UWorld Care & Comfort Part 2

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? 1. Ask about the client's recent bowel and bladder habits 2. Assess the home for sources of excessive noise 3. Provide info about respite and adult day care 4. Review behavior-management techniques with caregiver

1 Behavioral changes often result from the client's ability to identify a stressor. Stressors may include pain or problems with elimination or eating. The nurse's priority must be identifying and solving problems r/t client's basic physiological needs according to Maslow's hierarchy. Notes about 2: Environmental stressors should be addressed after intervening to meet the client's basic needs. Notes about 3: Caregiver support should be addressed after addressing client's needs via providing info about community support groups, respite care, and adult day care to help reduce caregiver fatigue. Notes about 4: Nurse should use behavioral management techniques (reassurance, distraction, redirection, etc.) to assist with deescalation AFTER assessing for and addressing sources of agitation first.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing CPR. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs." 2. "His heart has stopped and we are attempting to revive him." 3. "I don't know how he is doing but you need to come." 4. "I will have the HCP talk to you once you arrive."

1 Beneficence is the ethical principle of doing good. It involves helping to meet the client's emotional needs through understanding. This can involve withholding information at times. This answer meets the principle of veracity but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely. Notes about 4: It does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the HCP will tell the family members about the client's prognosis.

The nurse is reinforcing proper insulin self-admin technique to client of Native heritage. As the nurse describes necessary steps in injection process, client avoid eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue instructing the client and verify understanding by return demonstration 2. Discuss how important it is for the client to pay attention during the teaching 3. Maintain eye contact during the instruction by following the client's movements 4. Provide written instructions and a private place for the client to learn independently

1 Natives and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing nurse to maintain eye contact.

A 55yo client on the med-surg unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent that from happening." 3. "Well, we're all going to die sometime." 4. "You should concentrate on getting better rather than thinking about death."

1 The client is most likely not looking for a direct yes or no answer. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings. Provide empathy by acknowledging the distressing nature of the diagnosis. Provide situations via broad opening for discussions, etc. in which the client can share thoughts and feelings in a safe environment. Actively listen by being very attentive to what the client is thinking and feeling. Focus going beyond the words and explanations to attain new awareness of a client's concerns. Communicate effectively to assist the client in coping with difficult situations, reduce stress, and develop approaches for making necessary life changes.

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? SATA. 1. Apply moisture barrier cream to dry skin 2. Clean perineal area after incontinent episodes 3. Massage bony prominences frequently 4. Place foam-padded seat cushions on chairs 5. Reposition clients in bed every 6 hours

1, 2, 4 Notes about 3: Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin.

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? SATA. 1. Dimming the lights at night 2. Leaving the television on for diversion at night 3. Opening the window blinds/shades in the morning 4. Scheduling interventions and activities during the day when possible 5. Turning off equipment alarms in the client's room at night

1, 3, 4 Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, allowing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the window shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium.

The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? SATA. 1. 22 yo man with a head injury sustained during a college football game. 2. 30 yo woman recently hospitalized for reconstructve augmentation mammoplasty. 3. 56 yo man 2 weeks post MI 4. 68 yo woman recently diagnosed with pancreatic cancer 5. 74yo man with portal HTN and related to alcohol induced cirrhosis 6. 82yo woman 1 week post cataract surgery

1, 3, 5, 6 The valsalva maneuver means straining during defecation, involving holding the breath while bearing down on the perineum to pass stool. This is to be avoiding in clients recently diagnosed with ICP, stroke, or head injury as straining increase intra-abd and intrathoracic pressure, which raises the ICP. 3: The vagus nerve is stimulated when bearing down, which temporarily slows the heart and decrease CO, leading to potential cardiac complications in clients with heart disease. 5: Straining increases intra-abd and intrathoracic pressure and should be avoided in clients diagnosed with portal HTN r/t cirrhosis d/t risk of variceal bleeding. 6: Intraocular pressure is increased with this maneuver, which is why it's contraindicated in clients with glaucoma and recent eye surgery. - Notes about 2 and 4: Otherwise healthy clients with these diagnosis or recovery is not at risk for complications r/t Valsalva.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action. 1. Ask the client to explain the bruises on the torso. 2. Assess the client's general hygiene and nutritional status. 3. Report the bruises to the client's HCP 4. Talk to the client's child about the injuries

2 The client's explanation is consistent in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso. In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurses's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. Thus, the nurse will assess the client for general hygiene, clothing, nutritional status, hydration status, presence of other injuries, inappropriate med admin, signs of depression, and other statements by the client suggesting neglect. The nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship.

Which client is the greatest risk for development of hospital-acquired pressure injuries? 1. 25yo client with quadriplegia, urosepsis, temp of 101*F, WBC of 18,000 2. 50yo client with AIDS who is receiving norepinephrine infusion, weight loss of 20lb in a month, prealbumin level of less than 10, and MAP of 50 3. 80yo 2 days post hip replacement w/dementia, 2 Jackson-pratt drains, and hgb of 14 4. 87yo 2 days post op open cholecystectomy

2 This client has 5 risk factors: (1) Chronic, immune deficient disease (2) Significant weight loss (3) Prealbumin less than 16 indicating inadequate nutrition and protein deficiency (4) Hypotension that decreases perfusion pressure (5) Receiving norepinephrine that vasoconstricts--affecting circulation, capillary perfusion pressure, and ability to provide adequate nutrition to cells. Notes about 1: Client has 4 risk factors--(1) Deficit in independent mobility and activity (2) Spinal cord injury with quadriplegia (3) Decreased sensation (4) Fever and infection Notes about 3: Client has 3 risk factors--(1) Advanced age (2) Surgery (3) Dementia *Note: Hgb is in normal range* Notes about 4: Client as 2 risk factors--(1) Advanced age (2) Surgery *assoc w/deep-tissue injuries due to positioning and immobility during surgical procedures, receiving anesthetic, and vasoactive drugs for hypotension

The LPN is assisting the RN in creating a care plan for a client who is intubated, on mechanical ventialtion, and receiving continuous enteral tube feedings via a small bore NG tube. Which interventions should be included to prevent aspiration in this client? SATA. 1. Check gastric residual q12h 2. Keep HOB elevated at about 30-degrees 3. Maintain endotracheal cuff pressure 4. Monitor for abd distension q14h 5. Use caution when administering sedatives

2, 3, 4, 5 Nursing interventions to reduce aspiration risk includes: Assessing GI intolerance to feedings by monitoring gastric residual and assessing for abd distention, pain, BM, and flatus q4h Assessing tube placement at regular intervals Keep HOB at 30-45* to reduce reflux and aspiration risk Keep endotracheal cuff inflated at about 25cm H2O for intubated clients as low cuff pressure increases risk for aspirating oropharyngeal secretions and/or gastric contents Suction any secretions that collected above endotracheal tube before deflating the cuff, if deflation is necessary Monitor for oversedation when giving sedatives, since it slows gastric emptying and reduces gag reflex Avoid bolus feedings

A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? SATA. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting

2, 4, 5 Incisions may take 4-6 weeks to heal. Wash the incisions daily with soap and water in the shower then pat dry. Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to local nerves. Avoid tub baths due to risk of infection. Do not apply powders or lotions on incisions as these trap bacteria at the site. Report any redness, swelling, drainage increase, or if the incision has opened. Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling.

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence brief to protect the skin

3 Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory fxn (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, UTI, spread of infectio--such as C.diff--and contamination of wounds. Maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick layer of moisture barrier product to the skin.

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies. 1. Blisters with a garlic scent near the wrist 2. Circular bruised blemishes on the back 3. Markings appearing to be human bites on the arms 4. Welt-like linear lesions on the back

3 Notes about 1: Garlic application involves placing crushed garlic directly on the skin. It is thought to heal infections but can cause contact dermatitis and burns on the wrists. Notes about 2: Cupping is used by many cultures to remove illness from the body, where mouth of a steam-filled cup is placed on the skin, causing circular, bruised blemishes. Notes about 4: Coining is believed by some cultures--such as Chinese and Vietnamese--to remove illness from the body. A rounded surface such as coin and spoon is firmly stroked on the lubricated skin of the back and can produce wetlike linear lesions.

The nurse is conducting a home visit to assess an elderly client with advanced HF who lives alone. When the nurse asks about Na intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat when I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing." 2. "I know you are frustrated with losing control of your life." 3. "It sounds like you are angry. Tell me what's bothering you." 4. "Okay. I'll just check your blood pressure and then go."

3 The nurse's statement reflects the nurse's perception of the client's emotion and will allow the client to clarify feelings. The open-ended probing statement facilitates assessment of the client's concerns without making any assumptions about them. This promotes accurate assessment of the client's needs and concerns while preventing premature closure, incorrect assumptions, and escalation of the client's anger. Notes about 1: Further assessment is indicated if the client is willing to talk since the client's angry response likely indicates an unmet need. Notes about 2: The nurse is making an assumption of the client's source of frustration, which may cause the nurse to draw inaccurate conclusions about the client's concerns and contribute to further escalation of anger. Notes about 4: This response could diffuse the situation, but further assessment of the client's concern is more important. Also, if the client remains angry and the nurse attempts to take BP after being told to leave, the client may become angrier and put their safety at risk.

A client is experiencing an exacerbation of chronic lower back pain after working in the yard all weekend. The nurse should reinforce the primary importance of which nonpharmacologic intervention for acute muscle pain? 1. Heating pad 2. Positioning for comfort 3. Rest from pain-aggravating activities 4. Stretching exercises

4 Acute exacerbation of chronic back pain is associated with inflammation triggered by strenuous/repetitive activities that stress the previously injured area. Interventions should be directed towards reducing inflammation. Postponing/avoiding pain-aggravating activities will keep from promoting inflammation and delaying healing. Notes about 1: Applying heat can promote the inflammatory process via vasodilation. However, once the inflammation has resolved in a few days, heat application would be appropriate to reduce pain and muscle spasms. Notes about 2: Positioning for comfort will reduce pain but less likely to impact the inflammatory process causing the pain. Notes about 3: Stretching should begin after the acute pain and inflammation has subsided.

The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a BM in 3 days. Which action by the nurse would be the most appropriate? 1. Administer the prescribed PRN MOM 2. Ask dietary services to add more fruits and veggies to the clients tray 3. Notify the RN 4. Perform a focused abd assessment

4 Constipation may develop as SE of anesthesia, pain meds, physiological stress, and/or immobility. The nurse's first priority is to assess the client to determine the cause of this client's constipation. The nurse can administer the PRN laxative once it has been determined to be safe. The RN should be consulted if the focused abd assessment indicates a potential complication, such as postop ileus. Notes about 1: Laxative would not help if this client had intestinal obstruction (from adhesions). Notes about 2: The nurse would not change the diet under further assessment of the client is accomplished and the HCP has prescribed a new diet. Notes about 3: Nurse should complete a focused abd assessment before notifying the RN.

It is 0700 and the nurse is caring for an 84yo client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV q2h PRN for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture but the consent has not been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first. 1. Administer pain meds 2. Call the HCP to meet with the family to obtain informed consent 3. Complete the preop checklist 4. Perform the morning assessment

4 Morning shift assessment should be completed first to collect baseline assessment data--VS, lung sounds, LOC, etc--assess pain, and collect necessary info for the pre-op checklist. Notes about 1: Pain meds are not due until 0730 and can be administered after initial assessment if necessary Notes about 2: Nurse should call the HCP after initial assessment and arrange for meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it.

An elderly client with ERSD who has refused dialysis is admitted to a long-term care facility for rehab following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent. 2. The client is becoming delirious and should be assessed for infection. 3. The client is concerned that someone might steal possessions. 4. The client wants to take care of business before imminent death.

4 Notes about 2: Clients w/ERSD are at risk for delirium due to buildup of toxins, which may manifest as agitation and statements about needing to go somewhere. However, the nurse should not automatically assume that the client is delirious. Instead, it is important to assess the client's concern with an open mind so that appropriate interventions can be planned.

The nurse is preparing to irrigate the ears of a 67yo client with impacted cerumen. Place steps in order. 1. Straighten the ear canal by pulling the pinna up and back. 2. Place a towel and an emesis basin under the ear 3. Gently irrigate the ear canal with a slower, steady flow of solution 4. Assess the client for fever, ear infection, or tympanic membrane injury 5. Place the client in a sitting position with the head tilted toward the affected ear

4, 5, 2, 1, 3 Repeat as tolerated until ear canal is clear or prescribed amount is instilled. Document type, temp, volume of solution--along with exudate characteristics, response to irrigation, and client teaching. Notes about 4: Use otoscope to inspect external ear canal and verify tympanic membrane is intact with no foreign bodies Notes about 1: For a child 3yo and under, pull pinna down then back Notes about 3: Ensure the irrigation solution is at body temp and irrigate with a slow, steady flow of solution while directing the syringe tip towards the top of the ear canal. Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if client experiences severe pain, nausea, or dizziness.