Nclex3

A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? Select all that apply.

Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help. Explanation: The nurse should respect the client's opposition to analgesics, but this should be explored. A discussion will likely reveal a variety of alternative options, many of which may be known to the client already. Opioids are not the best drug of choice for migraines. Short-term use of opioids will not independently prolong the hospital stay and do not carry a higher risk of addiction.

The nurse assesses an 8-month-old infant for a possible head injury after a fall of about 3 feet. The child is awake, alert, and crying. Vital signs are within normal limits. What action should the nurse take next?

Assess the infant's pupillary responses. Explanation: With a possible head injury in an infant, the nurse must complete a neurological assessment that includes assessing pupillary response. A fall from 3 feet is considered a significant distance for an infant. Changes in normal pupil response can indicate increased intracranial pressure. The infant's crying indicates a patent airway, and vital signs are normal, which satisfies breathing and circulation. There is no indication the infant requires supplemental oxygen or intravenous therapy at this point. The nurse should complete the initial assessments to ensure the infant is stable prior to taking the time to interview the parents further.

A client has several patches of vesicles over both arms. Which care should the nurse provide to this client?

Cover the draining areas with sterile gauze. Explanation: Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Because vesicles contain serous fluid, the areas that are draining should be covered with a sterile dressing. Phototherapy is used to treat psoriasis. Warm soaks would irritate the vesicles and may cause them to burst. An antiparasitic agent is used to treat scabies or lice.

The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. What is the most appropriate goal for this client?

Gradually increase activity tolerance. Explanation: The most appropriate goal for this client with hepatitis is to increase activity gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no evidence that the client is physically immobile, unable to provide self-care, or needs to adapt to new energy levels.

The nurse is providing postoperative instructions to a client who will be discharged with a biliary catheter and must learn to irrigate the catheter. Which explanation would the nurse provide to the client regarding the procedure?

Notify the healthcare provider if there are any signs of purulent drainage. Explanation: Purulent drainage would be a sign of infection and the healthcare provider would need to be notified immediately. There is a risk for infection, even with aseptic technique by the patient or caregiver, because the catheter is being opened for irrigation. The client or caregiver would not aspirate due to the risk of drawing duodenal contents into the catheter or biliary tree. The client or caregiver would use sterile saline or water to irrigate with, not tap water.

The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best?

Serve foods that the client can carry with her. Explanation: Because the client is very active, it would be best to give her food she can carry with her and eat as she moves.Neither allowing the client to send out for her favorite foods nor serving food in small, attractively arranged portions will address her need to be active. Allowing the client in the unit kitchen is impractical, and she most likely would be too busy to eat anyway.

An older adult client seeks help for chronic constipation. Which recommendation would be most beneficial for the nurse to suggest?

Try eating an apple each day with peanut butter. Explanation: Causes of constipation include inadequate hydration, fiber intake, and exercise. Fruits, vegetables, and grains are a good source of fiber that will increase bulk. Decreasing a diuretic would not be recommended in an elderly person. A stool softener is needed regularly for effect and cannot be used on an as-needed basis. Exercise for constipation needs to increase heart rate to improve perfusion to the intestine.

A 14-month-old child has a severe diaper rash. Which recommendation should the nurse provide to the parents?

Wash the buttocks using mild soap. Explanation: Because the toddler has a severe diaper rash, it may be best to change all that the parents are doing. The buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is helpful to leave the diaper off and expose the buttocks to the air. Baby wipes commonly contain additives and perfumes that may be irritating to the baby's sensitive skin. The diaper needs to be changed more often than every 4 to 6 hours. Otherwise, the moist diaper environment will continue to irritate the skin, causing the rash to worsen. Powder has limited absorbing ability and will most likely irritate the area more. In addition, some powders contain perfumes or are scented and can irritate the skin.

The client is diagnosed with benign fibrocystic breast disease. Interventions to reduce discomfort from this disease include teaching the client to:

avoid caffeine. Explanation: Avoiding caffeine is reported to alleviate discomfort associated with fibrocystic breast disease for many women, but the rationale is not clearly understood.Activity level is not associated with fibrocystic breast disease.Wearing tighter garments could increase discomfort.A nurse should not recommend estrogen therapy as an intervention for discomfort from fibrocystic breast disease.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough Explanation: Formula in the mouth and cough are indicators of aspiration. Passage of flatus reflects intestinal motility, which does not pose a potential problem. A passage of flatus is not reflected in tolerating a feeding, it is an indication of bowel function. A rapid flow should not be administered by a nurse, and gastric tenderness does not indicate tolerance of tube feed.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position?

left lateral The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

A 3-month-old has moderate dehydration. The nurse should assess the client for which sign of moderate dehydration?

oliguria Explanation: A child with moderate dehydration, described as a loss of 50 to 90 mL/kg of body fluid, would have oliguria, gray skin color, increased pulse rate, and poor skin elasticity. Sunken eyes not bulging, are a sign of dehydration. The anterior fontanel may be sunken, but the posterior fontanel is normally closed by 6 to 8 weeks of age. A child with mild dehydration, described as a loss of less than 50 mL/kg of body fluid, would have pale skin color, decreased skin elasticity, decreased urine output, and normal or increased pulse rate.