role in the client's comment to the nurse.
A nurse is providing anticipatory guidance to the parents of a 2 1/2-year-old girl. To foster the development of autonomy, which instruction would the nurse include? "Allow the child to explore the why about things." "Encourage the child to dress herself." "Be sure to reprimand her for seeking out new things." "Encourage her to do things that are beyond her skill level."
"Encourage the child to dress herself." Explanation: As motor and language skills develop, the toddler (ages 1 to 3 years) learns from the environment and gains independence through encouragement from caregivers to feed, dress, and toilet self. If the caregivers are overprotective or have expectations that are too high, shame and doubt, as well as feelings of inadequacy, may develop in the child. Confidence gained as a toddler allows the preschooler (ages 4 to 6 years) to take the initiative in learning so that the child actively seeks out new experiences and explores the how and why of activities. If the child experiences restrictions or reprimands for seeking new experiences and learning, guilt results, and the child hesitates to attempt more challenging skills in motor or language development.
A client believes that the illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating? Ethnocentrism Cultural diversity Stereotyping Cultural blindness
Cultural blindness The nurse is demonstrating cultural blindness, which occurs when one ignores differences and proceeds as though they do not exist.
The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death? Select all that apply. Gurgling sounds emanating from the client's throat with each breath Distended abdomen with last bowel movement documented 7 days ago A regular apical pulse of 90 beats/minute Systolic blood pressure which rose from 100 to 110 mm Hg Cyanotic nail beds in hands and feet bilaterally
Gurgling sounds emanating from the client's throat with each breath Distended abdomen with last bowel movement documented 7 days ago Cyanotic nail beds in hands and feet bilaterally Signs of an impending death include noisy respirations, abdominal distention, constipation, and cyanosis of the extremities. The pulse may be slow and/or irregular. The systolic blood pressure would be decreasing, not increasing.
A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan? Eat more cabbage and Brussel sprouts to decrease gas and add fiber. Drink a soft drink daily to prevent gas and allow fiber to break down. Increase fiber slowly over a period of time to prevent gas. Include more protein in the diet to increase fiber and decrease gas.
Increase fiber slowly over a period of time to prevent gas Explanation: Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. By introducing fiber over a period of time, the client can get used to fiber intake and note which foods cause more gas. Flatulence, or flatus, results from swallowing air while eating or sluggish peristalsis. Drinking soft drinks can increase gas and have no effect on fiber breakdown in the body. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Protein does not produce gas that leads to flatus.
The nurse prepares to collect the client's stool for ova and parasites. Which actions should the nurse provide? Select all that apply. Instruct client to call immediately after having the bowel movement. Teach client to not place toilet paper with stool. Place stool in sterile container and label according to policy and procedure. Transport specimen to the lab immediately. Use a biohazard bag for the specimen.
Instruct client to call immediately after having the bowel movement. Teach client to not place toilet paper with stool. Transport specimen to the lab immediately. Use a biohazard bag for the specimen. Explanation: The stool for ova and parasites is collected in a container with medium and it is not a sterile technique. The nurse should ask that the client does not put toilet paper with the specimen. The nurse needs to collect the specimen immediately after the void and take it to the lab in a biohazard bag with the proper requisition following the facility's policy and procedure.
According to Kohlberg, which of the following considerations is central to human development? Morality Safety Influence Agency
Morality Explanation: Kohlberg's theory of development focuses specifically on the changes in morality that occur over time. Kohlberg's Theory of Moral Development includes three levels: preconventional morality, conventional morality, and post-conventional morality.
An older adult client is spiritual and has a deep faith. The client asks the nurse to say a prayer for the client. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse? Tell the client that the nurse is not comfortable praying out loud. Read a printed interfaith prayer to the client. Inform the client that the nurse will try to get another nurse to pray for the client. Tell the client the nurse is busy at the moment and hope the client will forget the request.
Read a printed interfaith prayer to the client. Explanation: A nurse unaccustomed to praying aloud or in public may find it helpful to have a printed interfaith prayer readily available. Interfaith prayers are designed for use regardless of the client's faith. The other action are not therapeutic.
A nurse is caring for a 6-year-old boy who is hospitalized for observation following a motor vehicle accident. Based on Havighurst's developmental tasks, what would be the best choice for a diversional activity for this client? Reading a storybook Playing video games Watching television Speaking to school friends on the telephone
Reading a storybook Explanation: Havighurst (1972) believed that living and growing are based on learning, and that a person must continuously learn to adjust to changing conditions. He described learned behaviors as developmental tasks that occur at certain periods in life. Development tasks of early childhood would include developing fundamental skills in reading and achieving personal independence, to name a few. The best answer above would be reading a story book. The other diversional activities would be appropriate for the adolescent.
Nurses are responsible for delivering culturally competent care for all clients. Culturally competent care does not account for: individual values. developmental level. client's height. available technology.
client's height. In partnership with the person, family, and others; the nurse develops an individualized plan considering the person's characteristics or situation including but not limited to: values, beliefs, spiritual and health practices, preferences, choices, developmental level, coping style, culture, environment, and available technology. A physical characteristic such as one's height does not contribute to cultural competence.
The nurse has just attended a seminar on concepts of cultural diversity. Which statement made by the nurse would require further education? "Culture helps to define identity within specific groups of people." "Culture cannot be influenced, and you are born with your culture." "Language is the primary way that people share their culture." "Culture can be seen in attitudes and institutions of certain populations."
"Culture cannot be influenced, and you are born with your culture." Culture is learned through life experiences from one generation to the next. Culture helping to define identity, language being the primary way that people share their culture, and culture being seen in attitudes of certain populations are correct options; these are all components that define culture.
The nurse is educating a client of Chinese descent regarding the reduction and elimination of lactose in the diet. Which statement(s) made by the client indicates that the education was effective? Select all that apply. "When I drink coffee or tea, I should use a non-dairy creamer instead of milk or cream." "I should replace 2% milk with lactose-free milk." "I can use foods that use milk solids since those are not milk products." "If I drink milk, I should drink one large glass a day and none at any other time." "I can use kosher parve foods because they are prepared without milk."
"When I drink coffee or tea, I should use a non-dairy creamer instead of milk or cream." "I should replace 2% milk with lactose-free milk." "I can use kosher parve foods because they are prepared without milk." The nurse determines that the client understands and can apply the education provided when the client states the intention to substitute milk for non-dairy coffee creamer, substitute milk for a lactose-free milk product, and use kosher parve (kosher neutral) products, which are not made with milk products. The statement about drinking a large glass of milk once daily instead of several times a day indicates the client requires further education, because the client should avoid milk or only drink small amounts. Dry milk solids contain milk and should be avoided; examples include some bread, cereals, puddings, gravy mixes, caramels, or chocolate.
The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person? Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. Look on the chart for a living will if a durable power of attorney for health care cannot be located. Allow the surgeon to handle the issue as part of his or her legal responsibility for explaining the surgical procedure and obtaining the appropriate signature on the consent form.
Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. The client cannot give consent due to confusion. In most cases, the durable power of attorney for health care document is discussed and obtained during the admission process. The nurse should act as a client advocate by seeking someone with durable power of attorney to sign the informed consent form. It is the surgeon's responsibility to explain the surgical procedure and obtain the appropriate signature on the consent form; however, the nurse still acts as the client advocate to locate the designated person. A living will specifies the types of medical treatment the client wants should the client become unable to speak in a terminal or permanently unconscious medical condition, but it does not address matters related to client confusion. Telling visitors about the need for surgery may violate client confidentiality. If the nurse identifies who they have permission to disclose medical information to, they can ask that person about a durable power of attorney for health care.
A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? cleansing enema retention enema carminative enema return-flow enema
cleansing enema The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.
A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? urge total reflex stress
stress Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.
A nurse is taking care of a client who has a new, permanent colostomy. The nurse is talking with the client about the new appliance and asking how the client feels about managing it. Which client response indicates understanding of the relationship between self-concept and health? "I have lots of help at home, so I am not too worried about having to take care of it myself." "I am a pretty smart guy, so I will learn to do this quickly." "I am developing a set of realistic expectations to help me manage my overall health and quality of life." "I realize my overall health is important in determining my quality of life, so I will make sure to keep all appointments for my appliance care."
"I am developing a set of realistic expectations to help me manage my overall health and quality of life." The statement indicating that the client is developing realistic expectations demonstrates understanding that self-concept is an integral part of overall health. Since self-concept is an important part of overall health, a client statement involving self-perception and self-concept should include an understanding of how the two are related. Spiritual beliefs, intellectual dimension, and physical dimension all are factors that influence a person's health-illness status. The client may be intelligent, but this is only a small component of self-concept. Having help at home is not a component of this client's self-concept. Likewise, realizing overall health is important, but keeping appointments is not a component of self-concept.
The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? "I can lower my blood pressure by losing weight." "Osteoarthritis in my knees may be because of my weight." "I can monitor my caloric intake by measuring portions." "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."
"I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week." Blood pressure can be reduced with weight loss. Osteoarthritis may be caused by destruction of cartilage from the pressure on the knee joints caused by excessive weight. Measuring portions is essential to understanding caloric intake. Healthy weight loss is generally accepted as 1 to 2 lb (0.45 to 0.90 kg) per week, or a reduction of 500 to 1,000 calories per day, which includes decreased intake of foods and burning calories with exercise.
When a client with end-stage renal failure states, "I am not ready to die," what is the appropriate nursing response? "This must be very difficult for you." "I'm sure you are angry and sad." "Yes, this is a terrible diagnosis you've received." "Have you talked with your spiritual leader about your fears?"
"This must be very difficult for you." Explanation: The nurse should use statements with broad openings, such as "This must be difficult for you," to allow the client to continue expressing concerns and to acknowledge the client's feelings. This facilitates communication and allows the client to choose the topic or manner of response during this stage of the grieving process. Assuming the client is angry and sad or indicating that this is "a terrible diagnosis" is not an appropriate way to promote coping. The nurse should automatically assume a spiritual leader is desired.
The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client? "Use a pillow to splint the incision." "Change your position frequently." "Raise the head of the bed before turning." "Wait for assistance before moving in bed."
"Use a pillow to splint the incision." Explanation: The client needs to use a pillow to splint the incision during movement to reduce pain. The client needs to change position every 2 hours or less; "frequently" could be misinterpreted by the client. It is easier to turn laterally when the head of the bed is flat. Independence is encouraged, so if the client feels capable, he or she may move in the bed on his or her own.
The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment? "I think all went well with your physical, don't you? "Do you have any questions about all that was discussed during the exam?" "We reviewed your diet and medication plans. Do you have any other questions?" "Will we see you in 6 months to see how your diet has progressed?"
"We reviewed your diet and medication plans. Do you have any other questions?" Explanation: Summarization highlights the important points of a conversation or interaction. Reminding the client that the diet plan and new medications were discussed best summarizes the appointment. The other answers do not review the topics discussed.
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? As fast as the client can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 75 mL/hr for the first 15 minutes, then 200 mL/hr 200 mL/hr
1 unit over 2 to 3 hours, no longer than 4 hours Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.
A client has been diagnosed with PVD. On which area of the body should the nurse focus the assessment? The lower extremities Lung sounds Heart rate and rhythm The abdominal area
The lower extremities Peripheral vascular disease mostly affects the lower extremities. While the lung sounds, heart rate and rhythm, and abdominal assessment will be important, the focused assessment should be on the lower extremities.
According to Sigmund Freud's theory of development, which infant is most likely to be experiencing a significant conflict in development? An infant whose mother is weaning in order to facilitate her return to work An infant boy who is being raised by a single mother and who has minimal contact with adult males An infant who is in daycare 3 mornings per week An infant whose impoverished mother is unable to afford nutritious food
An infant whose mother is weaning in order to facilitate her return to work Explanation: Freud's theory of development characterizes the stage from birth through 18 months as the oral stage. Consequently, the changes in sucking behavior that accompany weaning are a major conflict. This event is considered to be more developmentally significant than contact with the opposite sex, temporary separation from the mother or deficits in nutrition especially during this stage of development.
Why are health promotion and illness prevention a key responsibility of nurses? Chronic illnesses can cause pain and suffering. Treatment of chronic illnesses is very expensive. Chronic illnesses are the leading health problem in the world. People do not like to be sick and feel bad.
Chronic illnesses are the leading health problem in the world. Because chronic illnesses are the leading health problems in the world, health promotion and illness prevention activities are vital to nursing care. By endorsing health promotion and illness prevention, the nurse can assist the client to achieve optimal health even with a chronic illness. It is true that treating chronic illnesses can be expensive, they do cause pain and suffering, and people do not like to be sick, but these are not the most important reasons for promoting health and preventing illnesses.
Rapid growth in nursing research took place in the 1970s and 1980s. This was largely a result of which phenomenon? Rapid declines in hospital patient outcomes Development of the nursing process Increased numbers of nurses with master's degrees State and federal mandates
Increased numbers of nurses with master's degrees Explanation: With more nurses prepared at the master's level, rapid growth in nursing research continued during the 1970s and 1980s. This growth in research did not result from government mandates or worsening patient outcomes. The nursing process predates this historical period
A nurse assessing an older adult client finds that the client has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause? Decreased bladder contractility Diminished ability to concentrate urine Decreased bladder muscle tone Neurologic weakness
Decreased bladder contractility The nurse would suspect the client has decreased bladder contractility, which leads to the client having issues with urinary retention. Diminished ability to concentrate urine would be an issue with the kidney, not the urinary tract.
A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client? Tell the client how to move the walker as the client ambulates. Explain how the walker supports the client's lower extremities. Fully discuss the rationale for using the walker. Describe how the walker can improve the client's quality of life.
Describe how the walker can improve the client's quality of life. Motivating the older adult client can be done by showing the client how the new knowledge will improve the client's quality of life, regardless of how long that may be. It will also demonstrate how the new knowledge could improve the client's level of independence. Although demonstrating the use of the walker and explaining how the walker assists with ambulation (and the rationale for its use) can be used to educate the client, these actions would not promote motivation for the client to learn.
Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? Digital removal of stool may cause parasympathetic stimulation. Nurses find the procedure distasteful and difficult to perform. Most clients will not consent to have digital removal of stool. It often causes rebound diarrhea and electrolyte loss.
Digital removal of stool may cause parasympathetic stimulation. The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.
An older adult has come to the clinic for a follow up visit. During the visit, the client tells the nurse, "I've really had a good life. I've been successful in my work and I have a wonderful family. My grandchildren bring me so much joy." The nurse interprets this statement as indicating achievement of which developmental task? Ego integrity Generativity Despair Intimacy
Ego integrity Explanation: As a person enters the older years, reminiscence about life events provides a sense of fulfillment and purpose, indicating the achievement of ego integrity. Generativity is the developmental task associated with middle adulthood, characterized by involvement with family, friends, and the community, with a concern for the next generation. Despair would be evident in the older adult by statements related to the person's life being a series of failures or missed directions. Intimacy is the developmental task associated with young adulthood.
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? Remove the catheter every 8 hours, or more often in humid weather. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application. Fasten the condom securely enough to prevent leakage without constricting blood flow. Ensure the tip of the tubing is touching the tip of the client's penis.
Fasten the condom securely enough to prevent leakage without constricting blood flow. Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1 to 2 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.
The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching? Bacon Eggs Whole milk Grapefruit
Grapefruit Constipation may be avoided, minimized, or eliminated with proper food selection. Citrus fruits, such as grapefruit, are good choices for a client with constipation as they are rich in soluble fiber pectin, which increases gastrointestinal motility. Bacon contains high fat, which increases constipation. Eggs are low in fiber and high in fat, which slows gastrointestinal motility. Fat in whole milk is constipating.
A nurse assesses a client with an ostomy appliance and notes that the stoma is protruding into the bag. How should the nurse respond to this assessment finding? Put on sterile gloves and gently reposition the stoma. Promptly notify the client's primary care provider. Irrigate the client's colostomy. Have the client rest for half an hour and then reassess.
Have the client rest for half an hour and then reassess. If the stoma is prolapsed, the nurse should have the client rest for 30 minutes and, if the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to it. Irrigation and manipulation are not recommended responses to this situation.
Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease? The secretion of aldosterone and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Increased plasma levels of antidiuretic hormone lead to water excess. There may be an abnormal loss or accumulation of sodium, chloride, potassium, and fluid in the body, resulting in extracellular fluid and water excesses or deficits. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs in this disease's final stage. A disruption of acid-base balance occurs. A disruption in this organ's ability to excrete carbon dioxide causes the pH of the person's blood to fall.
Increased plasma levels of antidiuretic hormone lead to water excess. In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites. Complications from cardiac failure can be described as the secretion of aldosterone, and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs with acute kidney injury. Complications associated to respiratory failure include a disruption of acid-base balance and a disruption in this organ's ability to excrete carbon dioxide; this causes the pH of the person's blood to fall.
The nurse is preparing a client for coronary artery bypass graft cardiac surgery. Which interventions should the nurse provide during the preoperative phase? Select all that apply. Instruct the client how to use the incentive spirometer. Measure the legs for graduated compression stockings. Prep the skin of the chest and legs with surgical prep. Explain what to expect after the surgery. Assess the midsternal and leg dressings.
Instruct the client how to use the incentive spirometer. Measure the legs for graduated compression stockings. Explain what to expect after the surgery. During the preoperative phase the nurse would instruct the client on what to expect after surgery, including lines, chest tubes, and mechanical ventilator. The nurse would instruct the client on how to use the incentive spirometer and mark on it the client's maximum volume, so the goal after surgery is that the client can reach that level. This ensures that the client is taking a sufficient deep breath. Measurements for graduated compression stockings are made before surgery since the client will wear them after surgery. Surgical skin prep is intraoperative. Midsternal and leg dressings are assessed during the postoperative phase.
A nurse is working with young adults and assessing their moral development. The nurse relates which of the following theorists who developed the Theory of Moral Development? Erik Erikson Lawrence Kohlberg Robert Havighurst Sigmund Freud
Lawrence Kohlberg Explanation: Lawrence Kohlberg developed the Theory of Moral Development. Erik Erikson developed the Theory of Psychosocial Development. Robert Havighurst described learned behaviors as developmental tasks that occur through various times in a human's life. Sigmund Freud developed the theory of Psychoanalytic Development.
According to Shelly and Fish (1988), which of the following are spiritual needs underlying all religious traditions that are common to all people? Select all that apply. Meaning and purpose Power Formal religion Love and relatedness Forgiveness
Meaning and purpose Love and relatedness Forgiveness According to Shelly and Fish (1988), there are three spiritual needs underlying all religious traditions and common to all people: need for meaning and purpose, need for love and relatedness, and need for forgiveness.
When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings? Call the health department. Clean up the house. Move the client to an assisted living facility. Refer to the health care provider.
Refer to the health care provider. Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative. The nurse would refer the client to a health care provider for treatment of depression. Calling the health department or cleaning up the house will not help with the client's depression. Moving the client to an assisted living facility may not be necessary if the client receives treatment for the depression.
The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply. Report of muscle cramps Report of excessive urination Slurred speech Report of numbness and tingling of the mouth Seizure activity Blood clotting
Report of muscle cramps Report of numbness and tingling of the mouth Seizure activity Blood clotting
What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply. Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site. A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when an air embolus is present. Bleeding at the site when the IV is discontinued indicates an infection is present. Engorged neck veins, increased blood pressure, and dyspnea occur when a thrombus is present.
Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site. If the IV catheter has become dislodged and IV fluid is flowing into the tissues, then infiltration has occurred. Infiltration is indicated with swelling, pain, coolness, or pallor at the insertion site. Redness, swelling, heat, and pain at the site may indicate phlebitis of the vein. If the site has become infected, it may be contained as a localized infection, or it can spread throughout the bloodstream as a systemic infection. A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when fluids are administered too rapidly (speed shock). Bleeding at the IV site indicates the need for additional pressure to be applied to the site. This can occur if the client is taking anticoagulants or has a bleeding disorder. Engorged neck veins, increased blood pressure, and dyspnea occur when fluid overload has occurred.
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. A neurogenic bladder results from local anesthesia. A urinary tract infection results from the birth process. Catheterization is necessary for 1 week.
The birth can cause perineal swelling. Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period.
The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? The nurse can accept verbal orders to provide immediate care and record once the client is stable. The provider can input orders remotely into the EHR system for the nurse to retrieve. The nurse can implement care once written orders are received from the provider. The client must be stabilized before the nurse can obtain any orders from the provider.
The nurse can accept verbal orders to provide immediate care and record once the client is stable. In most agencies, the only circumstance in which the attending health care provider, nurse practitioner, or house office may issue orders verbally is in a medical emergency. In such a situation, the health care provider/nurse practitioner is present but finds it impossible to write the order due to the emergency circumstances. When a client is admitted to the unit, the prescriber writes orders either in the electronic record or on paper. Health care provider can insert orders remotely, but this is not the most appropriate option in an emergency. Stabilization of the client, while important, should not supersede receiving orders as the providers instructions could be integral to stabilizing the client.
The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing? Anticipatory grief Inhibited grief Normal grief Unresolved grief
Unresolved grief In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Inhibited grief occurs when a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating oneself from social contact), and spiritual (questioning the reason for the loss, the purpose of pain and suffering, the purpose of life, and the meaning of death).
What is a dynamic balance among the physical, psychological, social, and spiritual aspects of a person's life? Health Wellness Holism Promotion
Wellness Wellness is a dynamic balance among the physical, psychological, social, and spiritual aspects of a person's life. Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. Holism is care that addresses all dimensions of a person, including mind, body, and spirit. Health promotion refers to interventions used to improve health or prevent illness.
The nurse is caring for an older adult client who has been hesitant to seek health care. Which action(s) by the nurse would develop a trusting nurse-client relationship? Select all that apply. addressing the client by title and last name following through with requests by the client asking direct questions and waiting for responses touching the client's arm when speaking directly respecting the client's privacy
addressing the client by title and last name following through with requests by the client respecting the client's privacy The nurse should make all efforts to establish trust. Addressing the client professionally by using the title and last name of the client until told otherwise is an appropriate way for the nurse to establish a positive nurse-client relationship. When the client makes a request of the nurse, it should be performed in a timely fashion or with an explanation as to when it will be done. The nurse should proceed with open-ended questions rather than direct questions until trust has been established. Touch should not be employed unless it is acceptable to the client since many cultures are not comfortable with touch.
Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia? a woman experiencing a cesarean birth an adolescent having arthroscopic surgery a young adult with a fractured leg an older adult man with a fractured hip
an older adult man with a fractured hip The risk of hypothermia increases in the very young and the very old.
Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice? empathy positive regard analysis comfortable sense of self
analysis Empathy, positive regard, and a comfortable sense of self were among the key ingredients. Empathy is an objective understanding of the way in which a client sees his or her situation, identifying with the way another person feels, putting yourself in another person's circumstances, and imagining what it would be like to share that person's feelings. Communication is crucial because it affects the nurse's behavior and can enhance or detract from positive interactions or regard with the client and family. Comfortable sense of self is part of the nursing confidence in caring for clients. Analysis is part of the nursing process and not the key elements of therapeutic communication.
Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief? coping strategies self-care activities pain management spiritual distress
coping strategies Explanation: Dysfunctional grief can be unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed.
A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse likely document the results? progress note admission nursing assessment graphic sheet medical record
graphic sheet The graphic sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all of the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few.The admission nursing assessment records the findings of the nursing history and physical assessment upon admission.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find? hyperphosphatemia hyperchloremia hypokalemia hypomagnesemia
hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.
In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? normal response abdominal infection hernia development paralytic ileus
paralytic ileus Explanation: A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.
A nurse at a community-health centre is completing an audit of patient records. The outcomes of this project will serve what purposes? communication and evaluation knowledge and advocacy education and confidentiality quality assurance and reimbursement
quality assurance and reimbursement Audits of client records serve a dual purpose: quality assurance and reimbursement. Audits are not normally used for communication or advocacy purposes. Though confidentiality would need to be maintained, this is not the purpose of the exercise.
