PrepU CH 6,7,9,10

During the woman's first prenatal visit to the clinic -Screening for pregnant mothers should be started at the initial prenatal visit and continued periodically and postnatally. The partner should not be present during screening.

A 36-year-old woman has been a client of a fertility clinic for 2 years and has now scheduled an appointment, believing that she is pregnant. The nurse who provides care at the clinic should screen the woman for intimate partner violence (IPV) at what time?

Hallucination -A hallucination is a subjective sensory perception without real external stimuli. The client can hear, see, smell, taste, or feel something that does not exist in reality. In this case, his sister has passed away and cannot be speaking to him, although in his mind he can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.

A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception?

be respectful of the client's culture -The most important aspect of cross-cultural communication is maintaining a sense of respect for the client. An interpreter might be required however this will not ensure that communication is culturally appropriate. Avoiding eye contact might be appropriate but it will depend upon the client's culture. Limiting interaction with the client communicates disinterest which does not support culturally appropriate care.

A client from a non-English speaking culture is experiencing a health problem. What should the nurse do to ensure that communication with this client is culturally appropriate?

6 -Chronic non-malignant pain usually is associated with a specific cause or injury and described as a constant pain that persists for more than 6 months.

A client is diagnosed with chronic non-malignant pain. The nurse understands that this client has experienced this pain for at least how many months?

It indicates immunosuppression resulting from undernourishment. -Since nearly everyone has been exposed to diseases such as tuberculosis, measles, or yeast infections, an absence of reaction to intradermal injection can indicate immunosuppression resulting from malnutrition. Absence of a reaction does not indicate a sacrifice of skeletal muscle and blood proteins or unhealthy dietary habits. Specific blood tests are available to evaluate cholesterol and triglyceride levels as well as various body proteins.

A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. Which of the following would the nurse need to keep in mind about malnutrition if the client has no reaction?

Ask the client if she was in pain when the labs were drawn. -The stress response causes the release of epinephrine, norepinephrine, and cortisol. These hormones have neuroendocrine and metabolic functions. They use stored energy to facilitate the healing of injured tissues. Some effects of these hormones include increases in oxygen consumption, levels of blood glucose and lactate, metabolism, and ketones. The client's elevated blood glucose level may likely be a result of a pain response. A prescription for insulin is not needed before a thorough assessment of the causes of increased blood glucose. A capillary stick can be performed; however the initial action is to talk to the client. Cold, clammy skin is a sign of decreased blood glucose levels, not increased.

A client recovering from a motor vehicle crash sustained right rib fractures and a fractured pelvis. The nurse is reviewing the client's metabolic panel lab results and notes a blood glucose of 130 mg/dL; the client has no history of diabetes. What is the nurse's best initial action?

Wong-Baker Faces -The nurse should use the Wong-Baker Faces Scale (FACES) to rate the pain felt by the client. FACES scales show different facial expressions, where the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best-suited for children and clients who are unable to communicate in the same language as the nurse. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10, where 0 reflects no pain and 10 reflects pain at its worst. The Visual Analog Scale (VAS) rates pain on a 10 cm continuum numbered from 0 to 10, where 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

A nurse assesses a non-English-speaking client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

I drink two large bottles of caffeinated beverages every day -Excessive intake of diuretic fluids, such as coffee or other caffeinated beverages, can lead to dehydration. The nurse needs to validate how much a large bottle contains and collect objective data to assess for findings of dehydration. Packing a lunch to control calorie intake is healthy as well as exercise. Eating small amounts of food more frequently is also a helpful way to control weight

A nurse collects nutritional information on a client. Which statement by the client needs validated by careful objective data?

Go into a private conference area and question the interpreter about the communication style and context of the client. -After the interview, the nurse and interpreter should walk out of sight of the client and, in a private area, discuss the communication style and context of the interview. The nurse should establish if the client made sense, if sentences were structured properly and completely, if the client had difficulty with self-expression, if the client was oriented to reality, and if the nurse should be aware of any cultural practices or beliefs.

A nurse has interviewed a client with a mental health disorder who does not speak English. The nurse enlists assistance from an interpreter. What is important for the nurse and interpreter to do after concluding the interview?

Objectivity when performing the assessment -The client is the focus of the spiritual assessment, and objectivity is the key to a high-quality spiritual assessment. The nurse and the client do not need to share a religious affiliation. Repetition of the assessment is not normally necessary, and interventions do not precede assessment.

A nurse is admitting a client to a long-term care facility. In order to elicit reliable and valid data during the spiritual assessment, the nurse understands that the focus must be on which of the following?

Sedation -Opioids and opiates cause sedation, nausea, constipation, and respiratory depression, which is the main side effect to watch for with narcotics. Opioids and opiates do not lead to anxiety, diarrhea, or insomnia in clients.

A nurse is caring for a client who was administered opioid narcotics. The client complains of constipation. Which of the following is another potential side effect of opioid narcotics?

"What prescribed and over-the-counter medicines do you take?" -When collecting dietary data for an older adult, it is important to gather information about prescribed and over-the-counter medications to assess for food-drug interactions and adverse effects of medications.

A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment?

Serum albumin of 2.6 g/dL -A serum albumin level of 2/6 g/dL is low, which may indicate moderate depletion and is a potential indicator of malnutrition. A hemoglobin level of 13.1 g/dL, a hematocrit of 40%, and a total protein level of 7 g/dL are within normal range.

A nurse is reviewing the laboratory test results of a client. Which result would alert the nurse to potential malnutrition?

The quality of rapport between the nurse and the client -Spiritual assessment is influenced by many variables, including the nurse's spirituality, the nurse's knowledge, and the setting of the assessment. However, the character of the therapeutic relationship between the nurse and the client is paramount.

A nurse recognizes the need to perform a spiritual assessment of a newly admitted hospital client, but the circumstances surrounding the client's diagnosis and family dynamics make this challenging. What variable is likely to have the greatest impact on enhancing the quality of data from the nurse's spiritual assessment?

cholesterol, activity level, blood pressure -

A patient has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply.

Visual Analog Scale

A popular pain assessment scale for children is:

Spiritual dimension -The spiritual dimension refers to the meaning and purpose that the person "attributes to the pain, self, others, and the divine." In this case, it seems that the man is interpreting his accident and subsequent pain as divine retribution for his past wrongdoings. The cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management." The sociocultural dimension concerns the influences of the patient's social context and cultural background on the patient's pain experience. The affective dimension concerns feelings, sentiments, and emotions related to the pain experience.

An elderly farmer has sustained severe injuries after a serious accident involving a combine harvester. At the hospital, he tells the nurse that he thinks the pain he is feeling now is "payback" for living a "mean, selfish life." The nurse recognizes that this response by the man indicates which dimension of pain?

Visual perceptual and constructional ability -Asking a client to draw the face of a clock tests the client's visual perceptual and constructional ability. Concentration is evaluated by noting the client's ability to focus and stay attentive. Orientation is tested by asking the client to state his or her name and the names of family members, time, day or season, and place. Thought processes and perceptions are evaluated by asking the client to say more about or verbalize his or her understanding of the current situation. Expressions and feelings are evaluated by asking the client how he or she is feeling and about plans for the future.

As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status?

"What do you do if you have pain?" -To assess judgment ability in a client, the nurse should ask the client what he or she does when in pain. Asking about the first job and the last hospitalization helps in assessing remote memory. Asking the client about the difference between an apple and an orange elicits abstract reasoning.

As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?

Readiness for enhanced spiritual well-being related to coping with prolonged physical pain -A health promotion diagnosis reflects a desire or willingness to do something that will enhance life. Thus, a readiness for enhanced spiritual well-being would be most appropriate. Risk for activity intolerance would be considered a risk diagnosis. Bathing self-care deficit and chronic pain would be actual nursing diagnoses.

Based on the analysis of assessment data from a client with pain, the nurse writes a health promotion diagnosis. Which of the following diagnoses would be most appropriate?

"Choose low-fat versions of milk products such as yogurt." -A healthy diet should include low-fat or fat-free milk, yogurt, and other milk products. Approximately one-half of grain intake should be whole grain. The client should be encouraged to go easy on fruit juices, opting instead for a variety of fruits including fresh, frozen, canned, or dried fruits. A client also should vary vegetable intake but eat more dark-green and orange vegetables.

During a nutritional assessment, a client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be appropriate?

Memory and attention -While gathering the health history, it is possible to quickly discern the client's level of alertness and orientation, mood, attention, and memory. As the history unfolds, the nurse will learn about the client's insight and judgment and any recurring or unusual thoughts or perceptions. Calculation, behaviour, and abstract thinking are less likely to emerge during this phase of assessment.

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess?

The biopsychosocial and spiritual wellness of the person. -The eudaimonistic model of health emphasizes the biopsychosocial and spiritual wellness of the person. The complementary and alternative medicine model emphasizes the use of non-conventional treatment to restore health. Gordon's functional health model proposes that people are healthy if they can fulfill their social roles. Roy's adaptation model proposes health is dependent on the person's ability to adapt, compensate, manage, and adjust in order to maintain, restore, and promote health.

The eudaimonistic model of health emphasizes:

False

The meaning of ethnicity is broader than the term culture.

The exam can provide clues about the validity of the client's responses now and throughout. -Assessing mental status at the very beginning of the head-to-toe examination provides clues regarding the validity of the subjective information provided by the client during the history and throughout the exam. Thus it is best to determine validity of client responses before completing the entire physical exam only to learn that the client's answers to questions may have been inaccurate. Assessing mental status first will not necessarily lessen a client's anxiety or fears about a serious illness. The exam can provide data about mental health problems. However, this is not the primary reason for performing the exam at the very beginning.

The nurse begins the physical examination of a client by assessing the client's mental status. The nurse does this primarily based on which rationale?

Walk out of sight of the client to discuss the interview -After the interview, the nurse and interpreter should walk out of sight of the client and, in a private area, discuss communication style and context. The nurse should not talk with the interpreter with the client present or discuss with a family member what they thought about sentence structure and expression. Doing nothing is an inappropriate action because it is important to understand the nuances of the client's responses to interview questions.

The nurse completes a mental health assessment of a client who speaks no English. An interpreter is used. To obtain information from the interpreter immediately following the interview, what should the nurse and the interpreter do?

Difficulty ambulating, Ill-fitting dentures, Confusion -Risk factors for malnutrition include; physical disability, ill-fitting dentures and mental impairment. Physical disability limits accessibility to food. Ill-fitting dentures can cause discomfort or even pain when the client is eating. The client may avoid eating certain kinds to food leading to malnutrition. Mental impairment, such as confusion, prevents effective decision making regarding nutritional choices or forgetfulness about consuming meals and fluids. Living at home with family and receiving a monthly pension are protective factors and serve to promote nutritional health.

The nurse conducts an assessment of an older adult. Which of the following findings indicates the client is at risk for malnutrition?

Have the client complete a danger assessment. -If a client says that she prefers to return home, ask her if it is safe for her do so and have her complete a danger assessment tool. After doing so, the nurse would then help her devise a safety plan, including having a bag packed and giving her contact information for shelters and groups. The client would be urged to tell neighbors about the abuse and ask them to call the police if they hear a disturbance. This would not be something the nurse would do.

The nurse is assisting a female client who has been physically abused about a safety plan. The client prefers to return home. Which of the following would the nurse need to do first?

Lack of appetite, Disruption of family functioning, Depressive symptoms -Consequences of pain in children include decreased levels of usual activities such as play, lack of appetite and sleep, depression, and disruption of family functioning.

The nurse is caring for a child with pain. Which is a consequence of pain in children? Select all that apply.

Vocalization -Moaning is a vocalization pain indicator; other examples include groaning, gasping, and screaming. Verbalization would include the expression specific words, such as counting, praying, and swearing. Emotional pain indicators include excessive sleeping, anxiety, fear, and depression. Behavioral pain indicators include massaging, guarding, and immobilizing body parts.

The nurse is caring for a patient following an open reduction, internal fixation of the right hip. The nurse observes the patient moans when being repositioned. What type of pain indicator is moaning?

The cause of acute pain can be identified. -Acute pain is of short duration and has an identifiable cause. Chronic pain lasts beyond the normal healing period of 3 to 6 months. Neuropathic pain results from damage to nerves in the peripheral or central nervous system.

The nurse is explaining the difference between acute pain and chronic pain to the patient. Which should the nurse include in the explanation?

repeat the procedure three times and average the measurements. -To measure triceps skin fold thickness (TSF), instruct the client to stand and hang the nondominant arm freely. Grasp the skin fold and subcutaneous fat between the thumb and forefinger midway between the acromion process and the tip of the elbow. Pull the skin away from the muscle (ask client to flex arm: if you feel a contraction with this maneuver, you still have the muscle) and apply the calipers. Repeat three times and average the three measurements.

The nurse is preparing to measure the triceps skinfold of an adult client. The nurse should

Ranges from no pain to worst possible pain -The Verbal Descriptor Scale rates pain from no pain up to the worst possible pain with mile, moderate, severe, and very severe in between the two end-points. The Faces Pain Scale uses facial expressions to rate pain. A numeric pain intensity scale rates pain using a 0 to 10 number scale. A visual analog scale rates pain along a 10 cm line from no pain to pain as bad as it could possibly be.

The nurse is using the Verbal Descriptor Scale to assess a client's pain. This scale rates pain using which of the following?

Gamma-aminobutyric acid

When reviewing a client's medication administration record, the nurse should plan to administer a medication containing which substance that blocks pain sensations?

Abstract reasoning. -Abstract reasoning is the ability to compare objects. For example, "How are an apple and orange the same? How are they different?" Also, asking to explain a proverb. For example, "A rolling stone gathers no moss" or "A stitch in time saves nine."

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Dopamine -The stress response causes the release of epinephrine, norepinephrine, and cortisol.

Which of the following is not released during the stress response?

Perspiration, Sleeplessness & Increased heart rate -Sleeplessness, perspiration, and increased heart rate are physiologic responses to pain. Pain elicits a stress response in the human body triggering the sympathetic nervous system. Decreased, not increased, intestinal motility and insulin are physiologic responses to pain.

Which of these clinical manifestations are physiologic responses to pain? Select all that apply.