Basic Care and Comfort

A nurse is caring for a group of pediatric clients. The nurse understands that which age group would most likely identify their pain as punishment for past behavior? a. infant (age 9-12 months) b. preschool or toddler (age 2-5 years) c. school age children (age 6 -11 years) d. adolescents (age 12-17 years)

b. preschool or toddler (age 2-5 years) Explanation: Children in this age group are in Piaget's preoperational stage of cognitive development and relate pain as punishment for past behavior. A priority nursing action is to provide reassurance.

A client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis? a. a low-protein diet with an unlimited amount of water b. a low-protein diet with a prescribed amount of water c. a high-protein diet with a prescribed amount of water d. no protein in the diet and use of salt sparingly

a. a low-protein diet with an unlimited amount of water Explanation:

Which explanation would be most appropriate when teaching a child about general anesthesia induction? a. "You will be given an injection before you go to surgery to make you sleepy." b. "You will breathe in oxygen through a facial mask and receive intravenous medication to make you sleepy." c. "You will receive intravenous medication to make you sleepy." d. "You will breathe in medication through a facial mask to make you sleepy."

d. "You will breathe in medication through a facial mask to make you sleepy." Explanation: Children are induced for general anesthesia by giving them medication through a facial mask to make them sleepy. Children are not induced with an injection. Children usually are not induced by use of a facial mask with IV administration started while they are still awake.

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care? a. Place lamb's wool under the lift sheet. b. Turn the client every 2 to 4 hours. c. Use an egg crate mattress. d. Place the client on a pressure redistribution bed.

d. Place the client on a pressure redistribution bed. Explanation: A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown. Lambs' wool may trap heat and exacerbate skin breakdown. Turning should be at a minimum of every 2 hours. Egg crate has not been proven to be effective to prevent the development of pressure injuries and should not be used.

The student nurse is learning about non-pharmacological ways to relieve pain. The nurse educator asks, which interventions are used as distraction for pain relief?" What is the student's most appropriate response(s)? Select all that apply. - "exercise" - "using a TENs unit" - "playing cards" - "watching a movie" - "listening to music"

- "using a TENs unit" - "playing cards" - "watching a movie" - "listening to music" Explanation: Non-pharmacologic interventions for pain includes distraction. Distraction can include listening to music, watching a movie, and playing cards or a game. A TENs unit may provide distraction and is non-pharmacologic. Exercise does not provide distraction, and may cause more pain.

A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply. - Chilling the solution by placing it in the refrigerator for 10 minutes. - Assisting the client into Sims' position. - Washing hands and putting on gloves. - Inserting the tip of the container 1/2 inch (1.25 cm) into the rectum - Allowing gravity to instill the solution - Encouraging the client to retain the solution for 5 to 15 minutes

- Assisting the client into Sims' position. - Washing hands and putting on gloves. - Encouraging the client to retain the solution for 5 to 15 minutes Explanation: To administer an enema, the nurse should place the client into Sims' or a knee-chest position. Washing hands and putting on gloves are necessary to reduce the transmission of microorganisms. To promote the effectiveness of the enema, the nurse should encourage the client to retain the solution for at least 5 minutes. The solution should be warmed rather than chilled to promote comfort. To administer the solution effectively and deliver it to the appropriate location, the nurse should insert the full length of the tip into the rectum. The nurse should compress the container to deliver the solution under positive pressure and not by gravity.

A nurse is caring for a client with a hiatal hernia who states that abdominal and sternal pain occurs after eating and when lying down. Which instructions would the nurse recommend when teaching this client? Select all that apply. - Avoid constrictive clothing around the abdomen. - Lie down for 30 minutes after eating. - Decrease intake of caffeine and spicy foods. - Eat three meals per day. - Sleep in semi-Fowler's position. - Maintain a normal body weight.

- Avoid constrictive clothing around the abdomen. - Decrease intake of caffeine and spicy foods. - Sleep in semi-Fowler's position. - Maintain a normal body weight. Explanation: A hiatal hernia occurs when a portion of the stomach pushes through the diaphragm. A hiatal hernia may cause abdominal and sternal pain after eating. The discomfort is associated with reflux of gastric contents. To reduce gastric reflux, the nurse would instruct the client to avoid constrictive clothing around the thoracic and abdominal region, caffeine, and spicy foods; sleep with the upper body elevated; lose weight, if obese; remain upright for 2 hours after eating; and eat small, frequent meals.

Which of the following interventions will help prevent a pulmonary embolus (PE) in a postpartum woman? Select all that apply. - Encourage the client to increase fluid intake. - Teach the client leg exercises she can do in bed. - Encourage the client to ambulate in the room. - Give the client an anticoagulant prophylaxis. - Elevate the client's legs on a soft pillow.

- Encourage the client to increase fluid intake. - Teach the client leg exercises she can do in bed. - Encourage the client to ambulate in the room. Explanation: Pulmonary embolus (PE) is primarily caused by a clot in the veins of the leg or pelvis. Having the three elements of Virchow's triad increases the client's risk of postpartum DVT. Those elements include hypercoagulation, venous stasis, and vessel wall injury. To prevent hypercoagulation, the nurse should encourage fluid intake to prevent dehydration. Venous stasis and vessel wall injury can be prevented by early ambulation. Anticoagulation would be contraindicated in postpartum women. Elevating their legs on pillows could cause vessel wall damage.

A child is admitted with constipation and a diagnosis of possible appendicitis. The child is in acute pain. Which nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply. - Offer an ice pack. - Apply a heating pad. - Assume a position of comfort. - Limit the child's activity. - Request a prescription for a cathartic.

- Offer an ice pack. - Assume a position of comfort. - Limit the child's activity. Explanation: Cold is a vasoconstrictor and supplies some degree of anesthesia. The child is usually more comfortable on his side with his legs flexed to take the strain off the inflamed appendix. Limiting the child's activity puts less stress on the inflamed appendix and lessens the discomfort. Heat increases circulation to an area, causing more engorgement and pain and, possibly, rupture of the appendix. Heat is contraindicated in any situation where rupture or perforation is a possibility. A cathartic is contraindicated when appendicitis is suspected. Increasing peristalsis can cause the appendix to rupture.

What should the nurse include in the teaching plan for a client with peripheral arterial disease (PAD) to promote vasodilation? Select all that apply. - Participate in relaxation training or yoga. - Apply a heating pad to the abdomen. - Avoid exposure to cold temperatures. - Use hot water bottles to warm the extremities. - Substitute e-cigarettes for smoking or chewing tobacco.

- Participate in relaxation training or yoga. - Apply a heating pad to the abdomen. - Avoid exposure to cold temperatures. Explanation: Nurses should recommend that clients with PAD avoid exposure to cold temperatures, participate in relaxation training or yoga to decrease emotional upsets and stress, and use application of warmth in the form of heating pads to the abdomen, which can cause reflex vasodilation in the extremities. Hot water bottles to the extremities should be avoided due to risk for tissue damage. Any form of tobacco product causes vasoconstriction, including e-cigarettes. Therefore, e-cigarettes are not a good form of substitution.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. - Reposition the client every 2 hours. - Perform range-of-motion exercises. - Use commercial soaps to keep the skin dry. - Tuck bed covers tightly into the foot of the bed. - Encourage the client to eat a well-balanced diet.

- Reposition the client every 2 hours. - Perform range-of-motion exercises. - Encourage the client to eat a well-balanced diet. Explanation: To prevent pressure ulcer formation, the nurse should turn and reposition the client every 2 hours, perform range-of-motion exercises, avoid using commercial soaps that dry or irritate skin, avoid tucking covers tightly into the foot of the bed, and encourage the client to eat a well-balanced diet.

For which client(s) does the nurse anticipate the healthcare provider's orders for pneumatic compression devices? Select all that apply. - client who had extended low anterior resection for colonic mass - client who had outpatient endoscopy for anemia - client in the intensive care unit on a ventilator with sepsis - client with four vessel coronary artery bypass graft with bilateral chest tubes - client who had diagnostic laparoscopy for abdominal pain

- client who had extended low anterior resection for colonic mass - client in the intensive care unit on a ventilator with sepsis - client with four vessel coronary artery bypass graft with bilateral chest tubes Explanation: Pneumatic compression devices may be used with graduated compression stockings or alone to apply sequential pressure to the legs to enhance blood flow and venous return. They require a prescriber's order and are usually prescribed for high-risk surgical clients, clients with decreased mobility, and those at risk for deep vein disorders. Clients with extended low anterior resection and coronary artery bypass graft would be surgical clients at high risk for deep vein thrombosis. The client in the intensive care unit on a ventilator with sepsis has decreased mobility and is also at risk for deep vein thrombosis. Same-day procedures such as endoscopy and laparoscopy would not be considered high risk for deep vein disorders and would not require pneumatic compression devices.

A client who has terminal cancer is receiving morphine sulfate by patient-controlled analgesia (PCA). The client is grimacing and moaning frequently. The client sleeps for short periods during which the heart rate is 100 bpm, respiratory rate is 20 breaths/minute, and blood pressure is 138/90 mm Hg. What are the most important factors in the nurse's assessment? Select all that apply. - grimacing and moaning - short intervals of sleep - elevated heart rate and blood pressure - increased respiratory rate - type of medication

- grimacing and moaning - elevated heart rate and blood pressure Explanation: The client is grimacing and moaning, and the heart rate and blood pressure are elevated. This means that pain treatment is inadequate. Since the client is receiving morphine, the inadequacy of relief is not likely associated with the medication type; it is more likely related to inadequate dose. The respiratory rate is acceptable for an adult client, and short periods of sleep do not indicate that pain relief is obtained.

The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used. - Smoothly pull the stocking over the ankle and calf. - Turn the stocking inside out and ease the stocking over the foot and heel. - Review medical record and medical orders for graduated compression stockings. - Apply powder or lotion to legs. - Place the client in supine position. - Identify the client and explain procedure.

1. Review medical record and medical orders for graduated compression stockings. 2. Identify the client and explain procedure. 3. Place the client in supine position. 4. Apply powder or lotion to legs. 5. Turn the stocking inside out and ease the stocking over the foot and heel. 6. Smoothly pull the stocking over the ankle and calf. Explanation: When applying graduated compression stockings, the nurse should first review the medical record and verify the medical order for application. The nurse should then identify the client and explain the procedure to alleviate anxiety and prepare the client for what to expect. The nurse then places the client in a supine position to reduce congestion of blood in vessels. The nurse then applies powder or lotion to the legs to reduce friction and ease the application. Next, the nurse turns the stocking inside out as this technique provides for easier application and with the heel pocket down, eases the stocking over the foot and heel. The nurse then smoothly pulls the stocking up over the heal and calf, making sure there are no wrinkles, as wrinkles may compromise

A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

500 Explanation: The recommended energy intake for a lactating client is 500 calories more than her nonpregnant intake.

The prenatal client tells the nurse that she has been eating ginger cookies to treat her nausea and vomiting. Which response by the nurse is best? a. "When consumed as a spice in foods, ginger is generally considered safe in pregnancy." b. "It is safer to use a prescription medication than eating ginger while you are pregnant." c. "Wait at least 2 hours to take your prenatal vitamin after eating ginger cookies." d. "You should immediately stop eating ginger-containing foods."

a. "When consumed as a spice in foods, ginger is generally considered safe in pregnancy." Explanation: The herbal supplement ginger is taken to reduce nausea and vomiting. When consumed as spice in foods, such as ginger cookies, there is general consensus that ginger is safe. Prescription medications may be necessary to treat severe nausea and vomiting in pregnancy, but they can carry risks such as sedation. Prenatal vitamins should be taken when clients experience the least nausea rather than waiting a specific time after a food. There is no known pregnancy risk from eating ginger as a spice in foods.

The nurse is caring for a client with peripheral arterial occlusive disease (PAD). What nursing intervention is most appropriate to reduce platelet aggregation and promote circulation? a. Administer clopidogrel. b. Administer cilostazal. c. Administer atorvastatin. d. Administer oxycodone.

a. Administer clopidogrel. Explanation: Pharmacologic therapy for clients with PAD and claudication include pentoxifylline and cilostazal because these medications increase erythrocyte flexibility and decrease blood fibrinogen concentrations. Aspirin and clopidogrel are antiplatelet agents that prevent the formulation of emboli by reducing platelet aggregation. Statins are used to improve endothelial function. Therefore, clopidogrel should be administered because it is an antiplatelet agent that prevents the formulation of emboli by reducing platelet aggregation.

The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take? a. Have the client breathe into a paper bag. b. Instruct the client to put the head between the knees. c. Give the client a low concentration of oxygen by nasal cannula. d. Tell the client to take several deep, slow breaths and exhale normally.

a. Have the client breathe into a paper bag. Explanation: The best way to ease symptoms caused by hyperventilation is to have the client breathe into a paper bag. This helps to raise carbon dioxide level, which encourages deeper, slower breathing. The symptoms of hyperventilation will not be alleviated by having the client put the head between the knees, giving the client low concentrations of oxygen, or having the client take deep, slow breaths and exhaling normally.

A client is being discharged with nasal packing in place. What should the nurse instruct the client to do? a. Perform frequent mouth care. b. Use normal saline nose drops daily. c. Sneeze and cough with mouth closed. d. Gargle every 4 hours with salt water.

a. Perform frequent mouth care. Explanation: Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sneezing and coughing, the client should do so with the mouth open to decrease the chance of dislodging the packing. Gargling should not be attempted with packing in place.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings? a. Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. b. Apply an ice pack to the incision for 15 minutes prior to application. c. Cover the incision with a gauze bandage to provide cushion to the incision. d. Premedicate the client with prescribed acetaminophen 500 mg PO 15 minutes prior to application.

a. Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. Explanation: The application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application. Oral acetaminophen 500 mg will not likely provide effective pain relief 15 minutes prior to application of the graduated compression stockings. Although an ice pack may reduce pain, the prescribed morphine will be more effective for relieving pain rated 8/10. Placing a gauze pad to the incision prior to applying the graduated compression stockings may be necessary to absorb drainage, but will not provide pain relief during application.

The nurse is caring for a client during a prolonged hospital stay for congestive heart failure. The client has a prescription for thigh high antiembolism stockings. In regard to the antiembolism stockings, what is the priority action by the nurse? a. Remeasure the client's legs routinely. b. Launder the stockings every 3 days. c. Light dust legs with talcum powder before applying. d. Document the size of the stockings used.

a. Remeasure the client's legs routinely. Explanation: Using the correct size of antiembolism stockings is critical to their effectiveness. If a stocking is not tight enough, it will not improve venous return effectively. If the stocking is too tight, it may impair circulation. In a client who has had a prolonged hospitalization for congestive heart failure, the potential for changes in leg circumference related to increases or decreases in the amount of lower extremity edema requires the legs be remeasured routinely to ensure the appropriate sized stocking. Laundering the stockings every day is recommended, but not a priority. Lightly dusting the legs with talcum powder may ease the application of the stocking, but is not required. Documenting the size of the stockings used is important to provide a baseline, but remeasuring the legs routinely is the nurse's priority.

A child with newly diagnosed osteomyelitis has nausea and vomiting. The parent wishes to give the child ginger cookies to help control the nausea. What should the nurse tell the parents? a. You can try them and see how he does." b. "I will need to get a prescription." c. "Your child needs medication for the vomiting." d. "We discourage the use of home remedies in children."

a. You can try them and see how he does." Explanation: Some clients find ginger cookies or "snaps" help relieve nausea. Ginger, in small doses such as would be found in the cookies, has few side effects. There is no reason that the parent should not try this dietary intervention; however, the nurse must monitor the client's response. If the child has a diet as tolerated prescription, there is no need for an additional prescription. Ultimately, the child may need an antiemetic medication, but dietary strategies are often successful in treating vomiting related to osteomyelitis. Making a universal statement disregarding home remedies is not a client-centered approach.

A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: a. increase the client's fluid intake to 3,000 mL/day. b. administer an oil retention enema. c. place the client on the bedpan every 3 to 4 hours. d. perform passive range of motion to extremities.

a. increase the client's fluid intake to 3,000 mL/day. Explanation: The most appropriate nursing action is to first increase the client's fluid intake to 3,000 mL/day to soften stool.A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool.Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement.While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement.

A nurse is assessing a client with bone cancer pain. Which part of a thorough pain assessment is most significant for this client? a. intensity b. cause c. aggravating factors d. location

a. intensity Explanation: Intensity is indicative of the severity of pain and is important for evaluating the efficacy of pain management. The cause and location of the pain cannot be managed, but the intensity of the pain can be controlled. The nurse and client can collaborate to reduce aggravating factors; however, the goal will ultimately be to reduce the intensity of the pain.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease? a. low sodium b. high protein c. low carbohydrate d. low fat

a. low sodium Explanation: A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

After 2 days of breast-feeding, a postpartum client reports nipple soreness. Which client statement indicates an understanding of measures to help relieve nipple soreness? a. "I will apply warm compresses to my nipples just before feedings." b. "I should lubricate my nipples with expressed milk before feedings." c. "I will dry my nipples with a soft towel after feedings." d. "I will apply soap directly to my nipples and then rinse."

b. "I should lubricate my nipples with expressed milk before feedings." Explanation: Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.

The nurse is teaching the caregiver of an older adult client about urinary incontinence. What statement should the nurse make to the caregiver about urinary incontinence in the older adult? a. Urinary incontinence should be accepted as a relatively normal part of aging. b. Urinary incontinence has many causes and can often be improved with intervention. c. Among older adults, urinary incontinence is most often a sign of depression. d. Being incontinent can increase the client's risk for dehydration and confusion.

b. Urinary incontinence has many causes and can often be improved with intervention. Explanation: Urinary incontinence is not a normal part of aging, nor is it a disease. Urinary incontinence is not caused by depression. It may be caused by confusion or dehydration but does not cause these issues. Other risk factors include fecal impaction, restricted mobility, or other causes. Some medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients' urinary incontinence can be improved with careful assessment for contributing factors and targeted interventions.

Which is a priority nursing goal for a client with rheumatoid arthritis? The client will: a. minimize the frequency with which anti-inflammatory drugs are used to control joint discomfort. b. demonstrate use of adaptive equipment. c. learn to limit activity so as to avoid joint pain. d. verbalize that recovery from rheumatoid arthritis will require several years of treatment.

b. demonstrate use of adaptive equipment. Explanation: Depending on the degree of joint involvement, clients with rheumatoid arthritis may need to learn to function with adaptive equipment. Such equipment can help the client maintain independence. The consistent use of anti-inflammatory drugs is considered important to minimize joint inflammation and damage. Periods of activity should be alternated with rest periods, but limiting activity to avoid joint pain is not a realistic or desirable outcome. The client needs to understand that rheumatoid arthritis cannot be cured.

Which diet would be most appropriate for the client with ulcerative colitis? a. high-calorie, low-protein b. high-protein, low-residue c. low-fat, high-fiber d. low-sodium, high-carbohydrate

b. high-protein, low-residue Explanation: Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

When assessing a child for impetigo, the nurse expects which assessment findings? a. small, brown, benign lesions b. honey-colored, crusted lesions c. linear, threadlike burrows d. circular lesions that clear centrally

b. honey-colored, crusted lesions Explanation: In impetigo, honey-colored, crusted lesions develop once the pustules rupture. Small, brown, benign lesions are common in children with warts. Linear, threadlike burrows are typical in a child with scabies. Circular lesions that clear centrally characterize tinea corporis.

The nurse is assisting a healthcare provider with suturing an arm laceration on a school-age client. What relaxation strategy will the nurse instruct the client to use during this painful procedure? a. "Keep your eyes shut tight at all times, and don't peek." b. "You can scream into this pillow really loudly when it hurts." c. "Take a deep breath, and blow out until I say to stop." d. "This is going to hurt, but it will be over soon if you don't move."

c. "Take a deep breath, and blow out until I say to stop." Explanation: Having the child take a deep breath and blow it out is a form of distraction and will help the child cope better with the procedure. A child may prefer to keep the eyes open, not shut, during a procedure to see what is happening and anticipate what will happen next. Letting a child scream into a pillow can interfere with breathing, so it is not safe practice. When preparing a child for a procedure, the nurse should avoid using descriptors that mention or suggest pain. For example, the nurse might say, "Sometimes this feels like pushing or sticking, and sometimes it doesn't bother children at all."

The nurse is reading the nurse's note from the previous shift to evaluate the client with a risk for impaired skin integrity due to fluid volume excess. Which aspects would demonstrate this improvement? a. Presence of urine output that is amber in color. b. Foot of bed elevated 30 degrees for peripheral edema. c. Ambulation to the bathroom without noted dyspnea. d. Client statement of thirst and request for the cup of water.

c. Ambulation to the bathroom without noted dyspnea. Explanation: The client would have ambulation without dyspnea as a sign of improvement with fluid volume excess. Amber urine is a sign of a continued imbalance of fluid volume and the client's response of thirst is likely due to fluid restriction, not an indication of improvement. The foot of bed elevation would be a treatment and not a sign of improvement with fluid volume excess.

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants? a. Ask a child specialist to be present during treatment. b. Tell the infant that it will be over within a minute. c. Encourage parents to be present during the treatment. d. Provide the infant with soft toys or a feeding bottle.

c. Encourage parents to be present during the treatment. Explanation: When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child.

Which client requires increased sensory stimulation to prevent sensory deprivation? a. a 24-year-old client who has been admitted with an anxiety disorder and appears very agitated b. a 60-year-old client who is blind, reads books through use of Braille, listens to the radio, and regularly takes walks around the unit c. a 65-year-old client who has employment-induced presbycusis and advanced glaucoma d. an 84-year-old client who has hemiparesis and ambulates with a walker

c. a 65-year-old client who has employment-induced presbycusis and advanced glaucoma Explanation: There is more risk of sensory deprivation when the primary senses are impaired. This client is most at risk for sensory deprivation because of two sensory deficits: hearing and vision. These two are primary senses that help a person stay oriented and communicate with others. The 24-year-old client has senses intact but is experiencing an anxiety disorder. The 60-year-old client has one sensory deficit, blindness, but is compensating by reading books and listening to tapes. An elderly person with mobility problems, who is using mobility aids, and hence can still socialize is not experiencing sensory deficits.

In evaluating a client's response to nutrition therapy, which laboratory test would be of highestpriority to examine? a. serum potassium level b. lymphocyte count c. albumin level d. CBC differential

c. albumin level Explanation: Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge their nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of a. restricting fluids. b. restricting sodium. c. encouraging fluids. d. restricting potassium.

c. encouraging fluids. Explanation: The nurse should encourage fluid intake to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? a. high-carbohydrate, high-protein b. high-calcium, high-potassium, high-protein c. low-protein, low-sodium, low-potassium d. low-protein, high-potassium

c. low-protein, low-sodium, low-potassium Explanation: Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

Which action is most important for the nurse to perform post procedure in a client with impaired renal function who is scheduled for a multidetector-computed tomography (MDCT) to evaluate peripheral circulation? a. administering IV fluids b. administering IV sodium bicarbonate c. strictly monitoring intake and output d. assessing allergies

c. strictly monitoring intake and output Explanation: After an MDCT procedure, clients with impaired renal function should be monitored closely for urine output of at least 0.5 mL/kg/hr because they are at risk for contrast-induced nephropathy. Before the procedure, there may be an indication for IV fluids and sodium bicarbonate to alkalinize urine and protect against free radical damage. Allergies should also be assessed prior to the procedure and treated with steroids and/or histamine blockers if necessary.

The client with type 1 diabetes mellitus says, "If I could just avoid what you call carbohydrates in my diet, I guess I would be okay." What is the best response by the nurse? a. "It is correct that you do not need to count carbohydrates from fruits and vegetables." b. "Eliminating carbohydrates from your diet is a good first step toward getting off of insulin." c. "All we ask you to do is have your blood sugar in range." d. "A person with diabetes should monitor their eating of proteins, fats, and carbohydrates."

d. "A person with diabetes should monitor their eating of proteins, fats, and carbohydrates." Explanation: Diabetes mellitus is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The client's diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamins. Limiting carbohydrate intake is just part of a comprehensive diabetic diet plan. A client with type 1 diabetes will need lifelong insulin therapy. Carbohydrates from fruit and vegetable sources will still need to be factored into carbohydrate intake. Telling a client "all we ask you to do" is a value-judgement and is not therapeutic communication.

A client with a vaginal yeast infection asks the nurse if it is a good idea to start taking acidophilus along with the prescribed vaginal cream. What assessment question would the nurse ask prior to answering the client's question? a. "Do you experience gastrointestinal problems?" b. "How much sugar do you consume each day?" c. "Have you recently lost or gained any weight?" d. "How often do you eat yogurt with live cultures?"

d. "How often do you eat yogurt with live cultures?" Explanation: If the client consumes one cup of yogurt containing live lactobacillus acidophilus daily, there is no need to take additional acidophilus. Although acidophilus is used for gastrointestinal problems, this client is not using it for this reason. Diets high in sugar have been associated with yeast infections and weight fluctuations are a part of a comprehensive assessment, but do not provide background information to answer the client's question.

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs? a. Instruct client to bathe and dress by 0900. b. Provide client with assistance in hygiene, grooming, and dressing. c. Encourage family or support persons to assist with the client's hygiene needs. d. Provide complete bathing and grooming tasks for client.

d. Provide complete bathing and grooming tasks for client. Explanation: Interventions should be directed at helping the client complete activities of daily living with the assistance of staff members, who can provide needed structure by communicating tasks in clear, concise bits of instructions. This intervention promotes realistic independence. This client has inappropriate social interaction and it would not be in the client's best interest for the client's family to provide hygiene needs. The client's condition does not indicate a need for complete assistance, which would only foster dependence.

When teaching the parent of an infant with Hirschsprung's disease who received a temporary colostomy about the types of foods the infant will be able to eat, which diet would the nurse recommend? a. high-fiber diet b. low-fat diet c. high-residue diet d. regular diet

d. regular diet Explanation: A regular diet would be recommended for the child with a colostomy; no special diet is needed. A high-fiber diet is not necessary. Fat is necessary for brain growth in the first year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated.