Basic Care and Comfort

Nutritional recommendations for patient with Crohn's disease

low fiber, low residue - tender, ground well cooked meats - eggs, - fish - poultry -refined pasta and cereal - white rice and bread - canned or cooked veggies without skin or seeds - juices without pulp

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation? Select one: a. When the client has the urge to defecate. b. When the client feels abdominal cramping. c. Every hour while awake. d. Immediately before meals.

A. When the client has the urge to defecate

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client? Select one: a. Avoid inadvertently advancing the catheter into the bladder. b. Assess the client's knowledge of importance of perineal hygiene. c. Examine condition of catheter and drainage tubing. d. Assess for perineal pain or discomfort.

A. avoid inadvertently advancing the catheter into the bladder

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? Select one: a. This is a possible infection or irritation in the genital area b. Awareness of body structures and sensations is normal and expected c. Your child is probably imitating behaviors that she has observed d. This is an early emergence of sexual expression that should be discouraged

B. Awareness of body structures and sensations is normal and expected

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? Select one: a. Baked potato b. Broccoli with cheese sauce c. Wheat bread d. Chicken breast

B. Broccoli with cheese sauce *Cholecystitis: inflammation of the gallbladder

A nurse is educating a client on restful sleep. Which of the following statements by the client would alert the nurse that further teaching is necessary? Select one: a. "I don't take naps during the day." b. "I watch television until I fall asleep." c. "I go to bed and get up at the same time each day." d. "I drink some hot milk and take a bath before going to bed."

B. I watch tv until I fall asleep

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? Select one: a. The baby develops swelling or redness at the injection site b. The baby is crying inconsolably for more than three hours c. The baby develops a localized or generalized rash d. The baby has an axillary temperature of 100.4o F. (38o C)

B. The baby is crying inconsolably for more than three hours

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I should not remove the yellow exudate on the end of the penis." b. "I will clean his penis with each diaper change." c. "I can give him a tub bath in two days." d. "The circumcision will heal completely within a couple of weeks."

C. I can give him a tub bath in two days

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? Select one: a. "I should increase my fluid intake to 8-10 glasses of water a day." b. "I should increase my consumption of protein." c. "I should limit my sodium intake to 4 grams per day." d. "I should consume a diet low in carbohydrates."

C. I should limit my sodium intake to 4 grams per day

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner will put the condom on while his penis is erect." b. "My partner should leave an empty space at the tip." c. "I will remove the condom 30 minutes after intercourse." d. "I can use spermicidal gels or creams to increase effectiveness."

C. I will remove the condom 30 minutes after intercourse

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following? Select one: a. Finish a project they set out to do. b. Develop their sense of trust. c. Increase their independence. d. Gratify their oral fixation.

C. Increase their independence

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education? Select one: a. Measuring and assessing the stoma. b. Positioning the client standing or supine. c. Changing the pouch before a meal. d. Cleansing the peristomal skin with alcohol.

D. Cleansing the peristomal skin with alcohol

A nurse is caring for a client in Buck's Traction. Which of the following nursing interventions would ensure effective therapy? Select all that apply. Select one or more: a. Prevent wrinkling of the traction bandage. b. Assist the client to roll from side to side. c. Ensure that all weights are free hanging. d. Support the leg in adduction. e. Maintain countertraction with weights.

a. c

An older adult client with a history of heart failure is admitted to the hospital with a diagnosis of digoxin toxicity. Which of the following assessment findings should the nurse expect? Select all at apply. a. Digoxin level 1.5 ng/ml b. constipation c. increased appetite d. yellow vision e. heart rate of 52 bpm

a. d. e.

A nurse is caring for a client hospitalized with Guillain-Barré Syndrome who has been in the intensive care unit on a ventilator for four days. Which of the following would be most appropriate in assessing for complications of immobility? Select all that apply. a. assess the character bowel sounds and frequency of stools b. assessing the client's ability to move lower extremities c. Observe skin color over sacral, heels, and scapulae areas. d. performing range of motion on the client's ankles, knees, and hips e. assess rate and depth of respiratory effort.

a. c. d

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? Select one: a. Decreased urine output b. Abdominal distension c. Difficulty evacuating bowels d. Mild diarrhea

a. Decreased urine output

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching? Select one: a. Grilled chicken salad with fresh salsa b. Vegetarian wrap with chips c. French onion soup and salad d. Chicken bouillon and crackers

a. Grilled chicken salad with fresh salsa Grilled chicken salad and fresh salsa are both made from fresh (preservative-free) materials and therefore are likely to be of lower sodium content than French onion soup, chips, chicken bouillon, or crackers.

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid? Select one: a. Pork chop and brown rice. b. Broiled liver and white rice. c. Grilled salmon and cooked apricots. d. Roast chicken and cooked spinach.

a. Pork chop and brown rice

Which of the following client care assignments is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select all that apply. a. Apply a dressing to a superficial laceration on the client's arm. b. Assist a client with a new transurethral prostectomy with perineal care. c. obtain vital signs every 4 hours for a client with ulcerative colitis d. transport a client who is utilizing oxygen and has a peripheral IV catheter e. Provide initial food by mouth for a client who has experienced a brain attack

b. c. d.

A client with an ileostomy calls the clinic reporting stomal swelling along with decreased drainage of ileostomy contents. The nurse instructs the client to do which of the following? Select all that apply. a. ensure the pouch is attached correctly b. apply moist towels to the abdomen c. Lie down in a supine position d. drink hot tea e. begin abdominal massage

b. d. e.

A nurse is caring for a client who is neutropenic. Which of the following foods are appropriate for this client? Select one: a. Lettuce and alfalfa sprouts b. Cooked spinach and celery c. Fresh strawberries and carrots d. Raw cauliflower or broccoli

b. cooked spinach and celery . Raw or fresh foods contain bacteria that are generally well-tolerated by a person who has a healthy immune system. The client with leukemia is immunosuppressed has decreased resistance to infection; therefore, raw food should not be served because it could be a potential source of infection.

A nurse is managing client care. Which of the following should be implemented when prioritizing care? Select all that apply. Select one or more: a. Take on a task when inspired. b. Respond to needs as soon as they arise. c. Postpone items that do not have immediate deadlines. d. prepare a written list e. avoid delegation of difficult tasks

c. d.

A nurse is assisting a client with an advance directive. Which of the following nursing responsibilities should be included regarding advance directives? Select all that apply. a. Ensure that each family member receives a copy of the advance directive b. inform all members of the client's family of the client's wishes c. Confirm that the advance directive is current d. Provide written information to the client about advance directives e. Document the client's advance directive in the medical chart

c. d. e.

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "When did your contractions begin?" b. "Have you felt fetal movement over the last 24 hours?" c. "Have you noticed any bloody show or fluid coming from your vagina?" d. "What happens to your contractions when you move about?"

c. Have you noticed any bloody show or fluid coming from your vagina

A nurse is caring for a client who is one month post bariatric surgery and has been diagnosed with dumping syndrome. Which of the following recommendations is appropriate? Select all that apply. a. Eliminate liquids with meals, and for one hour before and after meals. b. Reduce the amount of protein and fat in the diet. c. Eat small, frequent meals during the day d. Sit up for at least an hour after each meal e. Avoid consuming milk, sweets, and sugars

c. eat small, frequent meals during e. avoid consuming milk, sweets, and sugars a. eliminate liquids with meals, and for one hour before and after meals

A nurse is calculating the client's intake and output. Based on the information below, which of the following values correctly represents the client's total output? Sipped 8 oz. clear broth. 100 mL ice chips. Voided 450 mL. IV push pain medication 50 mL. Drank 4 oz. juice and 6 oz. hot tea. Vomited 120 mL and voided 600 mL. Jackson Pratt drain emptied 40 mL. Select one: a. 680 mL b. 1068 mL c. 590 mL d. 1210 mL

d. 1210 mL

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "I will tighten my pelvic muscles when coughing." b. "I will avoid standing for prolonged periods of time." c. "I will increase my daily fluid intake." d. "I will increase my fiber intake to stay regular."

d. I will increase my fiber intake to stay regular

A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice? Select one: a. Spinach b. Eggs c. Tuna d. Rabbit

d. rabbit

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status? Select one: a. "We increase her protein intake when she's playing sports." b. "She eats a large breakfast every morning." c. "She enjoys helping to prepare her snacks in the kitchen." d. "We allow her to pick out a treat at the grocery store for good behavior."

d. we allow her to pick out a treat at the grocery store for good behavior

Nutrition restrictions for clients with Crohn's disease

raw veggies, dried fruits, rice/cereal/pasta, whole wheat/bran/oats/flax/buckwheat