304 EAQ Care and Comfort
An older adult is returned to the surgical unit after having a subtotal gastrectomy. Which dietary modification should the nurse anticipate that the healthcare provider will most likely prescribe? 1 Increase intake of dietary roughage quickly 2 Avoid oral feedings for a prolonged period 3 Resume small, easily digested feedings gradually 4 Limit intake to self-selection of personally preferred foods
3) Small, frequent feedings are tolerated best after a subtotal gastrectomy. Roughage may be irritating to the gastrointestinal (GI) tract after surgery. As soon as edema subsides, the individual generally is given small amounts of fluid, and then the diet is progressed gradually. Allowing only personal food preferences does not ensure inclusion of nutrients necessary for recovery.
tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item? 1 Apples 2 Chocolate 3 Rye bread 4 Cheddar cheese
1) Apples are low in phosphate; fresh fruit is low in phosphorus. Chocolate contains more phosphate than apples. Rye bread contains more phosphate than apples. Cheese is made with milk, which contains phosphate and should be avoided. Dairy products are high in phosphorus.
uring discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? 1 Diapers should be changed at least every 4 hours. 2 Frequent diaper changes with cleansing are needed. 3 Medicated ointment should be applied six times a day. 4 Powder may be used in the perineal area when it becomes wet.
Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown. Changing diapers every 4 hours is insufficient and may result in skin breakdown. Medicated ointments are unnecessary; if a skin irritation develops and an ointment becomes necessary, it should be prescribed by the healthcare provider. Powder will not keep the skin dry; when powder mixes with urine, it forms a pastelike substance that promotes skin breakdown. Also, powder is toxic if inhaled and should be avoided.
n a visit to the well-baby clinic the parents are upset because their 9-month-old infant has severe diaper rash; one parent wants to know how to treat it and prevent it from recurring. What cause of diaper dermatitis should the nurse include when answering the parent's question? 1 Use of disposable diapers 2 Prolonged contact with an irritant 3 Decreased pH of the infant's urine 4 Too-early introduction of solid foods
2 Diaper dermatitis is caused by prolonged repetitive contact with an irritant (e.g., urine, feces, soaps, detergents, ointments, friction). Both cloth and disposable diapers can cause diaper dermatitis if they are not changed frequently. An increased pH (i.e., alkaline) of the urine can contribute to diaper dermatitis. A change in diet may contribute, but there is no evidence that this is directly related.
A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent? 1 Golf 2 Bowling 3 Swimming 4 Badminton
3) The hyperextension required in swimming helps strengthen back muscles and necessitates deeper respirations, both of which are necessary before surgery and before wearing a brace or cast. The other options involve twisting the back muscles, which is not therapeutic for a child with this condition.
A client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet? 1 Fat-soluble vitamins 2 Dietary fiber and oat bran 3 Low-fat foods with essential fatty acids 4 Vitamins C and E
4 Vitamin C plays an important role in tissue formation, and vitamin E is required to protect against the oxidative stress associated with pregnancy. Too much emphasis on fat-soluble vitamins may result in an inadequate intake of important water-soluble vitamins. Dietary fiber and oat bran and low-fat foods with essential fatty acids have no known effect on natural defenses.
A nurse is teaching the parents of a school-aged child with celiac disease about the nutrients that must be avoided in a gluten-free diet. What nutrients should the nurse teach the parents to avoid? 1 Saturated oils and fats 2 Milk and hard cheeses 3 Corn and rice products 4 Wheat and oat products
4 Wheat, oats, rye, and barley are major dietary sources of gluten; the gliadin fraction of these grains is not tolerated by individuals with celiac disease. There is no gluten in oils and fats. There is no gluten in cheeses and milk. Corn and rice are used as substitute grains because they do not contain gluten.
what procedure should a nurse use when elevating the head of an infant in a spica cast? 1 Changing this position after an hour 2 Inserting pillows under the shoulders 3 Padding the edge of the cast with folded diapers 4 Raising the entire mattress at the head of the crib
4) When elevation of the head is desired, the entire mattress or crib should be raised at the head of the crib. There is no reason to place such a short time limit on this position. Pillows under the head or shoulders of a child in a spica cast will thrust the chest forward against the cast, resulting in discomfort and respiratory distress. Padding the edge of the cast with folded diapers will not help elevate the infant's head.
a client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema? 1 Left Sims 2 Back lying 3 Knee chest 4 Mid-Fowler
1) To take advantage of the anatomic position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.
A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client? 1 Maintain balance to improve stability 2 Relieve pressure on weight-bearing joints 3 Prevent further injury to weakened muscles 4 Aid in controlling involuntary muscle movements
1) Hemiparesis creates instability. Using a cane provides a wider base of support and, therefore greater stability. - Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. - Activity should strengthen, not injure, weakened muscles. -The use of a cane will not prevent involuntary movements if they are present.
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1) Pouring warm water over the perineum 2) Ensuring the patency of the catheter 3) Removing the catheter within 24 hours 4) Cleaning the catheter insertion site
3 Removing the catheter within 24 hours Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. - While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. - The catheter should be maintained in its place to avoid leakage and infection. -Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.
A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying? 1 Offer a pacifier 2 Provide a baby rattle 3 Hang a mobile over the crib 4 Wrap a soft blanket around the baby
Correct 1 Offer a pacifier Wrap a soft blanket around the baby During infancy, sucking provides comfort through oral gratification. -A rattle may provide visual and tactile stimulation, not comfort. - A mobile provides visual stimulation, not comfort. -A blanket may stimulate tactile senses through texture, but it does not provide comfort to a hungry infant.
Dyssomnias vs parasomnias
Dyssomnias: characterized by insomnia or excessive sleepiness Parasomnias—patterns of waking behavior that appear during sleep Insomnia, restless leg syndrome, and obstructive sleep apnea are examples of dyssomnias. Nightmares and sleep terrors are examples of parasomnias.
A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? 1 Maintain comfort 2 Prevent pressure ulcers 3 Prevent flexion contractures of the extremities 4 Improve venous circulation in the lower extremities
Pressure ulcers [1] [2] easily develop when a particular position is maintained; the body weight, directed continuously in one region, restricts circulation and results in tissue necrosis. Denervated tissue has less perfusion and is more prone to pressure ulcers. Clients often state that they are comfortable and wish to remain in one position. Proper positioning with supportive devices and range of motion are more effective measures to prevent contractures. Because turning usually is done laterally, the circulation to the lower extremities is not dramatically affected.
A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? 1 Allows excess tissue fluid to be excreted 2 Helps to control the volume of food intake and thus weight 3 Aids the weakened heart muscle to contract and improves cardiac output 4 Assists in reducing potassium accumulation that occurs when sodium intake is high
1) A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.
An infant has been admitted with failure to thrive (FTT). The nurse knows that more education is needed when one of the parents makes what statement? 1 "I can double the amount of water in the formula to save money." 2 "I need to hold her head up a little higher than her stomach when I feed her." 3 "I need to burp the baby when the feeding is done to get rid of swallowed air." 4 "I need to make sure that the formula is in the nipple so she doesn't swallow so much air."
1) Doubling the amount of water in the formula reduces the baby's caloric intake. Holding the head up, burping the baby, and making sure that formula is in the nipple are all ways to increase caloric intake and reduce the chance of postfeeding vomiting due to air swallowing.
After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time? 1 Addressing the pain 2 Reversing feelings of hopelessness 3 Promoting mobility in the residual limb 4 Acknowledging the grieving for the lost lim
1) Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.
The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? 1 Provide perineal care. 2 Turn and position the client. 3 Give a complete bed bath. 4 Document the bowel movement.
1) Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.
Which statement regarding Roy's theory of nursing needs correction? 1 The Roy adaptation model views the environment as an adaptive system. 2 The need for nursing care occurs when the client cannot adapt to internal and external environmental demands. 3 The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. 4 All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.
1) The Roy adaptation model views the client as an adaptive system. The need for nursing care occurs when a client cannot adapt to internal and external environmental demands. Roy's model believes the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.
What is the optimal nursing intervention to minimize perineal edema after an episiotomy? 1 Applying ice packs 2 Offering warm sitz baths 3 Administering aspirin as needed (prn) 4 Elevating the hips on a pillow
1) Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.
What would the nurse instruct the parent to refrain from doing if a 4-year-old child has nightmares on a routine basis? 1 Keeping the lights on 2 Sleeping with the child 3 Tucking in a favorite soft toy with the child 4 Leaving the room after comforting the child
2) If a child has nightmares, the parent should avoid sleeping with the child. Sleeping with the child may create a habit of delaying bedtime. In case of nightmares, keeping the lights on may help the child to overcome fear. Tucking in a soft toy gives the feeling of security to the child. The parent should comfort the child and leave the child in his or her own bed so that the child does not use the fear as an excuse to delay bedtime.
Which statement is true about the sleep pattern of preschoolers? 1 Daytime naps are very common among preschoolers. 2 On average, a preschooler sleeps about 12 hours a night. 3 Partial awakening leading to sleeplessness is common among preschoolers. 4 About 30% of sleep time in preschoolers is spent in the rapid eye movement sleep (REM) cycle.
2) the average preschooler sleeps about 12 hours a night. -By the age of five, children rarely take daytime naps except in cultures in which a siesta is the custom. - Partial awakening followed by a normal return to sleep is frequent. - About 30% of an infant's sleep time is in the rapid eye movement sleep (REM) cycle.
The nurse uses which principles of body mechanics when caring for immobilized clients? 1 Bending at the waist to provide the power for lifting 2 Placing the feet apart to increase the stability of the body 3 Keeping the body straight when lifting to reduce pressure on the abdomen 4 Relaxing the abdominal muscles while using the extremities to prevent strain
2) Placing the feet apart creates a wider base of support and brings the center of gravity closer to the ground. This improves stability. Bending at the waist should be avoided because it strains the lower back muscles; the power of lifting should be supplied by the muscles of the thighs and buttocks. Pressure on the abdomen is prevented by tightening the abdominal and gluteal muscles to form an internal girdle; keeping the body straight does not reduce strain on the abdominal musculature. Relaxing the abdominal muscles with physical activity increases back strain.
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 2 Encouraging continuation of breastfeeding 3 Placing the infant in the Trendelenburg position 4 Positioning the infant supine with the head of the crib elevated
2) 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 multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement? 1) Report these findings to the healthcare provider. 2) Encourage the family to bring in special foods preferred in their culture. 3) Order a high-protein milkshake to supplement between meals. 4) Call the dietitian to work with client to plan high calorie meals for the client to eat.
2) Encourage the family to bring in special foods preferred in their culture. In family-centered childbearing, care should be adapted to the client's cultural needs and preferences whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility but will not address the client's preferences. Ordering a high-protein milkshake as a between-meal snack may offer the client an option but is unlikely to meet the cultural preferences. Having the dietitian assist with planning meals does not address the underlying problem.
Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait? 1 Elbows should be kept in rigid extension. 2 Most of the weight should be supported by axillae. 3 The client must be able to bear weight on both legs. 4 The affected extremity should be kept off the ground.
3) In the four-point gait, the client brings the left crutch forward first, followed by the right foot; then the right crutch is brought forward, followed by the left foot. Thus, both legs must be able to bear some weight. Although the arms are extended to allow the hands to bear weight, the elbows are not maintained in this position. Pressure on the axillae may damage nerves in the area. Both extremities must be able to bear weight.
A client in active labor starts screaming, "The baby is coming! Do something!" What is the nurse's primary action? 1 Notifying the practitioner of the imminent birth 2 Telling the client that it is too soon and encouraging her to pant 3 Checking the perineal area for the presenting part 4 Helping the client hold her knees together and explaining what to expect
3) The primary action by the nurse should be to confirm whether birth is imminent by checking the perineal area to determine whether the presenting part is emerging. Confirming the client's sensation is the priority; the nurse should remain with the client and ask a colleague to call the practitioner if birth is imminent. Stating that birth is not imminent demeans the client, and she may be correct. Holding the knees together is contraindicated. If birth is imminent, this could cause injury to the fetus, and if it is not imminent, this position is uncomfortable and unnecessary.
A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? 1) Neurologic 2) Wound 3) Pain 4) Skin
3) Pain Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. -A neurologic check is not necessary unless the client's neurologic status has worsened since the stroke. -Both skin and wound checks can be assessed once client comfort has been determined and handled.
The nurse is providing postoperative care to a client who had surgery in which a hip prosthesis was inserted. An abductor splint is in place. When should the nurse remove the splint? 1 When the client gets up to sit in a chair 2 If the client needs a change of position 3 Once the client's edema and pain have ceased 4 During the client's skin care and physical therapy
4 During the client's skin care and physical therapy Until the prescription is written to discontinue the abduction splint, it is only removed for mobility such as physical therapy and hygiene; -adduction to or beyond the midline is not permitted until allowed by the primary healthcare provider. When the client gets up to sit in a chair, the splint is needed unless the client can be trusted to maintain abduction; flexing the hip with a prosthesis cannot be beyond 60 degrees for up to 10 days; from then on it cannot be beyond 90 degrees until permitted by the primary healthcare provider. -If the client needs a change of position, a splint helps to maintain position and keep the hip prosthesis in the hip socket. It is inappropriate to remove the splint once the client's edema and pain have ceased; there are no criteria for discontinuing abduction of the affected extremity.
he parents of a preschooler inform the nurse that their child often develops diarrhea and ask whether there might be anything wrong with the child's stomach. Upon assessment, the nurse also finds that the child has poor oral care and is at risk for dental caries. What is the most probable cause for the child's health issues? 1 The family often consumes fast foods. 2 The parents neglect the child's dietary needs. 3 The family does not follow hygienic practices. 4 The child consumes excessive amounts of fruit juice
4 If the child consumes excessive fruit juice or sweetened beverages, it increases the risk for dental caries and gastrointestinal conditions, such as chronic diarrhea. Consuming fast foods often result in childhood obesity, because fast foods are high in fats and starches. Neglecting the dietary needs or not following hygienic practices may cause gastrointestinal problems or make the child susceptible to infections.
A primary healthcare provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide to the client about the need to follow this diet? 1 "The use of salt probably contributed to the disease." 2 "Excess weight will be gained if sodium is not limited." 3 "The loss of excess sodium and potassium in the urine requires less renal stimulation." 4 "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
4) Clients with Cushing syndrome must limit their intake of salt and increase their intake of potassium. - The kidneys are retaining sodium and excreting potassium. - An excessive secretion of adrenocortical hormones in Cushing syndrome, not increased or high sodium intake, is the problem. -Although sodium retention causes fluid retention and weight gain, the need for increased potassium also must be considered. -Because of steroid therapy, excess sodium may be retained, although potassium may be excreted.
A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child? 1 Flexion of the hip 2 Extension of the hip 3 Adduction of the hip 4 Abduction of the hip
Abduction will enable the head of the femur to fit into the acetabulum, thereby correcting the dysplasia. Flexion causes the head of the femur to move away from the acetabulum. Extension causes the head of the femur to move away from the acetabulum. Adduction causes the head of the femur to move away from the acetabulum.
After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client? 1 Control of pain 2 Immobilization of joints 3 Motivation and teaching 4 Bladder training and control
After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.
Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? 1 Returning the aspirate and withholding the feeding 2 Discarding the aspirate and administering the full feeding 3 Returning the aspirate and subtracting the amount of the aspirate from the feeding 4 Discarding the aspirate and adding an equal amount of normal saline solution to the feeding
C! The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.
What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position? 1 1 to 2 hours 2 3 to 4 hours 3 15 to 20 minutes 4 30 to 40 minutes
Change of position at least every 1 or 2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility [1] [2]. Too protracted a period of time in one position, such as every 3 to 4 hours, increases the potential for respiratory, urinary, and neuromuscular impairment; prolonged physical pressure increases the possibility of skin breakdown. Fifteen to 20 minutes and 30 to 40 minutes are unnecessarily short time intervals; too frequent repositioning may interfere with the client's rest.
A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase? 1 "The client will adhere to the teaching plan." 2 "The client will achieve psychologic adjustment." 3 "The client will maintain present muscle strength." 4 "The client will prepare for a possible myasthenic crisis."
Correct3 "The client will maintain present muscle strength Until the diagnosis has been confirmed, the primary goal should be to maintain appropriate activity and prevent muscle atrophy. - It is too early to develop a teaching plan; the diagnosis has not yet been established. -The response "achieve psychologic adjustment" is too early; the client cannot adjust if a diagnosis has not yet been confirmed. -The response "prepare for a possible myasthenic crisis" is an intervention, not an objective.
An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip? 1 Changing the infant's position often 2 Using modified techniques for feeding 3 Monitoring the infant's daily intake and output 4 Keeping the infant's head elevated during feedings
Infants with a cleft in the lip are unable to suck like other newborns because they cannot form a vacuum to draw milk from the nipple. Frequent position changes are common for all infants, not just ones with cleft lip. Monitoring of intake and output is not necessary because hydration is maintained once a feeding method has been established. All infants should be fed with the head elevated to avoid pooling of milk in the mouth, which could result in aspiration. When feeding & post feeding position infant upright to prevent aspiration - Never position on prone, because cause damage to suture lines, place on back, side or infant seat - Post feeding clean suture with cotton swab with saline & hydrogen peroxide - Feed infant with rubber tip on opposite side of operation & have frequent bubbling syringe (because cleft lip infant swallow lots of air & need frequent bubbling)
What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea? 1 Improvement of fluid balance 2 Continuation of an antidiarrheal diet 3 Preservation of perianal skin integrity 4 Retention of weight appropriate for height
Rehydration and correction of electrolyte imbalances are the priorities; diarrhea causes loss of fluid and electrolytes that can be life threatening. Antidiarrheal diets are no longer prescribed for children with diarrhea. Oral rehydration therapy is the treatment of choice. Although maintaining skin integrity in the presence of diarrhea is important, the risk of disrupted skin integrity is not life threatening, nor is it the priority when a young child is dehydrated. There are no data to indicate that the child is overweight or underweight.
An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer? 1 Sacrum 2 Scapulae 3 Ischial spine 4 Greater trochanter
Sacrum is the center of the greatest body mass; an elevated torso exerts pressure toward this area. Although the scapulae are at risk, they do not bear the greatest body weight as when the client is in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an upright sitting position. Greater trochanter is at risk when the client is in a side-lying position.
Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching? 1 "I must eat foods high in calories." 2 "I should avoid alcoholic beverages." 3 "I will eat more often but in smaller amounts." 4 "I can eat foods high in fat now that the acute stage is over."
The nurse needs to follow up on the client statement that indicates eating foods high in fat can be allowed. A low-fat diet should be followed to avoid diarrhea. All the rest of the client responses are correct and do not require additional teaching. The response to eating foods high in calories is appropriate because additional calories are needed to maintain weight. The response to avoiding alcoholic beverages is appropriate to prevent overstimulation of the pancreas. Small, frequent meals limit stimulation of the pancreas and is appropriate.
What is the recommended size of the urinary catheter that can be used in a 3-year-old child?
The recommended size of a urinary catheter that can be used in a 3-year-old child is 8 to 10 Fr. A urinary catheter of 5 to 6 Fr is generally used in infants. A length of 14 to 16 Fr is recommended for most adult clients. A length of 16 to 18 Fr is commonly used in adult males.