Nursing Concepts Caring Interventions Part 4

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states

"Do not smoke and avoid being around others who are smoking." Explanation: A sudden and complete loss of voice and cough are symptoms of laryngitis. The nurse instructs the client to avoid irritants, such as smoking. Voice rest is indicated. Whispering places stress on the larynx. Inhaling cool steam or aerosal aids in the treatment. Dry air may make the symptoms worse. A "tickle" in the throat that many clients report is actually worsened with cold liquids.

After teaching nursing students about substance abuse and its effects on individuals and families, the instructor determines that additional teaching is necessary when the students state which of the following?

"Individuals frequently engage in substance use and abuse to enhance their decision-making ability." Explanation: Substance abuse refers to the use of alcohol and illegally obtained, prescribed, or over-the-counter drugs alone or combined in ineffective attempts to cope with the pressures, strains, and burdens of life. Thus, individuals with substance abuse often have difficulty identifying and implementing adaptive behaviors. Substance abuse occurs in all settings. Individuals who abuse substances are unable to make healthy decisions and to solve problems effectively.

An individual is considered obese when their BMI is what value?

30-39 Explanation: Those persons with a BMI 30 to 39 are considered obese. Persons with a BMI <18.5 are at risk for problems associated with poor nutritional status. Persons with a BMI 25 to 29 are considered overweight. Those with a BMI >40 are considered morbidly obese.

Which treatment involves implantation of interstitial radioactive seeds under anesthesia to treat prostate cancer?

Brachytherapy Explanation: Brachytherapy involves the implantation of interstitial radioactive seeds under anesthesia. Hormone therapy for advanced prostate cancer suppresses androgenic stimuli to the prostate by decreasing the level of circulating plasma testosterone or interrupting the conversion to or binding of DHT. Teletherapy involves 6 to 7 weeks of daily radiation treatments. High-dose ketoconazole (HDK) lowers testosterone through its abilities to decrease both testicular and endocrine production of androgen.

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Cerebrospinal fluid is cloudy in nature. Explanation: The nurse would note cloudy cerebrospinal fluid as a concern. Cloudy fluid is an indication of infection. The physician is correct to maintain aseptic procedure. A piercing feeling and pressure relief are common during and after the procedure.

Which medication is the most effective agent in the treatment of Parkinson disease?

Levodopa Explanation: Levodopa is the most effective agent and is the mainstay of treatment for Parkinson disease (PD). Benztropine, amantadine, and bromocriptine mesylate are utilized in the treatment of PD but are not the most effective.

A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period?

Logroll the client from side to side. Explanation: Logrolling the client maintains alignment of his hips and shoulders and eliminates twisting in his operative area. The nurse should encourage ROM exercises to maintain muscle strength. Because of pressure on the operative area, having the client sit up in a chair or with the head of the bed elevated should be allowed only for short durations.

Which disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks?

Systemic lupus erythematosus (SLE) Explanation: The most familiar manifestation of SLE is an acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and the cheeks. This type of rash does not characterize RA, scleroderma, or polymyositis.

The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care?

Advice for the family to have fruit juices readily available at the client's bedside. Explanation: To promote nutrition in the terminally ill, the nurse would encourage the family to have fruit juices and milkshakes readily available at the bedside so that the client can access them frequently. Cool foods may be better tolerated than hot foods. Cheese, eggs, peanut butter, mild fish, chicken, and turkey are often better choices than meat such as beef that may taste bitter and unpleasant. Meals should be scheduled when family members are present to provide company and stimulation.

The nurse prepares to auscultate heart sounds. What nursing intervention will be most effective to assist with this procedure?

Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard. Explanation: During auscultation, the client remains supine and the room should be as quiet as possible while the nurse listens to heart sounds. The client should breathe normally during the examination. Sitting on the edge of the bed is not the preferred client position. The room should be quiet so asking the families to remain quiet is acceptable. The client does not need to take deep breaths during heart auscultation.

A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections?

Chlorhexidine Explanation: Although povidone-iodine or alcohol may be used, the preferred agent to clean the skin prior to insertion of an intravenous device is chlorhexidine. Normal saline would not be appropriate.

A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with that diagnosis? Select all that apply.

Cyanosis Shoulder pain Dyspnea Tachycardia Explanation: Hypotension, along with the other correct choices, is a manifestation of an air embolism. Crackles on auscultation is a major indicator of circulatory system overload.

The nurse is caring for a client with diabetes who developed hypoglycemia. What can the nurse administer to the client to raise the blood sugar level?

Glucagon Explanation: Glucagon, a hormone released by alpha islet cells, raises blood sugar levels by stimulating glycogenolysis, the breakdown of glycogen into glucose, in the liver. Insulin is released to lower the blood sugar levels. Cortisone and estrogen are not released from the pancreas.

After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first?

Kegel exercises Explanation: Kegel exercises are noninvasive and are recommended as the initial intervention for incontinence. Fluid restriction is useful for the client with increased detrusor contraction related to acidic urine. Artificial sphincter use isn't a primary intervention for post-prostatectomy incontinence. Self-catheterization may be used as a temporary measure but isn't a primary intervention.

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client?

Listening to music Watching television Changing position Explanation: Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition?

Lymphedema Explanation: Lymphedema is a common postoperative effect of modified radical mastectomy and lymph node dissection. Elevation of the left arm and hand will allow gravity to assist lymph drainage. Other preventive measures include exercises in which the arms are elevated. Trousseau's sign is a sign of hypocalcemia and isn't an expected finding in this situation. IV infusions shouldn't be given in the left arm nor should venipunctures be done in this arm. Although muscle atrophy is a potential adverse effect if the client doesn't exercise her left arm, it wouldn't be prevented by elevation.

A client has developed urinary incontinence after having a urinary catheter in place for a few weeks. What is the initial nursing intervention the nurse should use to start the client with bladder training?

Place client on a timed voiding schedule. Explanation: Placing the client on a timed voiding schedule after a catheter removal will promote bladder muscle retraining. The nurse should do a bladder scan immediately after voiding, but this is not the initial action. The nurse does not need to complete urinary catheterization at specific intervals for initial bladder training. The client needs to limit fluids at night.

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase?

Provide factual information and emotional support. Explanation: During the most acute phase of injury, family memebers need factual information and support from the health care team. Allowing distance and space can alienate the family, and make them feel like they are not involved with the client. The family may be unsure of approaching the nurse and may not know what questions to ask. The nurse should be available and offer information to start. He or she should not provide false reassurance; they need factual information at this time

A nurse is caring for a patient experiencing anxiety related to being newly diagnosed with type 1 diabetes. Which of the following would be most appropriate for the nurse to do?

Provide written back-up instructions for care. Explanation: To assist in managing anxiety related to a new medical diagnosis, it would be most appropriate for the nurse to provide the patient with written back-up instructions related to care. Doing so prevents the patient from becoming overwhelmed with all the necessary information. In addition, the written instructions provide an as-needed future reference for the patient. Touch should be used only as appropriate and with the patient's permission. The focus should be on positive aspects in the present, the "here and now." Distraction can be helpful to relax and prevent the patient from becoming overwhelmed.

The nurse is attempting to take vital signs of an older adult hospitalized following knee surgery. The client continuously yells, "It's 1999 and you are going to hurt me!" What action should the nurse do first?

Reorient the patient. Explanation: The first action that should be taken by the nurse is to reorient the patient. Hospitalized older adults are at risk for disorientation and confusion. Although the nurse will still need to take the vital signs and assess for infection, reorienting the client remains the first action. If the client can be reoriented, then the nurse may be able to complete the other actions without difficulty or potentially harming the client. The nurse may need to notify the physician if the client is unable to be oriented or if the assessment is abnormal.

A patient with a strong history of breast malignancy in her family is scheduled for a breast biopsy in the morning. What would be the most appropriate nursing action when caring for this patient the evening before surgery?

Sit with her and provide an opportunity for her to talk about her concerns. Explanation: Emotional support from family and significant others provides love and a sense of sharing the burden. The emotions that accompany stress are unpleasant and often increase in a spiraling fashion if relief is not provided. Being able to talk with someone and express feelings openly may help a person gain mastery of the situation. Nurses can provide this support, but it is important to identify the person's social support system and encourage its use. People who are "loners," who are isolated, or who withdraw in times of stress have a high risk of coping failure.

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client

That medication will be prescribed for pain relief Explanation: Pain is expected postoperatively, and the client should be reassured that medication will be prescribed to relieve pain. The client may have less pain knowing that measures will be taken to reduce it. Diversional activities may be used in addition to analgesics. Anxiety about pain could increase the client's perception of pain. Another nursing activity is being an advocate for the client and notifying his surgeon of the client's fear.

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.

A client has been admitted to the hospital with a large sacral pressure ulcer. The physician orders the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?

Turn the client every 2 hours. Explanation: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Option A is the assessment phase of the nursing process. Option B is the planning phase of the nursing process, and option C is the evaluation phase of the nursing process.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

Using sterile technique during the dressing change Explanation: The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk of injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process.

Which diagnostic test is done to determine suspected pituitary tumor?

computed tomography scan Explanation: A computed tomography or magnetic resonance imaging scan is done to detect a suspected pituitary tumor. Radiographs of the chest or abdomen are taken to detect tumors. Radiographs also determine the size of the organ and their location. Measuring blood hormone levels helps determine the functioning of endocrine glands. A radioimmunoassay determines the concentration of a substance in plasma.

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy. Explanation: The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura?

pneumothorax Explanation: A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly.

Using the concept of the wellness-illness continuum, what would the nurse include in the development of a nursing care plan for a chronically ill patient?

Encourage positive health characteristics within the limits of the specific illness. Explanation: By viewing health and illness on a continuum, it is possible to consider a person as being neither completely healthy nor completely ill. Instead, a person's state of health is ever-changing and has the potential to range from high-level wellness to extremely poor health and imminent death. The use of the health-illness continuum makes it possible to regard a person as simultaneously possessing degrees of both health and illness. On the health-illness continuum, even people with a chronic illness or disability may attain a high level of wellness if they are successful in meeting their health potential within the limits of their chronic illness or disability (Manderscheid, Ryff, Freeman, et al., 2010).

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?

Withhold anticonvulsant medications for 24 to 48 hours before the exam Explanation: Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the client be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, meals are not omitted, because an altered blood glucose concentration can cause changes in brain wave patterns. The client is informed that a standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.