EAQ Set # 2
Which nursing interventions indicate client care that supports physical functioning? Select all that apply. 1 Interventions to facilitate client's learning 2 Interventions to alter client's undesirable behavior 3 Interventions to maintain client's nutritional status 4 Interventions to maintain client's regular bowel patterns 5 Interventions to prevent complications in the client related to electrolyte imbalance
Providing interventions to maintain the client's nutritional status and providing interventions to maintain the client's regular bowel patterns indicates interventions that support physical functioning[1] [2]. Providing interventions to facilitate a client's learning and providing interventions to alter the client's undesirable behavior indicates interventions to support psychosocial functioning and facilitates lifestyle changes. Providing interventions to prevent complications related to electrolyte imbalance indicates the nursing care that supports homeostatic regulation.
A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? 1 Fruits 2 Grains 3 Red meat 4 Vegetable oils
Red meat is high in dense saturated fats and should be avoided. Fruits do not contain saturated fats. Grains do not contain saturated fats. Vegetable oils contain unsaturated fats.
A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? 1.Encourage bed rest. 2.Space activities throughout the day. 3.Teach the limitations imposed by the disease. 4.Have one of the client's relatives stay at the bedside.
Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.
On a 6-week postpartum visit a new mother tells the nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach the mother that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for what? 1 Fat and calcium 2 Vitamin C and iron 3 Thiamine and sodium 4 Protein and carbohydrates
Whole milk does not meet the infant's need for vitamin C and iron. It contains adequate fats; however, the calcium content is 3.5 times that of human milk. The sodium and protein content of whole milk is 3 times that of human milk and unsuitable for an infant of this age.
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? Correct1 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.
A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client's plan of care include? 1 Foster self-activity whenever possible. 2 Plan care to be completed at one time followed by a long rest. 3 Teach family members how to assist with the client's basic care. 4 Limit visiting to evening hours before the client goes to sleep.
Because the family members are old enough to understand the client's needs, they should be encouraged to participate in the care. Self-care increases oxygen use, thereby increasing fatigue and dyspnea. Overworking the client causes undue fatigue; there should be frequent rest periods between different aspects of care. Limiting visiting to evening hours deprives the client of a support system.
The parent of a 2-year-old child with just-diagnosed cystic fibrosis expresses concern about the child's frailty and low weight. What is the most appropriate reply by the nurse? 1 "Digestive enzymes will be given to help your child digest food." 2 "Your child's appetite will improve once respiratory therapy is started." 3 "Your child's coughing and shortness of breath prevent adequate chewing of food." 4 "I suggest that you offer baby foods to your child because they are more easily digested."
Because the pancreatic ducts are blocked and fibrotic, oral pancreatic enzymes must be given to make the nutrients digestible and absorbable. Children with cystic fibrosis have good, even voracious, appetites despite respiratory impairment. Chewing is adequate despite coughing and shortness of breath; undernourishment results from inadequate nutrient absorption. It is not the consistency of the foods that leads to inadequate digestion and absorption, but the lack of enzymes from the pancreatic duct.
A client is out of touch with reality, spending most of the time pacing the hall and responding to auditory hallucinations. The client does not perform the activities of daily living. What should the nurse plan to do? 1 Set limits on the client's pacing until self-care is initiated 2 Disregard the behavior until the client seeks help in caring for own needs 3 Take away the client's privileges until the activities of daily living are completed 4 Assist the client in meeting physical needs until they can be performed independently
Client safety and comfort needs are nursing priorities, according to Maslow's hierarchy of needs. At this time the client is not capable of being self-sufficient and needs assistance. Setting limits on the client's pacing until self-care is initiated is punitive when a client is out of touch with reality. Behavior may not be acknowledged, but it should never be disregarded or ignored. Taking away the client's privileges until the activities of daily living are completed is punitive when a client is out of touch with reality.
A client with severe chronic rheumatoid arthritis reports that pain lasts for 2 to 3 hours after exercising. What should the nurse should teach the client to do? 1 Substitute isometric exercises for isotonic exercises. 2 Stop the exercises for one day and then resume the exercises. Incorrect3 Delay doing aerobic exercises until the pain subsides. 4 Decrease the total time and number of repetitions of the exercise,
Exercise should be decreased to a level of tolerance. Isometric exercises promote muscle contraction, not joint movement. The exercise should not be stopped. The purpose of aerobic exercises is to improve cardiovascular functioning, not joint movement; there is no reason to interrupt aerobic exercises if they are tolerated.
The practitioner prescribes a diet high in vitamin B1 (thiamine) for a client with a long history of alcohol abuse. The nurse concludes that the client understands the teaching about foods high in thiamine when the client makes which statement? 1 "I'll choose fish, aged cheese, and breads." 2 "I'll choose lean beef, organ meat, and nuts." 3 "I'll choose poultry, milk products, and eggs." 4 "I'll choose green vegetables, lentils, and citrus fruits."
Lean beef, organ meats, and nuts all provide high levels of thiamine; other sources include legumes, whole and enriched grains, and lean pork. Of fish, aged cheese, and bread, only fish is considered a source of thiamine. Of poultry, milk products, and eggs, only eggs are considered a source of thiamine; this list contains sources of protein. Of green vegetables, lentils, and citrus fruits, only lentils (legumes) are considered a source of thiamine; most vegetables contain only traces of thiamine, and citrus fruits provide vitamin C.
