Fundamentals chpt 32 skin,39 Oxygen, 30 pre op, Chp41SELF CONCEPT

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

A Penrose drain promotes passive drainage into a dressing.

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

The nursing instructor wants to evaluate the student's knowledge of sensory functioning. The instructor knows the student understands sensory reception when the student states which of the following?

"Stereognosis is the sense that perceives the solidity of objects."

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

A figure-of-eight turn is used for joints like the elbows and knees

A nurse is attempting to provide education to a newly diagnosed diabetic. The client states, "It doesn't matter what I eat, my future health is up to God." The nurse understands that this client has:

A person with external locus of control perceives that outcomes happen because of luck, chance, or the influence of powerful others. A person with internal locus of control believes that personal behavior influences outcome, and that he can achieve desired results.

The nurse is taking a history on Kumar, who informs her that he has an allergy to adhesive tape. When the nurse asks Kumar to describe his reaction to the tape, he describes it as "blotchy and reddened." What type of allergic reaction is this?

A type IV reaction is characterized by local inflammation, pruritus and erythema.

According to Sullivan's Interpersonal Theory, a person undergoes the process of individuation during which stage?

According to Sullivan's Interpersonal Theory, the process of individuation occurs during the school-age child stage as peer relationships develop. Toddler stage is characterized by beginning differentiation. Preschoolers are not addressed by Sullivan. During adolescence, identity, body image, and role continue to develop or be redefined as individuation progresses.

Which describes an ascribed role?

An ascribed role is one in which the person has no choice (e.g., to be born a male and therefore be someone's son). On the other hand, assumed roles are ones that are chosen. This includes the choice to be a nurse, a husband, or a mother.

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house fire. When oxygen is prescribed, what delivery device will the nurse gather?

An oxygen tent is often used when caring for active toddlers who require oxygen because they are less likely to keep a mask on. Other devices are inappropriate for a child of this ag

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

A client started a nursing program and is trying to balance going to school full-time, a part-time job, and spending time with family. The client states, "I am trying to do everything and doing nothing well." Which role problem is this client experiencing from this role transition?

Role strain occurs when the person perceives himself as inadequate or unsuited for a role and can occur when a person is forced to assume many roles. Role ambiguity occurs when a person lacks knowledge of role expectations. This lack of knowledge causes anxiety and confusion. Role conflict is related to expectations concerning the role.

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply.

Spinal block Nerve block Epidural block

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective?

The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

The client has fistula formation. A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is no information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:

a partial airway obstruction.

The nurse assessing a client with chronic obstructive pulmonary disease (COPD) suspects chronic hypoxia based on which assessment finding?

clubbing fingers

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

o promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

to provide drainage for bile.