Basic Care and Comfort

For which of the following clients would benefit most from use of a walker? Select one: a. A 32-year-old female client who fractured her left tibia. b. A 67-year-old male client post cerebrovascular accident with minimal right sided weakness. c. A 43-year-old avid jogger one week status post right knee replacement. d. An 82-year-old female client post right hip replacement that has had two falls in the past wee

. d. An 82-year-old female client post right hip replacement that has had two falls in the past wee Correct - Walkers are needed for clients with balance problems or those that cannot support their own weight

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? Select one: a. "I should limit my sodium intake to 4 grams per day." b. "I should increase my consumption of protein." c. "I should consume a diet low in carbohydrates." d. "I should increase my fluid intake to 8-10 glasses of water a day."

a. "I should limit my sodium intake to 4 grams per day." CORRECT. Excessively high protein and sodium diets put clients at risk for glomerulonephritis. Clients with this condition should implement sodium and protein restriction.

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "I will remove the condom 30 minutes after intercourse." b. "I can use spermicidal gels or creams to increase effectiveness." c. "My partner should leave an empty space at the tip." d. "My partner will put the condom on while his penis is erect."

a. "I will remove the condom 30 minutes after intercourse." CORRECT. To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status? Select one: a. "We allow her to pick out a treat at the grocery store for good behavior." b. "She enjoys helping to prepare her snacks in the kitchen." c. "We increase her protein intake when she's playing sports." d. "She eats a large breakfast every morning."

a. "We allow her to pick out a treat at the grocery store for good behavior." CORRECT. This statement indicates a need for further teaching. This client's mother should be educated about the importance of praising the client's abilities and skills rather than using food as a reward, which may lead to an increased risk for obesity.

A nurse needs to determine a client's strength before ambulating. Which of the following should the nurse do? Select one: a. Ask the client to plantar flex the feet against resistance. b. Ask the client if they have been up before. c. Assess how strong the client feels today. d. Assess pedal pulses and feet for edema.

a. Ask the client to plantar flex the feet against resistance. CORRECT. It is necessary to assess the client for muscle strength (legs and upper arms) as immobile clients have decreased muscle strength, tone, and mass, which affects the ability to bear weight and raise the body.

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client? Select one: a. Avoid inadvertently advancing the catheter into the bladder. b. Examine condition of catheter and drainage tubing. c. Assess for perineal pain or discomfort. d. Assess the client's knowledge of importance of perineal hygiene.

a. Avoid inadvertently advancing the catheter into the bladder. CORRECT. Accidental advancement of the catheter into the bladder during cleansing increases the risk of introducing bacteria into the bladder. Therefore, avoiding inadvertent advancement of the catheter into the bladder is the priority intervention

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? Select one: a. Decreased urine output b. Mild diarrhea c. Abdominal distension d. Difficulty evacuating bowels

a. Decreased urine output CORRECT. Decreased urine output indicates dehydration and should be reported immediately to the provider. Listlessness, sunken eyes, decreased tears, and dry mucous membranes are other symptoms of dehydration that should be immediately reported.

A nurse is teaching a client with right-sided hemiparesis to ambulate with a quad cane. Which instructions are appropriate? Select one: a. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. b. Place quad cane in left hand, extend left hand with quad cane, and then left leg followed by right leg. c. Place quad cane in right hand, extend left lower extremity, and then right hand with quad cane and left lower extremity. d. Place quad cane in right hand, extend right hand with quad cane and left lower extremity.

a. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. CORRECT. Place quad cane in left hand, extend left hand with quad cane and right lower extremity followed by left leg. Holding the quad cane on the stronger side of the body and moving the cane in unison with the weaker leg gives support and helps to maintain stability for the client.

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "What happens to your contractions when you move about?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "When did your contractions begin?" d. "Have you felt fetal movement over the last 24 hours?"

b. "Have you noticed any bloody show or fluid coming from your vagina?" CORRECT. Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor.

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "I will tighten my pelvic muscles when coughing." b. "I will increase my fiber intake to stay regular." c. "I will increase my daily fluid intake." d. "I will avoid standing for prolonged periods of time."

b. "I will increase my fiber intake to stay regular." CORRECT. A full liquid diet is provided immediately after surgery, followed by a low-residue diet to decrease bowel movements and allow time for the incision to heal. Foods that are high in fiber should be avoided until it has been determined that normal bowel function has been regained. Stool softeners should be administered as prescribed to facilitate bowel elimination and prevent stress on stitches.

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? Select one: a. This is a possible infection or irritation in the genital area b. Awareness of body structures and sensations is normal and expected c. This is an early emergence of sexual expression that should be discouraged d. Your child is probably imitating behaviors that she has observed

b. Awareness of body structures and sensations is normal and expected CORRECT. Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! It should be ignored unless the behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come and do some fun and exciting activity

A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education? Select one: a. Wheat bread b. Cheddar cheese c. Small amounts of kiwi d. Small sweet potato

b. Cheddar cheese CORRECT. Client's with renal failure need to restrict protein and phosphorus which is present in cheese and many milk products.

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education? Select one: a. Changing the pouch before a meal. b. Cleansing the peristomal skin with alcohol. c. Positioning the client standing or supine. d. Measuring and assessing the stoma.

b. Cleansing the peristomal skin with alcohol. CORRECT. This intervention is not appropriate. The peristomal skin should not be cleansed with alcohol.

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching? Select one: a. French onion soup and salad b. Grilled chicken salad with fresh salsa c. Chicken bouillon and crackers d. Vegetarian wrap with chips

b. Grilled chicken salad with fresh salsa CORRECT. Grilled chicken salad and fresh salsa are both made from fresh (preservative-free) materials and therefore are likely to be of lower sodium content than French onion soup, chips, chicken bouillon, or crackers.

A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice? Select one: a. Eggs b. Rabbit c. Spinach d. Tuna

b. Rabbit CORRECT. Of the "beasts of the earth" (which basically refers to land mammals with the exception of swarming rodents), clients observing Kosher laws may eat any animal that has cloven hooves and chews its cud. Any land mammal that does not have both of these qualities is forbidden. The Torah specifies that the camel, the rock badger, the hare and the pig are not kosher because each lacks one of these two qualifications. Cattle, sheep, goats, deer and bison are kosher

A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client? Select one: a. The infant is unable to sit with support b. The infant does not raise his head when placed on his abdomen c. The infant demonstrates stranger anxiety d. The infant is unable to point to objects

b. The infant does not raise his head when placed on his abdomen CORRECT. When placed on the abdomen the 3 month old should attempt to raise his head. Some sources refer to this as "tummy time" which provides the infant with the stimulation to strengthen upper body and neck muscles in preparation for good head control when sitting upright and the some of the muscles required for crawling.

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation? Select one: a. When the client feels abdominal cramping. b. When the client has the urge to defecate. c. Immediately before meals. d. Every hour while awake.

b. When the client has the urge to defecate. CORRECT. Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and subsequent constipation. Therefore, the best time to toilet a client to encourage bowel training is when the client has the urge to defecate.

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I will clean his penis with each diaper change." b. "The circumcision will heal completely within a couple of weeks." c. "I can give him a tub bath in two days." d. "I should not remove the yellow exudate on the end of the penis."

c. "I can give him a tub bath in two days." CORRECT. The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks.

A nurse is educating a client on restful sleep. Which of the following statements by the client would alert the nurse that further teaching is necessary? Select one: a. "I go to bed and get up at the same time each day." b. "I don't take naps during the day." c. "I watch television until I fall asleep." d. "I drink some hot milk and take a bath before going to bed."

c. "I watch television until I fall asleep." CORRECT. When activities other than sleeping, like watching TV, are done in bed, they are not correlated to the expectation of sleep like simply lying down to sleep. The nurse should facilitate maintenance of the client's usual bedtime routines as appropriate.

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? Select one: a. Wheat bread b. Chicken breast c. Broccoli with cheese sauce d. Baked potato

c. Broccoli with cheese sauce CORRECT. Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may be contraindicated include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods.

A nurse is caring for a client after an open radical prostatectomy. Which of the following interventions is the highest priority in the immediate postoperative period? Select one: a. Administer a stool softener to prevent constipation. b. Teach the client how to care for a urinary catheter and leg bag. c. Encourage use of patient-controlled analgesia (PCA) as needed. d. Suggest methods for reducing urinary incontinence, such as Kegel exercises

c. Encourage use of patient-controlled analgesia (PCA) as needed. CORRECT. Assessment of the client's pain level, along with monitoring the effectiveness of pain management given through patient-controlled analgesia, is the priority intervention in the immediate postoperative period.

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following? Select one: a. Gratify their oral fixation. b. Finish a project they set out to do. c. Increase their independence. d. Develop their sense of trust.

c. Increase their independence. CORRECT. The drive for independence is expressed by the toddler opposing the desires of those in authority (tantrums) and attempting to do everything for themselves. The Erickson developmental stage for this age is "Autonomy vs. Shame and Doubt."

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? Select one: a. The baby develops swelling or redness at the injection site b. The baby has an axillary temperature of 100.4o F. (38o C) c. The baby is crying inconsolably for more than three hours d. The baby develops a localized or generalized rash

c. The baby is crying inconsolably for more than three hours CORRECT. Inconsolable crying lasting more than three hours and/or seizures within 48 hours of vaccination is a sign of encephalopathy that must be treated immediately.

A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good understanding of how to use a bulb syringe to suction excess mucous from the infant's airway? Select one: a. "The bulb syringe should reach to the back of my baby's throat." b. "The bulb syringe should be sterilized after each use." c. "I should compress the bulb syringe after I place it in my baby's mouth." d. "I should suction my baby's mouth before the nose."

d. "I should suction my baby's mouth before the nose." CORRECT. The mouth should always be suctioned before the nose to prevent aspiration during the gasp response that occurs when the nose is suctioned.

A nurse is caring for a client who is receiving intermittent tube feedings. What intervention reduces the risk of aspiration? Select one: a. Performing nasotracheal suctioning before initiation of the feeding. b. Instructing the client to cough forcefully as the feeding is started. c. Assisting the client into a supine position in preparation for the feeding. d. Assessing gastric residual volume immediately before administering the feeding Clear my choice

d. Assessing gastric residual volume immediately before administering the feeding CORRECT. Measuring the gastric residual volume (GRV) every 4 to 6 hours in clients who are receiving continuous feedings and immediately before the feeding in clients receiving intermittent feedings is an effective way to reduce the risk of aspiration. Nursing measures to reduce the risk of aspiration, such as keeping the head of bed elevated and routine assessment for aspiration, should be implemented for clients who are receiving tube feedings. Feedings should be withheld if the GRV is greater than 200 mL in two successive measurements.

A nurse is caring for a client who is neutropenic. Which of the following foods are appropriate for this client? Select one: a. Lettuce and alfalfa sprouts b. Fresh strawberries and carrots c. Raw cauliflower or broccoli d. Cooked spinach and celery

d. Cooked spinach and celery CORRECT. Clients who are neutropenic are at increased risk for the development of infection. The reduced numbers of neutrophils and other white blood cells can limit the presence of common infection manifestations. The focus of care for client with neutropenia is on keeping the client's own normal flora under control and preventing the transmission of organisms. Raw or fresh foods may be a source of bacteria. The client should avoid raw fruits and vegetables, undercooked meats, eggs, or fish.

A nurse is changing a dressing on a pre-school-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child? Select one: a. Teaching the child how to go 'to a different place' using their imagination. b. Assisting the child to take deep breaths and focus on relaxing. c. Promising the child a special treat in exchange for cooperation. d. Encouraging the child to watch a favorite cartoon on television.

d. Encouraging the child to watch a favorite cartoon on television CORRECT. Accidental advancement of the catheter into the bladder during cleansing increases the risk of introducing bacteria into the bladder. Therefore, avoiding inadvertent advancement of the catheter into the bladder is the priority intervention

A nurse is providing dietary education to a client with a new ileostomy. What foods should the nurse instruct the client to avoid in the first weeks after surgery? Select one: a. Cream cheese b. Strained fruit juices c. Lean meats d. Fresh vegetables

d. Fresh vegetables CORRECT. Fresh vegetables are high in fiber and therefore, should be avoided in the first weeks after surgery. During the first weeks after surgery, many providers recommend low fiber diets, particularly for clients with ileostomies, because the small bowel requires time to adapt to the diversion. As ostomies heal, clients are able to eat almost any food and high fiber foods are encouraged to help ensure a more solid stool to achieve success at irrigation, but high fiber foods should be avoided in the first weeks after surgery

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid? Select one: a. Broiled liver and white rice. b. Grilled salmon and cooked apricots. c. Roast chicken and cooked spinach. d. Pork chop and brown rice.

d. Pork chop and brown rice. CORRECT. Pork chops and brown rice are high in roughage content which will stimulate peristalsis and makes the symptoms of ulcerative colitis worse. Other foods to be avoided include whole grains, nuts, raw fruits and vegetables, caffeine, alcohol, tough meats, pork and highly spiced meats.