Caring PrepU
The wife of a comatose client wishes to wash the client's hair. Washing the client's hair meets which basic human need? Love Self-actualization Esteem Physiologic
Physiologic Washing the client's hair meets physiological needs of hygiene.
The nurse is providing supportive care to a client receiving hemodialysis in the management of acute kidney injury. Which statement from the nurse best reflects the ability of the kidneys to recover from acute kidney injury? The kidneys can improve over a period of months. Once on dialysis, the need will be permanent. Kidney function will improve with transplant. Acute kidney injury tends to turn to end-stage failure.
The kidneys can improve over a period of months. The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. As long as recovery is continuing, there is no need to consider transplant or permanent hemodialysis. Acute kidney injury can progress to chronic renal failure.
The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? Reassure the client that the procedure will only take a few minutes. Stop lifting the client and reassure him. Administer a sedative to the client and try again when the sedative takes effect. Enlist the help of another nurse to hold the client steady during the procedure.
Stop lifting the client and reassure him. The nurse should stop lifting the client and reassure him. If the client continues to be agitated, the nurse lowers the client back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the client may result in injury. An order for sedation would only be requested if it was absolutely necessary to obtain the client's weight at this time. Another nurse holding the client steady does not address the client's agitation.
A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? Providing a back rub before bed Giving the client something to drink Engaging in a therapeutic conversation Providing multiple stimuli to make the client tired
Providing a back rub before bed A back rub is used after a bath or as a nursing intervention for the following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication between the nurse and the client. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client.
Which is not a primary behavior of caring, one of the core values of nursing? giving of the self Meeting the client's needs in a timely manner Setting boundaries within the relationship Providing comfort measures to clients and their families
Setting boundaries within the relationship Caring involves giving of oneself for the benefit of the other. Although boundaries are therapeutic, they are not typically seen as an element of caring.
What would be an example of the nurse practicing fidelity? The nurse: regulates visitors. stays with a client during death as promised. withholds information as requested. provides continuity of care.
Stays with a client during death as promised. Fidelity requires the nurse to keep promises made and to be faithful to one's commitments. Regulating visitors is a demonstration of the value of privacy. Withholding client's information as requested is an example of maintaining confidentiality. Providing continuity of care is an example of integrity and professionalism.
The nurse is caring for a client who is receiving a combination of antineoplastic agents. The client has been told that alopecia is likely to occur, and the client is tearful and distraught about this. What is the nurse's best response? Reassure the client that other people who are treated with cancer also experience this. Encourage the client to view the hair loss as something that indicates cancer is being eradicated. Reassure the client that the hair loss will be temporary rather than permanent. Validate the client's sense of impending loss and offer guidance for getting a wig.
Validate the client's sense of impending loss and offer guidance for getting a wig. The nurse should empathically validate the client's sense of loss. Offering to assist with a practical solution is also useful. The facts that the hair loss is temporary and happens to other people are unlikely to provide any real consolation. Similarly, telling the client to see it as a positive is likely to be interpreted as simplistic.
A nurse is assigned to care for a 6-month-old infant hospitalized with diarrhea and dehydration. Because the infant does not have developed speech, what can the nurse do to communicate with the infant? Write on a whiteboard. Use puppets to communicate with the infant. Sing to the infant. Use a stuffed animal to tell a story.
Sing to the infant. Infants primarily communicate through touch, sight, and hearing. Communication can occur through cuddling, holding, rocking, and singing to the infant. The child cannot read, so writing on the whiteboard would be beneficial only for the parents. A 6-month-old infant uses toys as developmental tools, not communication tools. The infant may want to snuggle with the stuffed animal while the nurse tells the story or sings.
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm? The interaction may cause the client to become violent. The interaction may cause migraine in the client. The stimulation can increase intracranial pressure (ICP) or trigger a seizure. The client may become emotional and lose interest in the treatment.
The stimulation can increase intracranial pressure (ICP) or trigger a seizure. Although visitors' and family members' desire to interact with the client are well intentioned, the stimulation can increase ICP or trigger a seizure. The nurse can suggest that they take turns and stay briefly. Interactions are not likely to make the clients violent or emotional, which may cause the client to lose interest in the treatment. The interactions also may not cause migraine in the client.
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Apply warm compresses. Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing.
Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently are suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
A nurse is providing care to a client who has undergone a mastectomy. The nurse provides the woman with information about where to obtain a breast prosthesis. This is an example of which type of community-based nursing intervention? health education program health screening program health system referral telephone consultation
health system referral The nurse is passing along information about the location of and services offered for the client, an example of a health system referral. Health education programs assist clients in making health-related decisions about self-care and use of resources. Health screening programs focus on detecting unrecognized or preclinical illness among individuals such as mammography. Telephone consultation involves listening and providing support, information or instruction given over the phone, and documenting the interaction.
The nurse recognizes that palliative surgery is performed for what purpose? to remove a part of the body that is diseased to lessen the intensity of an illness to make or confirm a diagnosis to restore function to tissue that is traumatized
to lessen the intensity of an illness Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery.
Which is most likely to encourage parents to talk about their feelings related to the poor prognosis their child has been given? being sympathetic using direct questions using open-ended questions avoiding periods of silence
using open-ended questions Therapeutic communication is an interaction between two people that is planned, deliberate, has structure, and is helpful and constructive. Using open-ended questions is an example of a therapeutic communication technique. Nurses should demonstrate empathy to clients, not sympathy. Empathy is the ability to put yourself in another person's place and understand and be sensitive to the feelings of another. Direct questioning is a nontherapeutic form of communication and requires only yes or no answers. In instances where there is no cure for the child, if the nurse practices therapeutic communication the nurse still has the ability offer support by the words used or nonverbal communication such as touch. In perspective, these are the most valued, most appreciated, and most helpful aspects of care.
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth? "The baby is coming. Relax and everything will turn out fine." "Do you want me to call in your family?" "Even though the baby is coming, the health care provider will be here soon." "The baby is coming. I'll explain what's happening and guide you.
"The baby is coming. I'll explain what's happening and guide you." Continuous labor support with a trained nurse or doula has been shown to be effective in increasing coping ability of laboring woman. To keep her calm, the nurse needs to explain all procedures and discuss all events to the mother. The nurse cannot know the final outcome and should be careful of making general statements indicating everything will be OK. It is the nurse's responsibility to calm the client down and not wait for the health care provider. While calling the family may help, there is no guarantee and the nurse needs to work to calm the client down.
The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse? "Let me document that you can walk." "Those physical therapists work wonders. "You have made an amazing recovery." "Are you supposed to be out of the wheelchair?
"You have made an amazing recovery." Reinforcement of learning shows that the nurse supports and wants to encourage the client. Giving credit where it is due communicates these values. Documenting is necessary, but stating this does not show interest in the client's progress. Crediting the therapists does not encourage the client. Asking about permission to ambulate negates the goal for improving wellness.
A charge nurse has implemented staff education on nursing values. The nurse would determine that further education is required when which statement(s) are overheard? Select all that apply. "I can't believe the client is giving that precious infant up for adoption." "The gonorrhea test was positive. That's what the client gets for sleeping around." "If that was my mother, I sure wouldn't agree to a no-code." "If you are going to have extramarital sex, please protect yourself by using a condom." "Smoking has been shown to be a risk for many illnesses, including heart disease and cancer."
"I can't believe the client is giving that precious infant up for adoption." "The gonorrhea test was positive. That's what the client gets for sleeping around." "If that was my mother, I sure wouldn't agree to a no-code." Being judgmental, as in the options about adoption, gonorrhea, and code-status, does not reflect the values desired in a nurse. Professional nurses do not assume that their personal values are more correct than those of their clients. Nurses are obligated, however, to provide health information such as recommending condom use and smoking cessation.
The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate? "It must be very difficult for you." "There's no need for anger." "I can't imagine how awful this is for you." "You should try to make things right with your family."
"It must be very difficult for you." Use statements with broad openings such as "It must be difficult for you" and "Do you want to talk about it?" Such language encourages communication and allows the client to choose the topic or manner of response. Accept the client's behavior. Anger is part of the grieving process. Indicating that this is "awful" is not an appropriate way to promote coping. It is not the nurse's role to tell the client to make things right with the family. While this may be desired, the client should initiate it.
The nurse is preparing a hospitalized child for a lumbar puncture. The health care provider states the procedure will be performed in the child's hospital room. To advocate for the child, what should the nurse inform the health care provider? "We will have to have the parents hold the child down because there is not enough assistance on the floor." "The parents want to be present during the procedure, and I informed them that this is not the policy of our facility." "I will prepare the hospital room for the child, because that room is where the child will feel most comfortable." "I will have the procedure prepared in the treatment room, so that the child may view the hospital room as safe and secure."
"I will have the procedure prepared in the treatment room, so that the child may view the hospital room as safe and secure." In the hospital, all invasive procedures should be performed in the treatment room or a room other than the child's room. The child's room should remain a safe and secure area. The lumbar puncture requires special positioning and holding. This should be done by the nurse and not the parents. The decision to have the parents watch the procedure is up to the health care provider and/or hospital policy. If the parents observe the procedure, they need education prior to the procedure about what to expect.
A 10-year-old child tells the school nurse that she is embarrassed that she is afraid of the dark. Which is the best response by the nurse? "I was afraid of the dark at your age. You will grow out of that fear soon." "It is normal for a 10-year-old to be afraid of the dark so there is no need to be embarrassed. Would you like to talk about it?" "Are you afraid that something is going to happen to you or that something or someone may be outside that you can't see?" "That is so horrible that you are afraid of the dark. Can you sleep at night at all?"
"It is normal for a 10-year-old to be afraid of the dark so there is no need to be embarrassed. Would you like to talk about it?" The school-age child needs reassurance that his or her fears are normal for this developmental age. Parents, teachers, and other caretakers should discuss the fears and answer questions posed by the child. However, the adult should not embellish the fear in any way. In addition, telling the child that she will "grow out of it" is not reassuring to the child.
The nurse is caring for a preschooler who requires postsurgical breathing exercises. Which approach will best elicit the child's cooperation? "Let's see who can blow these cotton balls off the table first." "You need to do the breathing or you could get pneumonia." "Do you want to play a breathing exercise game with me?" "You will need to cooperate. Otherwise, you might not feel better."
"Let's see who can blow these cotton balls off the table first." Any intervention should be developmentally appropriate, and play can often serve as a vehicle for care. Turning breathing exercises into a game is likely to engage the preschooler. Telling the child he needs to do breathing exercises or he will develop another illness or not feel better is not likely to impress the young child. Connecting the two events in a meaningful way is beyond his cognitive ability. Asking if the child "wants" to play a breathing game is an open invitation for a "No" answer.
The nurse is preparing a 6-year-old for a venipuncture. The boy appears anxious and is crying. How can the nurse foster feelings of control to help minimize his anxiety about the procedure? "Pick your favorite Band-Aid and show me which arm to use." "Mrs. Jones, why don't you have him sit on your lap?" "See how fast you can make this pinwheel whirl." "What questions do you have about what I am doing?"
"Pick your favorite Band-Aid and show me which arm to use." Allowing the child options related to the style of the Band-Aid and the extremity to use gives the child some control over the happenings. Offering a pinwheel is a distraction technique. Encouraging the parent to hold the child during the procedure promotes feelings of security. Encouraging the child or parents to ask questions facilitates communication.
The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"? This heart attack really saddens you." "I don't understand. You have survived this heart attack. Why do you think life will never be the same?" "Hope has important healing powers. You need to be a little more hopeful of your recovery from this heart attack." "You're very concerned when you think about how this will change your life."
"You're very concerned when you think about how this will change your life." The response should be attuned to the feelings of sadness and dejection the client is experiencing and should allow concerns to be shared. This response also addresses the content of the client's statement, namely how life will change. "This really saddens you." addresses the feelings but does not attend to the feelings about life. "Why" questions are nontherapeutic, and telling the client to be more hopeful negates what the feelings are.
The nurse is providing care to a client following a knee arthroscopy. What would the nurse expect to include in the client's plan of care? Keeping the affected knee flexed. Applying warm packs to the insertion site. Maintaining the client's NPO status. Administering the prescribed analgesic.
Administering the prescribed analgesic. After an arthroscopy, the client's entire leg is elevated without flexing the knee. A cold pack is placed over the bulky dressing covering the site where the arthroscope was inserted. A prescribed analgesic is administered as necessary. The client is allowed to resume his or her usual diet as tolerated.
A nurse is preparing to administer medication to a preschool-age child. What can the nurse do to ensure communication with the child is effective? Show the child a video about medication administration. Use medical terminology when discussing the medication with the child. Allow the child to choose between juice, water, or soda to take the medication. Allow the child to determine if he or she wants to take the medication at that time.
Allow the child to choose between juice, water, or soda to take the medication. When a child is ill and medication is needed to be administered the child should not have a choice in the timing of medication administration. The medication is administered for the benefit of the child. The preschooler does, however, have choices in the matter. The preschooler can choose how he or she wants to take the medicine, that is, in a medicine cup or through a syringe, if the child wants to squirt the medicine by himself with nursing support or what type of liquid the child would like the medication mixed with. Showing a preschool-age child a video does not accomplish the education, because a child of this age sees the person on the screen separate from himself/herself. The nurse should always speak to the child in words the child can understand.
When caring for a child newly diagnosed with special needs, which nursing action is priority? Answering the caregiver's questions. Explaining the diagnosis to the caregivers. Setting up respite care for the caregivers. Providing resources for the family.
Answering the caregiver's questions. Answering questions and providing education to the caregivers is the priority to prevent unrealistic expectations of the child and the health care system. Accurate, kind explanations given promptly help to promote a more positive environment for all involved. The nurse will supplement education on the diagnosis as needed as this should have already been discussed with the primary health care provider who made the diagnosis. The nurse will also provide any resource material the family needs. Respite care may be needed once the caregivers feel fatigued.
A client's friend is visibly distressed by the client's condition and lack of improvement. The friend says they feel powerless and unable to help the friend. How should the nurse respond? Agree with the client's friend. Tell the client's friend that there's nothing they can do. The nurse states understanding of how the friend must feel. Ask the client's friend if they would like to help with comfort measures.
Ask the client's friend if they would like to help with comfort measures. The client's friend expressed a need to help. The nurse should encourage the friend to do whatever they feel comfortable doing, such as applying lubricant to the client's lips, placing a moist cloth on the forehead, or applying lotion to the client's skin. Agreeing with the client's friend or stating that the nurse understands how the friend feels doesn't diminish the friend's sense of powerlessness. There are many ways the client's friend can help if they choose to do so.
A nursing instructor is teaching a class on empathy. The instructor determines that the class needs additional education when the students identify that empathy involves what? Careful listening Being in touch with what the client is saying Feeling the same emotions that the client is feeling at a given time Having insight into the meaning of clients' thoughts, feelings, and behaviors
Feeling the same emotions that the client is feeling at a given time Empathy is the ability to experience, in the present, a situation as another did at some time in the past. It is the ability to put oneself in another person's circumstances and to imagine what it would be like to share in those feelings. The nurse does not actually have to have had the experience but has to be able to imagine the feelings associated with it.
In preparation for transesophageal echocardiography (TEE), the nurse must: Instruct the patient to drink 1 L of water before the test Heavily sedate the patient Inform the patient that blood pressure (BP) and electrocardiogram (ECG) monitoring will occur throughout the test Inform the patient that an access line will be initiated in the femoral artery
Inform the patient that blood pressure (BP) and electrocardiogram (ECG) monitoring will occur throughout the test The patient will have BP and ECG monitored throughout the test and must be NPO 6 hours before the procedure. The patient is sedated to make him or her comfortable, but will not be heavily sedated. Also, the patient will have an IV line initiated before the procedure.
The nurse is caring for a client postoperatively who has recently experienced a family member's death. The nurse is demonstrating empathetic linkage with the client with which action? Explaining to the client that pain medication will be administered soon. Asking the client about whether a support system is available after discharge. Telling the client that it is normal to feel sad when someone has died. Offering to help the client with picking out meal selections for the next day.
Telling the client that it is normal to feel sad when someone has died. When the nurse is demonstrating empathetic linkage, it is the ability to feel the same feelings experienced by the other person as discussed with Peplau's theory. Telling the client it is normal to feel sad empathizes with this feeling for the client. Explaining about medication and offering to pick out menu items are a way to offer support in maintaining activities of daily living. With determining a support system, the nurse is helping to prepare the client for discharge.
Which situation should concern the nurse treating a postpartum client within a few days of birth? The client is nervous about taking the baby home. The client feels empty since she gave birth to the neonate. The client would like to watch the nurse give the baby her first bath. The client would like the nurse to take her baby to the nursery so she can sleep.
The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.
The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing? art of nursing science of nursing evidence-based practice application of research
art of nursing In this example, the nurse is utilizing a holistic approach to the provision of nursing care based on the knowledge of providing psychosocial interventions, such as allowing the client to verbalize feelings/fears. This application of knowledge is the art of nursing. The science of nursing is the knowledge base for the provision of care. Evidence-based practice and application of research are using research to make decisions on how to care for clients.
The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: care that will reduce the client's physical discomfort and manage clinical symptoms. care that is provided at the very end of an illness to ease the dying process. an alternative therapy that uses massage and progressive relaxation for pain relief. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care.
care that will reduce the client's physical discomfort and manage clinical symptoms. Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.
A parent wants to wait outside the room while a procedure is completed on his young child, saying, "I don't think I can stand to see you do this!" The nurse's best response is: "Certainly. I will stay with your child during the procedure." "Stay. It will be less scary for your child." "This will only take a few minutes. You should be with your child." "Good. That is what the team doing the procedure would prefer." "Come, stand by his head. You won't see much up there."
"Certainly. I will stay with your child during the procedure." Excusing the parent from the procedure is the best response. The parent's needs and abilities need to be respected and supported. Children usually receive the most support from parents. However, others can provide effective support, including nurses and child life personnel. Consider, also, that an anxious parent usually means an anxious child. Assist the parent to comfort the child after the procedure.
A nurse is caring for a 30-year-old woman who was just diagnosed with cervical cancer. Which psychosocial need would be the priority for the nurse with her client? clear information on the disease, management, and treatment touching the client's hand for comfort remaining cheerful through all of the interactions offering words of hope to the client
clear information on the disease, management, and treatment Women diagnosed with cancer of the reproduction tract need to understand their disease, prognosis, and what treatment options they have. The nurse's role is to educate with effective and clear communication techniques. The nurse should be sincere and may provide realistic hope, but her role as educator is primary.
A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? I am so sorry you are going through this. Can we talk?" "I know this is hard for you. Is there any way I can help?" "Sitting in the dark is not going to cure your cancer. Let's open the curtains." "Can you please tell me why you are crying?"
"I know this is hard for you. Is there any way I can help?" Empathy is identifying with the way another person feels. An empathic nurse is sensitive to the client's feelings and problems but remains objective enough to help the client work to attain positive outcomes. By retaining this quality, you can establish successful helping relationships without appearing cold or stern. The statement "I am so sorry you are going through this" demonstrates sympathy. Sympathy differs from empathy because it shifts the emphasis from the client to the nurse as the nurse shares feelings and personal concerns and projects them onto the client, limiting the ability to focus objectively on the client's needs. Asking about why the client is crying is part of information gathering but is not empathy. Stating that sitting in the dark will not cure cancer is an abrasive statement that may work against the nurse-client relationship.
The nurse is helping with the health assessment of a school-age client with special needs for attendance at summer camp. The mother tears up, saying that she wishes the child would not attend. What is the best response by the nurse? "Camp is only for 1 week. That is not a long time." "Your child will benefit from attending." "Maybe you haven't had enough time to prepare mentally for this." "It is not unusual for you to have strong feelings about this."
"It is not unusual for you to have strong feelings about this." Acknowledging the feelings of the mother indicates empathy and understanding and allows the parent to share more specific concerns to which the nurse can respond. The length of the camp session and the benefit for the child are true, but these comments do little to acknowledge the mother's feelings and promote dialogue. The camp health assessment has made the advent of camp "real" to the mother, but the "mental preparation" response by the nurse is a poor validation of her feelings.
A client with major depression is admitted to the health facility and expresses feelings of worthlessness and abandonment by significant others. Which replies by the nurse would convey empathy? I can understand what is going on with you." "Are you feeling like others have abandoned you?" "It sounds like this is a really difficult time for you." "Can you tell me what you are thinking right now?"
"It sounds like this is a really difficult time for you." "It sounds like this is a really difficult time for you" is an empathetic response that signifies that the nurse understands the client's ideas and feelings. Stating "I can understand what is going on with you" blocks effective communication because the nurse is minimizing the client's feelings. It indicates that the nurse cannot empathize with the client. Asking about if the client feels abandoned names the feelings and does not convey empathy. Asking what the client is thinking is not an empathetic response but is a therapeutic technique called exploring.
An 18-year-old highly dependent on the parents fears leaving home to attend college. Shortly before the fall semester starts, the client reports paralyzed legs and is rushed to the emergency department. When physical examination rules out a physical cause for the paralysis, the physician admits the client to the psychiatric unit. The client is diagnosed with functional neurologic symptom disorder and asks the nurse, "Why has this happened to me?" What is the nurse's best response? "You've developed this paralysis so you will have a reason to stay with your parents. You must deal with this conflict if you want to walk again." "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical." "Your problem is real, but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." "It's common for someone with your personality to develop a conversion disorder during times of stress."
"Your problem is real, but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." The nurse must be honest by telling the client that the paralysis has no physiologic cause while also conveying empathy and acknowledging that the symptoms are real. The client will benefit from psychiatric treatment, to help understand the underlying cause of the symptoms. After the psychological conflict is resolved, the symptoms will disappear. Telling the client that being unable to move the legs must be awful wouldn't answer the client's question; knowing that the cause is psychological rather than physical wouldn't necessarily make the client feel better. Saying that the client developed paralysis to avoid leaving the parents or that the client's personality caused the disorder wouldn't help the client understand and resolve the underlying conflict.
The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Sedate her with sleeping pills and leave the restraints on. Take the restraints off, stay with her, and talk gently to her. Leave the restraints on and talk with her, explaining that she must calm down. Talk with the client's family about taking her home because she is out of control.
Take the restraints off, stay with her, and talk gently to her. Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged.
A 76-year-old female client visits the primary care doctor for an annual physical. The client's spouse recently died and the client lives by themselves with no adult children nearby. The client's appearance is clean but disheveled and the client has lost weight since the last visit 3 months ago. The nurse is concerned about the client being able to care for themselves at home. complete the following sentence by choosing the list of options: based on the client's findings and history, the client is at risk for (self neglect, elder abuse, alzheimer's disease) and the nurse should (complete the lawson scale for instrumental activities of daily living/ /IADLs, complete the katz activity of daily living)
self neglect complete the lawson scale for IADS The client is exhibiting early signs of self-neglect, which will likely become worse over time. The nurse should complete the Lawson Scale for Instrumental Activities of Daily Living (IADLs) to determine if the client is able to live independently and to determine what social services the client may benefit from, such as meals delivered to their home. There is no indication that the client is at risk for Alzheimer disease. Although a disheveled appearance and weight loss could be signs of elder abuse in other scenarios, there is no indication that elder abuse is occurring in this situation and the findings more directly point to self-neglect. The Katz Activities of Daily Living index assesses a client's ability to perform activities of daily living (ADLs) such as bathing, eating, toileting, and dressing independently; while there may be a concern about eating enough due the client's weight loss, the client's appearance is clean, and the main concern is whether they can live independently. The nurse should not consult a social worker before assessing the client, using the Lawson Scale
