1125 PrepU Patient-Centered Care
A client is taking numerous eye drops to prepare for cataract surgery. Which teaching about ophthalmic application will the nurse provide?
"Wait 5 minutes between instillation of different types of eye drops.
The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?
Aspiration of a brain abscess
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?
Encourage the client to drink liberal amounts of fluids
A client is receiving targeted therapy for treatment of stage 2 breast cancer. The nurse explains to the client that this means that the therapy is matched/based on which factor?
Genetic signature of the tumor
A nurse is talking on the phone with a doctor and states, "I am calling you about Mrs. Nye, my client with cancer in room 213." This is an example of what type of language that is important to all people?
People-first
A client has been prescribed diuretic therapy for hypertension. It has been causing frequent urination at night and now the client is refusing to take the morning dose of furosemide. What would be the best response by the nurse?
Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal
An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will:
create an exercise plan that is realistic and valued.
A new client is admitted to the unit, and the nurse's initial assessment will include a systematic appraisal of the client's cultural characteristics, health practices, and beliefs. What type of assessment will the nurse perform to gather this information?
cultural
Parasympathetic
-Dominates at rest -Conserves energy -Decreases HR -Increases GI tract functions -Constricts pupils -Main end NT is aceytylcholine -Input to all organs -Initial nerver longer, second nerve shorter
Sympathetic
-Fight or flight response -Expends energy -Increases HR -Dilates pupiles -Dilates bronchi -Decreases secretions -Main ending NT is norepinephrine -Input to all organs -Initial nerve shorter, second nerve longer
A client has been receiving chemotherapy for cancer treatment. The client is competent and has been actively involved in decisions regarding care; however, the client has now decided to refuse treatment. What should the nurse do when the client refuses the next dose of chemotherapy?
Document the client's choice and offer to discuss feelings about the chemotherapy.
The nurse is caring for a hospitalized client with an inoperable brain tumor. A family member expresses disappointment with being unable to care for the client at home, because the client requested to die at home. Which response by the nurse is best?
Have you and your family explored hospice care?
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be:
Ineffective airway clearance.
A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?
It will allow for us to see the client and possibly increase client participation in care
A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?
Plans to eat a snack of fruit twice per day.
A nurse is teaching a male client to perform monthly testicular self-examinations. Which point is appropriate to make?
Testicular cancer is a highly curable type of cancer.
The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?
The nurse encourages the client to participate in all treatment decisions as the center of the health care team. By becoming involved and "speaking up" research shows that patients who take part in decisions about their health care are more likely to have better outcomes
When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?
Trochanter roll
Which suggestion would the nurse include for a client who has had a thyroidectomy to reduce tension on the suture line?
Use the hands to support the head when rising from a sitting position.
What does decreased pulse pressure reflect?
reduced stroke volume
The nurse is caring for a client with muscular dystrophy who is confined to bed. The client develops a pressure ulcer on the sacrum. The nurse documents the pressure ulcer as a(n)
secondary condition.
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated.
An urgent care nurse is cleaning a forehead laceration on a 7-year-old. The mother is present. The child is crying and screaming. The nurse should:
tell the child, "It's OK to cry, but I need you to hold still."
A client who requested a do-not-resuscitate (DNR) order upon admission to the hospital now states a desire for the medical team to do everything possible to help the client get better. The client is concerned about the DNR order. Which response by the nurse is best?
"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."
A client with severe and persistent depression is debating undergoing electroconvulsive therapy (ECT). The client's family asks a nurse to convince the client that this treatment would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make?
"The client, treatment team, and family can meet to discuss this treatment option."
Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Choose all that apply.
-Jaundice -Clay-colored stools -Dark urine -Pruritis
The client who has the chronic condition of diabetes, reports blurry vision, and admits to nonadherence to the diet and medications. The home health nurse checks the client's fasting blood glucose level, which is 412 mg/dL. What phase of the Trajectory Model of Chronic Illness does the nurse assess this client is in?
Acute
A nurse assesses a client with a terminal illness and determines that the client is in denial about the condition. Which of the following would be most important for the nurse to do when developing the client's plan of care?
Accept the client's denial of the situation. denial is often a useful coping mechanism that enables the client to gain temporary emotional distance from a situation that is too painful to think about.
Which word is best described as protection and support of another's rights?
Advocacy
The instructor provides corrective information to the nursing student when the student refers to the client as the
COPDer in 216 People-first" language means referring to the person first. Using "COPDer in 216" conveys that the illness or disability is of greater importance than the person.
A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:
Deficient knowledge (treatment regimen).
Which example most accurately depicts the ethical principle of autonomy?
Describing a surgery to a client before the consent is signed
Which is a sympathetic effect of the nervous system?
Dilated pupils
A client at a mental health clinic who has recently emigrated from another country identifies isolation and loneliness as current stressors. The client describes being withdrawn but does not know how to change the situation. Which is the most appropriate step for the nurse to take to help the client?
Support the client in developing attainable socialization goals.
A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action?
Walk with the nurse the length of her room.
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as:
effleurage a form of massage involving a circular stroking movement made with the palm of the hand.
A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring?
endorphins a natural analgesic substances released by the movement of the client on the birth ball
The nurse is caring for a 16-year-old boy with injuries from a car accident. Which activity describes the nurse's manager role?
facilitating return to school by working with the school nurse
The nurse is discussing life management with the client with rheumatoid arthritis in a health clinic. What assessment finding indicates the client is having difficulty implementing self-care
increased fatigue
The nurse is working with a client who has difficulty controlling her blood sugar. The overweight client does not adhere to a low-calorie diet and forgets to take medications and check her blood glucose level. The client's glycohemoglobin is 8.5%. When establishing a goal for the client, the nurse first
Collaborates with the client to establish an agreed-upon goal
The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the most appropriate action by the nurse?
Consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration.
A client who is HIV positive is receiving highly active antiretroviral therapy (HAART) that includes a protease inhibitor (PI). The client comes to the clinic for a follow-up visit. Assessment reveals lipoatrophy of the face and arms. The client states, "I'm thinking the side effects of the drug are worse than the disease. Look what's happening to me." The nurse would most likely identify which nursing diagnosis as the priority?
Disturbed body image related to loss of fat in the face and arms experiencing lipoatrophy, which results in a localized loss of subcutaneous fat in the face (manifested as sinking of the cheeks, eyes, and temples), arms, legs, and buttocks. These changes as well as his statement about the side effects of the drug being worse than the disease indicate that he is concerned about how he appears to others
