Nursing Concepts Behaviors/Addiction Part 3

The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?

"Are you only able to breathe when you are sitting upright?" Explanation: To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.

A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate?

"Evidence shows that there are changes in nerve cells and brain chemicals." Explanation: Specific neuropathologic and biochemical changes are found in patients with Alzheimer's disease. These include neurofibrillary tanges and neuritic plaques as well as altered neurotransmitter function, specifically acetylcholine. Vascular dementia is associated with a subclinical stroke. Although genetics is being studied as an underlying mechanism for Alzheimer's disease, no specific gene or gentic marker has been identified. Delirium is often the result of the interaction or use of multiple drugs.

A nurse is teaching an older adult client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation." Explanation: The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.

The public health nurse has been talking to a group of community members about sexually transmitted infections. Which statement by one of the participants demonstrates an understanding of methods during sexual intercourse to decrease the risk of a sexually transmitted infection?

"I will make sure and wash my genital area before and after having sexual intercourse." Explanation: It is important that an individual urinate and wash the genital and perineal area before and after sexual intercourse. An individual who has a sexually transmitted infection (STI) should not have sexual intercourse with anyone until treatment is completed. Condoms must be used with spermicide to be effective against STIs. To ensure that an individual does not get a STI, the individual should abstain from sexual intercourse. STIs can be passed by contact with an infected individual without actually having sexual intercourse.

A client is diagnosed with type 2 diabetes mellitus. The client takes metformin and exenatide and reports adhering to a diet. The glycohemoglobin is 5.9%. According to the stable phase of the Trajectory Model of Chronic Illness, how should the nurse respond?

Acknowledges that the client is performing satisfactorily Explanation: In the stable phase of the Trajectory Model of Chronic Illness, the nurse reinforces positive behaviors. The glycohemoglobin is at a level of good control for a client with diabetes. No adjustments need to be made to the diet or the medications.

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

Administering 1 ampule of 50% dextrose solution, per physician's order Explanation: The nurse should administer 50% dextrose solution to restore the client's physiological integrity. Feeding through a feeding tube isn't appropriate for this client. A bolus of normal saline solution doesn't provide the client with the much-needed glucose. Observing the client for 1 hour delays treatment. The client's blood glucose level could drop further during this time, placing him at risk for irreversible brain damage.

A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?

Control blood glucose levels. Explanation: Controlling blood glucose levels and any hypertension can prevent or delay the development of diabetic nephropathy. Drinking plenty of fluids does not prevent diabetic nephropathy. Taking antidiabetic drugs regularly may help to control blood glucose levels, but it is the control of these levels that is most important. A high-fiber diet is unrelated to the development of diabetic nephropathy.

The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group?

Enuresis Explanation: The nurse would be most correct to document that enuresis, the involuntary voiding during sleep or commonly called "wetting the bed," is a normal finding in a pediatric client younger than 5 years old. Dysuria (pain on urination), hematuria (red blood cells in urine), and anuria (urine output less than 50 mL/day) are all abnormal findings needing further investigation.

Which factor is a nonmodifiable risk factor for mental health problems?

Gender Explanation: Nonmodifiable risk factors for mental health problems include age, gender, genetic background, and family history. Modifiable risk factors include marital status, family environment, and housing problems.

Which type of nursing diagnosis has a goal to increase well-being and enhance specific health behaviors?

Health promotion Explanation: Health promotion nursing diagnoses look for ways to enhance health. Risk nursing diagnoses identify potential problems and use the stem risk for, as in Risk for Impaired Skin Integrity related to inactivity. Syndrome diagnoses are used when the diagnosis is associated with a cluster of other diagnoses. Problem-focused nursing diagnoses identify existing problems.

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?

Hepatic encephalopathy Explanation: The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.

Development of malignant melanoma is associated with which risk factor?

History of severe sunburn Explanation: Ultraviolet rays are strongly suspected as the etiology of malignant melanoma. Fair-skinned, blue-eyed, light-haired people of Celtic or Scandinavian origin are at higher risk for developing malignant melanoma. People who burn and do not tan are at risk for developing malignant melanoma. Elderly individuals who retire to the southwestern United States seem to have a higher incidence of developing malignant melanoma.

The nurse is obtaining a health history from a client with stress-related illnesses. When the nurse asks the client how the client copes with stress, which coping mechanism causes the nurse the most concern?

I run eight hours per day. Explanation: The nurse is most concerned about the maladaptive coping mechanism of running eight hours per day. Playing video games, exercising or lifting weight, and going out with friends are more positive, beneficial coping mechanisms which, if done appropriately, can reduce stress.

During which phase of the Trajectory Model of chronic illness is the focus of nursing care on reinforcing positive behaviors and offering ongoing monitoring?

In the Stable phase, the focus of nursing care is on reinforcing positive behaviors and offering ongoing monitoring. During the Pretrajectory phase, the focus is on referring the person for genetic testing and counseling, if indicated, and providing education about prevention of modifiable risk factors and behaviors. The trajectory onset phase provides explanation of diagnostic tests and procedures and reinforces information and explanation given by the primary health care provider. During the Unstable phase of the Trajectory Model, the focus of nursing care is on providing guidance and support and reinforcing previous teaching.

Which stage of the transtheoretical model occurs when the patient has serious consideration of change, but it is sometime in the future?

In the contemplation stage, the patient has serious consideration of change, but it is sometime in the future. When the patient is not considering any change in behavior in the next 6 months, he or she is in the precontemplation stage. During the action stage, concrete activities that lead to the desired change have been made for less than 6 months. During the maintenance stage, active efforts to sustain the changes made for more than 6 months.

The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?

Increases ability for glucose to get into the cell and lowers blood sugar Explanation: Exercise increases trans membrane glucose transporter levels in the skeletal muscles. This allows the glucose to leave the blood and enter into the cells where it can be used as fuel. Exercise can provide an overall feeling of well-being but is not the primary purpose of including in the daily routine of diabetic clients. Exercise does not stimulate the pancreas to produce more cells. Exercise can promote weight loss and decrease risk of insulin resistance but not the primary reason for adding to daily routine.

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication?

N-acetylcysteine Explanation: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

Which nursing suggestion would be most helpful to the client with recurrent otitis externa?

Place ear plugs into the ears before swimming Explanation: The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, he or she advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.

A perimenopausal woman informs the nurse that she is having irregular vaginal bleeding. What should the nurse encourage the patient to do?

See her gynecologist as soon as possible. Explanation: All women should be encouraged to have annual checkups, including a gynecologic examination. Any woman who is experiencing irregular bleeding should be evaluated promptly.

Report this Question The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation?

Sit with the client's daughter privately and encourage her to express her feelings frankly. Explanation: Failure to verbalize feelings, express emotions, and show tenderness for the dying person is often a source of regret for grieving relatives. Therefore, families must feel that they can express their feelings with nurses who are compassionate listeners. If nurses encourage family members and listen to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. Families must feel that they can express their feelings with nurses who are compassionate listeners. Reminding a family member that their loved one will die soon shows a lack of compassion in this situation. Although the client is the nurse's main priority, it is the nurse's role to encourage family members to identify strengths and express feelings as a method of coping with the death of their loved one. The response regarding making the father's final days happy ones shows a lack of caring on the part of the nurse.

When developing an educational program for a group of adolescents about sexually transmitted infections (STIs), what should the nurse inform the group about the single greatest risk factor for contracting an STI?

The number of sexual partners Explanation: The single greatest risk factor for contracting an STI is the number of sexual partners. As the number of partners increases, so does the risk of exposure to a person infected with an STI.

Acetaminophen overdose is treated with administration of which medication?

Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

A young college student recently had her tongue and lip pierced. She has developed a superinfection of candidiasis from the antibacterial mouthwash. Which of the following would be the correct recommendation for her?

Use an antifungal mouthwash or salt water. Explanation: The client can substitute an antifungal mouthwash or salt water if a superinfection of candidiasis develops from the antibacterial mouthwash. A soft-bristled toothbrush should be used to avoid additional oral injury, but it is not the recommended solution for this problem. After eating, the client should rinse her mouth for 30 to 60 seconds with an antifungal mouthwash or salt water. Moving the jewelry at the piercing area back and forth during washing helps clean the pierced tract but does not solve the problem.

Which of the following would be most important to determine when assessing a client being admitted for suspected toxic shock syndrome (TSS)?

Use of superabsorbent tampons Explanation: TSS is commonly associated with the use of superabsorbent tampons that are not changed frequently and internal contraceptives that remain in place longer than necessary. Assessing the use of oral contraceptives, psychological trauma, or menorrhagia is not required for diagnosing the cause of TSS.

Which of the following is a strategy to promote urinary continence?

Void regularly, 5 to 8 times a day Explanation: Strategies to promote urinary continence include increasing awareness of the amount and timing of all fluid intake; avoid taking diuretics after 4 PM; avoiding bladder irritants, such as caffeine, alcohol, and aspartame (NutraSweet); taking steps to avoid constipation by drinking adequate fluids, eating a well-balanced diet high in fiber, exercising regularly, and taking stool softeners if recommended; and voiding regularly, 5 to 8 times a day (about every 2 to 3 hours).

A client has been diagnosed with diabetes and has received instructions about managing the disease. The client has undertaken an activity to improve quality of life and maintain functional status. The nurse recognizes this activity as

Walking at least one mile 5 days each week Explanation: Behaviors, such as exercise or walking, are essential to quality of life and maintaining functional status for a client who has a chronic illness. The other activities, such as ingesting low caloric foods, taking medications, and checking blood glucose level, relate to managing symptoms and avoiding complications.

A nurse would perform handwashing instead of using an alcohol-based product for which situation?

When hands are visibly soiled from client care Explanation: Handwashing would be done when the hands become visibly dirty or contaminated wtih biologic material from client care. Otherwise, an alcohol-based product could be used, for example, before putting on gloves for inserting a urinary catheter, after taking a client's temperature or blood pressure, or during client care when moving from a contaminated body site to clean body site.

A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check:

glycosylated hemoglobin level. Explanation: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

A client with a lengthy history of alcohol addiction is being seen for jaundice. The appearance of jaundice would most likely indicate:

liver disorder. Explanation: Jaundice is a sign of disease, but it is not itself a unique disease. Jaundice accompanies many diseases that directly or indirectly affect the liver and is probably the most common sign of a liver disorder.

The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:

usual pattern of elimination. Explanation: Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause