Med Surg Nursing

Which nursing intervention is required when caring for a client with alcoholism who is diagnosed with Imbalanced Nutrition: Less than Body Requirements?

Obtain a baseline weight

The nurse is working with a client who speaks limited English. Which of the following statements/questions would facilitate communication with this client?

"First remove the dressing."

The nurse knows that a client being screened for prostate cancer needs further instruction when he makes which statement?

"I understand blood in the urine is the first symptom of prostate cancer."

A nurse is caring for clients from various cultural backgrounds. The care involved occasionally requires close physical contact. Which of the following are concepts for the nurse to consider interacting with diverse cultural clients? Choose all that apply.

A wheelchair is considered part of the person in it. Sitting too close may be threatening to a client. Sitting too far away may signal disinterest to a client.

The nurse assesses a radial pulse rate of 48 beats per minute (bpm). Using critical thinking, what will be the best action for the nurse to take?

Check the client's previous pulse rates to validate the findings.

A nurse has developed a plan of care for a patient with a nursing diagnosis of "risk for spiritual distress." Which interventions would the plan most likely include? Select all that apply.

Actively listen to the patient. Demonstrate acceptance of the patient. Encourage the patient to talk about his or her faith.

Which of the following is an effect of glucocorticoids?

Altered fat and protein metabolism

Which perspective of illness believes that narrowing of the carotid arteries can cause a stroke?

Biomedical

The nurse observes unlicensed staff insisting that he will bathe a female client, including her perineum, even though the client's caregivers request that a female aide perform this task. The nurse realizes that the unlicensed caregiver is exhibiting which characteristic?

Cultural imposition

The two underlying goals of transcultural nursing are to provide which of the following? Choose the two that apply.

Culture-specific care Culture-universal care

The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan?

Data gathering, identification of client strengths, and assurance of client safety during the assessment phase

The licensed practical nurse is caring for a client who has been admitted to the unit with a possible head injury caused by a motor vehicle accident. The LPN would contact the RN before implementing which nursing intervention?

Encourage the client to turn, deep breathe, and cough every 2 hours.

A nursing student who has just completed a chapter on transcultural nursing knows that all ethnic cultures share four basic characteristics. Choose the correct four from the following list.

It is dynamic and ever-changing. It is shared by all members of the same cultural group. It is influenced by specific environmental and technical factors. It is learned from birth through language and socialization.

A nurse is teaching a client about the rationale for administering allopurinol with chemotherapy. Which example would be the best teaching by the nurse?

It lowers serum and uric acid levels.

The nurse is working in a health clinic. Which statements are correct regarding characteristics of chronic conditions? Select all that apply.

Managing chronic conditions must be an individual process. The health care team needs to focus on preventing complications. Difficult ethical issues arise in the care of people with chronic conditions.

A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client?

Monitor the client to prevent sepsis.

The yin/yang theory of harmony and illness is rooted in the holistic or naturalistic paradigm of health. The nurse is preparing a snack for an Asian patient who has a fever. Which of the following beverages would be appropriate according to the yin/yang theory of harmony?

Orange juice

The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective?

Position the client for comfort.

A nurse assesses an oncology client with stomatitis during a chemotherapy session. Which nursing intervention would most likely decrease the pain associated with stomatitis?

Provide a solution of viscous lidocaine for use as a mouth rinse.

While providing personal care for a client, the nurse observes that the client is not comfortable with the close physical proximity. How will the nurse alleviate the discomfort of the client during personal care?

Provide simple explanations of the need for physical proximity.

The nursing student is working with three other students on a transcultural nursing project. They have been tasked with naming examples of groupings that can be used to identify subcultures. Which of the following would be included in their list? Select all that apply.

Religion Occupation Sexual orientation

When caring for a patient who is receiving an opioid analgesic agent, the nurse knows to assess for the most serious side effect of:

Respiratory depression

A client asks the nurse what is causing the fatigue following radiotherapy. What is the nurse's best response?

Substances are released when tumor cells are destroyed.

The nurse is caring for a client with hypoxia. What is the nurse's consideration with regards to the client experiencing brain cell death?

The client may have brain cell death in 3 to 6 minutes.

Which statements about the placebo effect are correct? Select all that apply.

The placebo effect refers to the healing or improvement that takes place simply because the individual believes a treatment method will be effective. The placebo effect often is used as an example of how the mind and body are connected.

A nurse and client have a complete language barrier. An interpreter is necessary. Which of the following are important considerations for the nurse when choosing an interpreter? Choose all that apply.

Voice quality Nonverbal communication skills Use of silence

Which newest diagnostic tool might be efficient in diagnosing psychobiologic disorders in the future?

brain mapping

A nurse is caring for a client with prostate cancer and assesses bleeding gums and hematuria. What serum indicator should the nurse relate the bleeding?

platelet count of 60,000/mm3

A client who is going to have surgery is slightly nervous. What nursing intervention is most important for the nurse to perform?

provide education

The nurse is preparing to serve on the hospital's ethics committee. What are ethical dilemmas in the nurse's clinical practice that can show direct conflict with the principle of veracity? Select all that apply.

revealing a diagnosis to people other than the client with the diagnosis administering placebos for pain relief keeping a client's medical diagnosis from the client