Basic Comfort & Care EAQ Quiz
A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA). The client is right-handed. Which task will be most difficult for this client? 1 Eating meals 2 Writing letters 3 Combing the hair Correct4 Dressing every morning
4 Dressing every morning If the client is right-handed there will be difficulty with dressing because it requires the use of two hands, and some clothing requires movement of both sides of the body when dressing. A right-handed client is able to continue to use the right hand for eating meals, writing letters, and combing the hair because it is the left side that is affected by a lesion on the right side of the brain.
A nurse is discussing weight loss with an obese individual with Ménière's disease. Which suggestion by the nurse is most important? 1 Limit intake to 900 calories a day. 2 Enroll in an exercise class. 3 Get involved in diversionary activities when there is an urge to eat. Correct4 Keep a diary of all foods eaten each day.
4 Keep a diary of all foods eaten each day. Keeping a record of what one eats helps to limit unconscious and nervous eating by making the individual aware of intake. Limiting calories to 900 per day is a severe restriction that requires a health care provider's prescription. Exercise causes rapid head movements, which may precipitate a Ménière's attack. Although diversionary activities are a therapeutic intervention, the nurse first should make suggestions that help increase the client's awareness of personal eating habits.
A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include? 1 Withholding oral feedings for several days Correct2 Encouraging continuation of breastfeeding 3 Placing the infant in the Trendelenburg position 4 Positioning the infant supine with the head of the crib elevated
Correct2 Encouraging continuation of breastfeeding The goal is to prevent constipation to limit trauma to the surgical site. Breast milk produces a softer stool. Oral feedings are started soon after surgery. Placing the infant in the Trendelenburg position will not promote healing in the anal area and may impede respiratory excursion. Positioning the infant supine with the head of the crib elevated will increase pressure in the perianal area, which could compromise healing.
A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care? 1 Use calamine lotion for pruritus Correct2 Keep skin lubricated with lotion 3 Apply warm soaks to inflamed areas 4 Take frequent baths to remove scaly lesions
Correct2 Keep skin lubricated with lotion With scleroderma, the skin becomes dry because of interference with the underlying sweat glands. Pruritus, inflamed areas, and skin lesions are not associated with scleroderma. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option
A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force? Correct1 30 degrees 2 45 degrees 3 60 degrees 4 90 degrees
1 30 degrees Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and cause this phenomenon. Forty-five, 60, and 90 degrees will raise the head of the bed too high, and the client will slide down in the bed, causing shearing forces.
A client sustains a fracture of the femur after jumping from the second story of a building during a fire. The client is placed in Buck's traction until an open reduction and internal fixation is performed. The client keeps slipping down in bed. To alleviate this problem the nurse should: Correct1 Elevate the foot of the bed 2 Shorten the rope on the weights 3 Release the traction so the client can be repositioned 4 Move the client toward the head of the bed every couple of hours
1 Elevate the foot of the bed Elevating the foot of the bed provides slight countertraction, which will prevent sliding down in bed. Shorting the rope on the weights will have no effect. Releasing the traction so the client can be repositioned is unsafe; an interruption in the traction may result in disruption of bone alignment Moving the client toward the head of the bed every couple of hours will not alleviate the cause of the problem; it may be necessary more often than every couple of hours.
What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure? Correct1 Providing small, frequent feedings. 2 Positioning the child flat on the back 3 Encouraging nutritional fluids often. 4 Measuring the head circumference daily.
1 Providing small, frequent feedings. Small, frequent feedings with adequate rest periods in between may improve the infant's intake at each feeding; infants with tetralogy of Fallot become extremely fatigued while suckling. Positioning the child with the head elevated facilitates respiration; an infant cardiac seat, similar to a car seat, helps maintain the child in the semi-Fowler position. As a means of reducing the cardiac workload, excessive fluids usually are not offered, and fluids may even be restricted. The head circumference is not an important assessment for infants with congenital heart disease; daily head measurements should be taken for infants with hydrocephaly.
A 75-year-old female client tells the nurse that she read about a vitamin that may be related to aging because of its relationship to the structure of cell walls. The nurse determines that the client is probably referring to: Correct1 Vitamin E 2 Vitamin A 3 Vitamin C 4 Vitamin B1
1 Vitamin E Vitamin E hinders oxidative breakdown of structural lipid membranes in body tissues caused by free radicals in the cells. Vitamin A assists in the formation of visual purple needed for night vision. Vitamin C is used for formation of collagen, which is important for maintaining capillary strength, promoting wound healing, and resisting infection. Vitamin B1 is necessary for protein and fat metabolism and normal function of the nervous system.
A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1 Low purine Correct2 Low calcium 3 High phosphorus 4 High alkaline ash
2 Low calcium Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout. Foods high in phosphorus must be avoided. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.
A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends: 1 Meatloaf and tea Correct2 Meatloaf and strawberries 3 Chicken soup and baked apple 4 Chicken soup and buttered bread
2 Meatloaf and strawberries The meat provides proteins and the fruit provides vitamin C; both promote wound healing. Although meatloaf provides protein, tea does not provide vitamin C. Chicken soup and a baked apple do not meet the client's need for protein or vitamin C. Chicken soup and buttered bread do not meet the client's need for protein or vitamin C.
A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? 1 Instruct the client to call for help with elimination needs; answer the client's call light immediately to avoid incontinence. 2 Place a waterproof pad under the client to prevent incontinence and soiling the linens. Correct3 Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence. 4 Offer toileting to the client every two hours to prevent incontinence.
3 Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence. Checking the client for incontinence and cleaning immediately after each episode will prevent skin irritation by the digestive enzymes in stool. Placing a call bell within reach and instruct client to call for help with elimination needs is not helpful because the client is confused and unable to use the call bell. Putting a waterproof pad helps to prevent soiling of the bed but does not keep feces away from the client's skin and therefore does not prevent skin breakdown. Toileting the client every two hours in order to prevent incontinence is not helpful because the client is confused and unable to follow commands, and has no control over elimination needs.
nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? 1 "We'll have to start serial casting right away." 2 "The casts will have to be changed every week." 3 "The baby may have to have surgery if the problem's not fixed in a few months." Correct4 "We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."
4 "We'll have to have the baby fitted with prosthetic devices before he'll be able to walk." Most children with bilateral clubfeet are eventually able to walk without much difficulty. Prosthetic devices generally are not indicated. Serial casting with cast changes every week is usually successful. If serial casting is not effective, surgical intervention may be necessary. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason
A nurse provides a list of foods for a breastfeeding client with phenylketonuria (PKU) to avoid. Which nutrient is included on the list? 1 Lactose 2 Glucose 3 Fatty acids Correct4 Amino acids
4 Amino acids PKU is an inborn error of metabolism involving an inability to metabolize phenylalanine, an essential amino acid. Lactose, glucose, and fatty acids are all metabolized by people with PKU.
The nurse is planning nutritional education for a client with lower extremity arterial disease (LEAD). What diet modifications should the nurse include? 1 Decreasing both fluid and sodium intake 2 Increasing both calcium and potassium intake 3 Increasing both vitamin E and refined grain intake Correct4 Decreasing both cholesterol and saturated fat intake
4 Decreasing both cholesterol and saturated fat intake Lower extremity arterial disease frequently is accompanied by generalized atherosclerosis; decreasing both cholesterol and saturated fat intake will help decrease lipid buildup on artery walls. Decreasing both fluid and sodium intake are inappropriate dietary modifications; this client does not have edema. Increasing both calcium and potassium is not appropriate for the client's condition because it may alter the client's electrolyte balance. Recent research indicates that supplemental vitamin E can precipitate cardiac problems and only should be taken when prescribed by a health care provider who can monitor the client's ongoing status. Increasing grain intake will add calories and may contribute to unnecessary weight gain. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.
A client is diagnosed as having malabsorption syndrome secondary to celiac sprue. The client asks the nurse if there is anything that can help improve symptoms of the syndrome. The nurse encourages the client to incorporate which addition for symptom improvement? 1 Folic acid 2 Vitamin B12 3 Corticosteroids Correct4 Gluten-free diet
4 Gluten-free diet Gluten, a cereal protein, appears to be responsible for morphologic changes of the intestinal mucosa with nontropical sprue (adult celiac disease). Folic acid, along with antimicrobial agents, is used to treat tropical, not celiac, sprue; it causes dramatic improvement in tropical sprue. Vitamin B12 may be administered if macrocytic anemia or achlorhydria develops; however, it does not correct the major pathology. The use of corticosteroids may be advantageous with either form of sprue; however, this does not produce the dramatic effect achieved by a gluten-free diet .
