prep u Basic Care and Comfort
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?
"Can you describe the type of pain you are having?" Asking the client to describe the pain establishes quality. Asking the client to rate pain on a 1-10 scale reflects intensity. Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset. Reference: Chapter 35: Comfort and Pain Management - Page 1236
While reviewing a client's chart, the nurse notes the client has been experiencing enuresis. To assess whether this remains an ongoing problem for the client, the nurse asks which question?
"Do you urinate while sleeping? Enuresis is defined as involuntary voiding during sleep. The remaining questions do not relate to this problem associated with changes in the client's voiding pattern. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Table 53-3, p. 1556.
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?
"No, it can initiate premature uterine contractions." Castor oil can initiate premature uterine contractions and other adverse effects in pregnant women. Castor oil doesn't promote sodium retention and isn't known to increase absorption of fat-soluble vitamins.
A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss?
158.0 lbs (71.7 kg) Explanation: A loss of 0.5 kg, or 1.1 lb, represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to the loss of 2.2 lbs (1 kg), bringing the client's weight to 158.0 lbs (71.7 kg). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 13: Fluid and Electrolytes: Balance and Disturbance, p. 260. Chapter 13: Fluid and Electrolytes: Balance and Disturbance - Page 260
The nurse is caring for four clients. For which client is a sitz bath most appropriate?
51-year old with hemorrhoids Explanation: A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water. This removes blood, serum, stool, or urine. Therefore, the client with hemorrhoids would benefit from this type of cleansing treatment. The other clients do not get as much benefit from this type of bath. Reference: Chapter 31: Hygiene - Page 1000
The nurse explains to the client which statement is true regarding the difference between allopathic therapy and complementary and alternative therapy?
Allopathic therapy emphasizes treatments for diseases. Complementary and alternative therapy emphasizes treatments for health. Explanation: Allopathic therapy emphasizes treatments for diseases using traditional western medicine provided by an MD or DO. Examples of Allopathic therapy include pharmacotherapy, surgery, and radiology. Alternative medicine and complimentary medicine are terms that describes medical treatments that are used instead of traditional western therapies. Examples of complementary therapy include acupuncture, aromatherapy, homeopathy, and yoga. Alternative therapy includes acupuncture, homeopathy, and eastern oriental practices. Chapter 28: Complementary and Alternative Therapies - Page 797
A nurse is caring for a legally blind client. What would the nursing interventions can the nurse use to promote the client's control over the hospital environment?
Ask where to store the client's self-care items Explanation: Ask client's preference for where to store hygiene articles and other objects needed for self-care. Involving the client promotes in self-care, promotes control over the environment. Hinkle, J.L., and Cheever, K.H. (2014). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, p. 1849.
A 20-year-old male who is addicted to crystal methamphetamine has been admitted to hospital with a diagnosis of protein-calorie malnutrition after many months of inadequate food intake. Which treatment plan would the care team most likely favor?
Incrementally feeding combined with vitamin and mineral supplementation Explanation: Slow administration of protein and calories combined with mineral and vitamin supplementation is important in the treatment of protein-calorie malnutrition. Albumin transfusions and total parenteral feeding would likely not be necessary. Rapid administration of fluids and carbohydrates may precipitate congestive heart failure. Reference: Chapter 39: Alterations in Nutritional Status - Page 1020
What is the primary function of the larynx?
Producing sound Explanation: The larynx, or voice box, is a cartilaginous framework between the pharynx and trachea. Its primary function is to produce sound. While the larynx assists in protecting the lower airway, this is mainly the function of the epiglottis. Facilitating coughing is a secondary function of the larynx. Preventing infection is the main function of the tonsils and adenoids. Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 20: Assessment of Respiratory Function, p. 481.
Which is an inaccurate principle of traction?
Skeletal traction is interrupted to turn and reposition the client. Explanation: Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 40: Musculoskeletal Care Modalities, p. 1139-1140.
A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device?
The splint immobilizes the body part in a functional position." -Rationale Contoured splints are used for health issues to immobilize the area and support the body part in a functional position. Splints are easily removed and are not indicated for use in traction. The splint prevents, not permits, free range of motion of the body area. Remediation: Supportive And Protective Devices, Spine, Physical Therapy
Which of the following would be incorporated as a teaching strategy for a hearing-impaired person?
Use slow, directed, and deliberate speech - When teaching persons with a hearing impairment, the nurse should use slow, directed, and deliberate speech. Use of large print materials, arrangement of materials in a clockwise position would be used for persons with a visual impairment. Demonstrating information and having the person perform a return demonstration would be appropriate for a person with a developmental disability. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2017, Chapter 4: Gerontologic Considerations
Which would facilitate the swallowing reflex?
Using different textured foods Explanation: The swallowing reflex can be facilitated in a number of ways if swallowing (food or medication) is a problem. Icing the tongue by sucking on an ice pop or an ice cube blocks external nerve impulses and allows this more basic reflex to respond. Icing the sternal notch or the back of the neck, although not as appealing, has also proved effective in stimulating the swallowing reflex. In addition, keeping the head straight (not turned to one side) allows the muscle pairs to work together and helps the process. Providing stimulation of the receptors in the mouth through temperature variations and textured foods helps initiate the reflex.
A nurse is caring for a child who is grimacing but reports having no pain. What might be the rationale for a child being reluctant to express pain?
fearing getting a "shot" to relieve the pain Explanation: The nurse should be aware that some children may be reluctant to admit pain because they are trying to be brave. Some may be reluctant to say they have pain because they are afraid they will receive a "shot" to relieve it, which will cause more pain. Although children may not know how to express pain, it is still important to assess their pain level. Anxiety about pain may be high, but it does not prevent children from trying to express it. Chapter 36: Pain Management in Children - Page 1249
A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence?
functional Explanation: The nurse should document the client's condition as functional incontinence when the client is unable to retain urine for some time after getting an urge to void. Stress incontinence can result in the loss of small amounts of urine when intra-abdominal pressure rises. Urge incontinence is the need to void, perceived frequently with a short-lived ability to sustain control of flow. Total incontinence is the loss of urine without any identifiable pattern. Reference: Chapter 37: Urinary Elimination - Page 1361
A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?
stress Rationale: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control. Reference: Chapter 37: Urinary Elimination - Page 1356
A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:
Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. The unit transforms the data into a visual display, and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. -Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. -Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. -Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief. Reference: Chapter 35: Comfort and Pain Management - Page 1253
An older adult client who has a BMI of 28.1 and gastroesophageal reflux disease (GERD) reports heartburn frequently. The nurse plans to teach the client how to manage and prevent heartburn. What information will the nurse include in the teaching for this client? Select all that apply.
Do not use products that contain nicotine, such as tobacco and vaping devices. Maintain a diet that is low in fat. Plan a nutritious diet that will allow you to lose weight. Rationale: When teaching a client who has GERD, the nurse will include the following information: no smoking, a diet low in fat, and lose weight. Nicotine in tobacco and vaping products lower esophageal sphincter pressure, allowing reflux of stomach contents into the esophagus. Fat in the diet delays emptying of the stomach and increases the likelihood of reflux. Being overweight (a BMI greater than 25) increases intra-abdominal pressure, pushing gastric contents into the esophagus. The client is instructed to raise the head of the bed 30 to 40 degrees. This means placing the legs of the head of the bed on blocks. Using two pillows causes a bend in the neck. Pillows do not raise the level of the esophagus. The client is also instructed to avoid eating before bedtime. Again, eating before bedtime allows for reflux. Alcohol relaxes the lower esophageal sphincter pressure and increases the production of gastric acid. Both of these physiologic actions allow for reflux. Chapter 36: Nutrition - Page 1302
The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." How would the nurse document the type of pain experienced by this client?
Intractable Explanation: Malignant pain is acute pain episodes, persistent chronic pain, or both associated with a progressive malignant-type process. The etiology for malignant pain is resistant to cure, and the pain may be described as intractable. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 35: Comfort and Pain Management, p. 1237. Chapter 35: Comfort and Pain Management - Page 1237
A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?
the client's pain based on a pain rating Explanation: The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.