Basic care and comfort Prep U

A client inquires about the use of herbal therapy. Which statement by the nurse is most accurate? "All herbs are equal in purity, so purchase the cheapest brand." "Herbs can have side effects and can interact with prescription medications." "Be sure to pay attention to the packaging's therapeutic and prevention information." "It is best if you select a licensed herbalist as a practitioner."

"Herbs can have side effects and can interact with prescription medications."

The nurse is providing teaching for the parents of an 8-year-old girl who has undergone surgery. The nurse emphasizes the importance of maintaining adequate hydration. Which response by the mother would indicate a need for further teaching? "I will remind her that she will need an IV if she does not drink." "Anything that melts at body temperature is counted as a fluid." "Ice chips count as fluid intake. One cup of ice equals a half-cup of water." "I should offer her small amounts of fluid frequently."

"I will remind her that she will need an IV if she does not drink."

A nurse is discussing good sleep habits with an older adult. Which statement made by the client tells the nurse that further instruction is necessary? "I will try to go to bed at the same time every night." "I will limit the amount of coffee I drink during the day." "I will take my Lasix in the morning." "I will stay up later to make sure that I am very tired.

"I will stay up later to make sure that I am very tired.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? "It distracts your brain from the sensations of pain." "It causes the release of endorphins." "It blocks the transmission of nerve messages of pain at the receptors." "It disrupts the nerve signal of pain via mechanical irritation of the nerves."

"It distracts your brain from the sensations of pain."

What percentage of weight change in 6 months is considered abnormal? 1% 2% 5% 10%

10%

The nurse is caring for four clients. For which client is a sitz bath most appropriate? 42-year old recovering from a C-section delivery 51-year old with hemorrhoids 60-year old who is 1-day postop from a knee replacement 73-year old with pneumonia who can get up to bedside commode

51-year old with hemorrhoids

The nurse is recording the intake and output for a client: D5NS 1,000 ml, urine 450 ml, emesis 125 ml, Jackson-Pratt drain #1 35 ml, Jackson-Pratt drain #2 32 ml, and Jackson-Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.

654

What is the length of time a client undergoes a complete sleep cycle? 30-60 minutes 60-80 minutes 90-110 minutes 120-160 minutes

90-110 minutes

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? Suggestions that the family offer the client foods that are hot. Encouragement of the family to serve the client meat, especially beef. Advice for the family to have fruit juices readily available at the client's bedside. Arrangements for the client to eat meals while others are out of the home.

Advice for the family to have fruit juices readily available at the client's bedside.

An older adult is experiencing bowel changes. She used to have a bowel movement every day, but she is now having one every 3 to 4 days. She also states that the stools are hard. Which of the following assessments would the nurse make? Select all answers that apply. Amount of dietary fiber Use of laxatives Activity level of the client Quantity of daily fluid intake Caloric intake

Amount of dietary fiber Use of laxatives Activity level of the client Quantity of daily fluid intake

The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort? Dress the child warmly to bring out the rash so that it fades quickly. Apply cool compresses to the skin to stop local itching. Discuss with the child the importance of not scratching lesions. Administer infant aspirin every 4 hours as necessary for comfort.

Apply cool compresses to the skin to stop local itching.

The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client? Apply warm or cool cloths to the forehead or back of the neck Maintain hydration by drinking eight glasses of fluid a day Perform the Heimlich maneuver Use pressure-relieving pads or a similar type of mattress

Apply warm or cool cloths to the forehead or back of the neck

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse's best intervention in this situation? Ignore the boy's pain if he is not complaining about it. Ask the boy to draw a cartoon about the color or shape of his pain. Medicate the boy with analgesics to reduce the anxiety of experiencing pain. Distract the boy so he does not notice his pain.

Ask the boy to draw a cartoon about the color or shape of his pain.

Why will it be necessary for the nurse to be very supportive of parents' attempts to feed the infant with recently repaired myelomeningocele? The infant will have a poor sucking reflex. Pain will interfere with the feeding process. Assuming the usual feeding position will be difficult. Nausea and vomiting often follow repair of the cystic mass.

Assuming the usual feeding position will be difficult.

A group of students is studying for a test on traction. The students demonstrate understanding of the types of traction when they identify which of the following as an example of skin traction? Crutchfield tongs Thomas splint Buck's Balanced suspension

Buck's

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Turn and reposition the client at least once every 8 hours. Vigorously massage lotion over bony prominences. Develop a written, individual turning schedule. Slide the client, rather than lifting, when turning.

Develop a written, individual turning schedule.

Which process breaks up food into absorbable nutrients? Secretion Motility Digestion Absorption

Digestion

The health care provider is preparing to bivalve the client's cast. Which supplies should the nurse assemble? Elastic compression bandages Gauze bandages and tape Sterile saline and basin Stockinette and cotton padding

Elastic compression bandages

An oncology nurse is caring for a client who relates that certain tastes have changed. The client states that "meat tastes bad." What nursing intervention can be used to increase protein intake for a client with taste changes? Stay away from protein beverages. Encourage maximum fluid intake. Encourage eating cheese, eggs, and legumes Suck on hard candy during treatment.

Encourage eating cheese, eggs, and legumes

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Talk slowly and enunciate each word. Switch topics frequently to keep the client's attention. Talk in a louder than normal voice. Face the client and establish eye contact.

Face the client and establish eye contact. Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers

A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? Fluid intake should be double the urine output. Fluid intake should be about equal to the urine output. Fluid intake should be half the urine output. Fluid intake should be inversely proportional to the urine output.

Fluid intake should be about equal to the urine output.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action? Comprehend spoken words Form words that are understandable Form words that are understandable or comprehend spoken words Speak at all

Form words that are understandable or comprehend spoken words

The nurse likes to use humor to help clients deal with pain. What guidelines should the nurse follow when using humor to foster pain relief? Humor should take into account the client's personality and circumstances. Humor is not typically appreciated by elderly clients. Humor is most effective when clients are experiencing moderate or severe pain. Humor should be restricted to clients who are from the nurse's own cultural group.

Humor should take into account the client's personality and circumstances.

The nurse knows that chronic pain lacks which of the characteristic pain-related reactions? Increased heart rate Loss of appetite Disturbed sleep patterns Depression

Increased heart rate

A nurse is caring for a client diagnosed with Alzheimer disease who sleeps at irregular intervals, having no consistent sleep-wake cycle. The nurse suspects that the client is experiencing: Irregular sleep-wake rhythm Advanced sleep phase syndrome Delayed sleep phase syndrome Free-running sleep disorder

Irregular sleep-wake rhythm

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority? Keeping the perineal area clean and dry Offering the client the urinal every 3 hours Maintaining a fluid intake of 1 L/day Applying moist, warm compresses to the client's groin

Keeping the perineal area clean and dry

What should the nurse do when caring for a client with alcoholism who is diagnosed with Imbalanced Nutrition: Less than Body Requirements? Obtain a baseline weight Encourage daily exercise Avoid providing liquid sleep medications Avoid providing foods that contain alcohol

Obtain a baseline weight

An 82-year-old client experiences urinary incontinence. Which factor should the nurse assess before beginning a bladder training program for this client? Physical and environmental conditions History of allergies Occupational history Smoking habits

Physical and environmental conditions

After a week in which a client worked four 12-hour shifts and went home to two children with the flu, the client is feeling fatigued. How should this client's fatigue be categorized? Physiologic Psychological Pathologic Idiopathic

Physiologic

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? Immersing the client in warm water in a pool or hot tub Practicing effleurage on the abdomen Administering a sedative such as secobarbital or pentobarbital Administering an opioid such as meperidine or fentanyl

Practicing effleurage on the abdomen

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems? Promote arterial and venous circulation. Relieve pain caused by decreased circulation. Provide a self-care program for the client and family. Monitor skin integrity.

Promote arterial and venous circulation.

Reviewing pathology for an exam on pulmonary vasculature, the nursing student states that blood enters the right side of the heart via the vena cava, then to the right atrium, right ventricle, and then which vessel carries the deoxygenated blood into the pulmonary system? Pulmonary capillaries Reviewing pathology for an exam on pulmonary vasculature, the nursing student states that blood enters the right side of the heart via the vena cava, then to the right atrium, right ventricle, and then which vessel carries the deoxygenated blood into the pulmonary system? Pulmonary capillaries Pulmonary artery Pulmonary vein Ductus arteriosus

Pulmonary artery

A nurse is caring for a client with bulimia nervosa. Strict management of the client's dietary intake is necessary. Which intervention is the most important? Fill out the client's menu and make sure the client eats at least half of what is on the tray. Let the client eat meals in private. Engage the client in social activities for at least 2 hours after each meal. Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal. Let the client eat food brought by family, but have the client keep a strict calorie count.

Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure? Position the client on his back and drape properly. Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. Introduce solution quickly over a period of 3 to 5 minutes. Encourage the client to hold the solution for at least 20 minutes.

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult.

The nurse is discussing types of treatment used when working with children who have orthopedic disorders. Which form of treatment covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open? Internal fixation device External fixation device Spica cast Stockinette

Spica cast

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as Supervisory Technical Surveillance Maintenance

Supervisory

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? Take a mild laxative such as magnesium citrate when necessary. Take a stool softener such as docusate sodium daily. Administer a tap-water enema weekly. Administer a phospho-soda enema when necessary.

Take a stool softener such as docusate sodium daily.

For a client with anorexia nervosa, which goal takes the highest priority? The client will establish adequate daily nutritional intake. The client will make a contract with the nurse that sets a target weight. The client will identify self-perceptions about body size as unrealistic. The client will verbalize the possible physiological consequences of self-starvation.

The client will establish adequate daily nutritional intake.

Which of the following is a reliable source for quantifying pain? The client's vital signs The nature of the client's injury or condition The client's description of the pain The extent of the client's injury

The client's description of the pain

Mr. Faulkner is a 69-year-old man who has enjoyed generally good health for his entire adult life. As a result, he has been surprised to receive a new diagnosis of hypertension after a series of visits to his primary care provider. The nurse who is working with Mr. Faulkner should recognize which of the following aspects of aging and hypertension? The diagnostic criteria for hypertension in adults over 65 differ from those for younger adults. The incidence and prevalence of hypertension increase with age. Blood pressure remains stable throughout adulthood but tends to be assessed more often by health care providers of older adults. Older adults are less vulnerable to the pathophysiological effects of hypertension than are younger adults.

The incidence and prevalence of hypertension increase with age.

The nurse is caring for a client who has produced an average of 20 mL/hour for the previous day. The nurse recognizes this compares in which way to the normal urine output? This represents normal urinary output for 24 hours. The kidneys should produce about 1.5 L of urine each day. The kidneys should produce a minimum of 10 mL/hr over one day. The normal kidney produces an average 3000 mL of urine daily.

The kidneys should produce about 1.5 L of urine each day.

A preschool-age child who is receiving gastrostomy feedings occasionally vomits following a feeding. When the parent describes the feeding process, what does the nurse note as the likely cause of the vomiting? The mother does not check gastric residual prior to feedings. Caretakers omit flushing the tube at the conclusion of bolus feedings. Bolus feedings are administered over a period of about 25 minutes. A feeding pump is used to administer the feedings.

The mother does not check gastric residual prior to feedings.

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy? Use enteral feedings after the procedure Offer plenty of thin liquids when intake resumes Season food to suit an increased sense of taste and smell Recommend the long-term use of zinc lozenges

Use enteral feedings after the procedure

Which action would be incorporated in a teaching strategy for a hearing-impaired client? Use of slow, directed, and deliberate speech Use of large-print materials Arrangement of materials in a clockwise pattern Having the person perform a return demonstration

Use of slow, directed, and deliberate speech

A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make? current medications fetal growth liver functions mood status

current medications St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, she can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.

When the bladder contains 400 to 500 mL of urine, this is referred to as anuria. specific gravity. functional capacity. renal clearance.

functional capacity.

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? sitting up lying prone lying flat lying flat with feet raised slightly

lying flat

The nurse instructs the unlicensed assistive personnel (UAP) to be sure to turn the client every 2 hours to avoid pressure on the skin and avoid a pressure injury. What type of stimuli is the nurse encouraging the UAP to avoid? thermal stimuli chemical stimuli mechanical stimuli pain stimuli

mechanical stimuli

The term used to describe total urine output less than 0.5 mL/kg/hour is oliguria. anuria. nocturia. dysuria.

oliguria. Oliguria is associated with acute and chronic renal failure.

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should stay with the client and encourage them to eat. help the client fill out their menu. give the client privacy during meals. fill out the menu for the client.

stay with the client and encourage them to eat.

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension? "A glass of red wine each day will lower my blood pressure." "I should eliminate caffeine from my diet to lower my blood pressure." "If I include less fat in my diet, I'll lower my blood pressure." "Limiting my salt intake to 2 grams per day will improve my blood pressure."

"Limiting my salt intake to 2 grams per day will improve my blood pressure."

The nurse is recording a client's intake and output at the end of an 8-hour shift. The client had 300 ml in nasogastric suction container and 200 ml of urine in the foley bag. There was 300 ml of D5W infused from a 1000-ml bag during the shift, and the client was documented to have consumed 500 ml of liquids. What conclusion should the nurse reach regarding the client's intake and output? The client's intake was 300 ml greater than output. The client's output is 300 ml greater than intake. The client's intake and output are equal. The client's intake is 900 ml greater than output.

The client's intake was 300 ml greater than output.

The nurse is performing a health history with a new client in the clinic. What is the most common reason for a client to seek medical attention for arthritis? pain joint swelling stiffness weakness

pain

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary overflow postpartum diuresis urinary tract infection trauma to pelvic muscles

postpartum diuresis

On the advice of friends, a client on a palliative care unit has requested acupuncture. What it is the goal of this form of CAM? restoring a healthy flow of energy along the meridians of the body reconnecting the client's body, spirit, and emotions altering the client's perception and acceptance of reality allowing accumulated toxins to be released from the body

restoring a healthy flow of energy along the meridians of the body

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? reflex incontinence stress incontinence urge incontinence functional incontinence

stress incontinence

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? visceral pain referred pain cutaneous pain somatic pain

visceral pain