Client Needs: Basic Care and Comfort

A nurse is educating a group of teenage girls about dietary sources of iron. Which statement by one of the teenagers indicates to the nurse the need for more instruction? "Fish is a good source of iron." "We need 8 mg of iron each day." "We need more iron during pregnancy." "Iron can be taken with 6 oz of orange juice."

"We need 8 mg of iron each day." Adolescents need 18 mg, not 8 mg, of iron per day. Excellent sources of iron that can be absorbed by the body include meat, poultry, and fish. Iron requirements increase during pregnancy and lactation, and iron supplementation may be needed. Juices and fruits high in vitamin C, taken with foods that contain iron, promote iron absorption.

A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, the nurse should encourage the client to: Assume a standing position for voiding Void every four hours and attempt to hold urine between set times Attempt to void more frequently in the afternoon than in the morning Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake

Assume a standing position for voiding Assuming a standing position for voiding reduces tension (physical and psychological), facilitates the movement of urine into the lower portion of the bladder, and relaxes the external sphincter (increasing pressure and initiating the micturition reflex). Bladder training should be instituted by encouraging voiding every one to two hours and progressively increasing the time between attempts. Voiding should be encouraged at regular and frequent intervals during waking hours, not just in the afternoon. Four liters is a large fluid intake and is unnecessary; it will result in a large volume of urine, probably increasing the frequency of incontinence.

A nurse is assessing a client with the diagnosis of hemorrhoids. Which factors in the client's history probably played a role in the development of the client's hemorrhoids? Select all that apply. Constipation Hypertension Eating spicy foods Bowel incontinence Numerous pregnancies

Constipation Numerous pregnancies Straining at stool increases intraabdominal, systemic, and portal venous pressures that promote the development of hemorrhoids. The enlarging uterus puts pressure on the inferior vena cava that leads to increased portal venous pressure, causing anorectal varicosities. Hypertension does not contribute to the development of hemorrhoids. Spicy foods may irritate hemorrhoids but do not cause them. Bowel incontinence is unrelated to the development of hemorrhoids.

The nurse is caring for a client who is wearing a prosthesis after a single-leg amputation. Which crutch gait should the nurse teach the client to use? Tripod Four-point Three-point Swing-through

Four-point A four-point gait provides for weight-bearing on all points that touch the floor and maximum support during ambulation. A tripod is for clients learning to do a swing to gait pattern. A three-point gait is used when one extremity cannot bear weight. A swing-through gait does not simulate ambulation; it is used when the individual can bear weight but lacks the muscular control needed for ambulation without an assistive device.

A 16-year-old adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the practitioner. What must the nurse ensure when adjusting the crutches? That they reach to 1 inch below the axillae That they extend to 6 inches from the side of each foot That the elbows are extended when the crutches are held by the crossbars That the shoulders are slightly stooped when the crutches are bearing body weight

That they extend to 6 inches from the side of each foot Having the crutches extend to 6 inches from the sides of the feet ensures the maximal base of support when the adolescent ambulates. Having the crutches reach to 1 inch below the axillae may cause trauma to the brachial plexus; the crutches should be 2 inches below the axillae. The elbows should be flexed, not extended, when the client holds the crossbars. Hunched shoulders indicate that the crutches are too short, which could result in trauma to the brachial plexus.

A toddler undergoes the implantation of a low-profile (skin-level) device (button) for a gastrostomy. The gastrostomy is now healed, and the parents are being taught to care for the stoma. What parental behavior indicates to the nurse that additional teaching is needed? A parent is cleaning the stoma with soapy water. Gastric contents are aspirated before the start of a feeding. A parent inserts an adapter into the button to initiate a feeding. The button is being maintained in the same position within the stoma.

The button is being maintained in the same position within the stoma. Further teaching is necessary because the button should be rotated to prevent adherence to the skin. The stoma and the skin around the button should be kept clean and free of drainage. As with other gastrostomy tube feedings, use of a gastrostomy button requires patency to be determined; residual gastric fluid should be present. Extension tubing should be inserted into the device for feedings.

A client who is 28 weeks into her second pregnancy is experiencing increasing edema in the lower extremities. The nurse advises rest with the legs elevated and provides dietary instructions. What other advice should the nurse provide? The preferred diet will include favorite foods. A nutritionist should be involved in planning a diet. The selected foods do not need to have a low salt content. The client should consult the health care provider at the prenatal clinic.

The selected foods do not need to have a low salt content. Dependent edema is common during the last trimester; there is no need to lower the salt content of the client's diet. Teaching should be based on optimal nutrition, as well as the caloric content of the diet. Not all preferences can be included; the diet should include a normal sodium and high protein intake and sufficient calories. Immediate planning based on the nurse's knowledge of dietary needs is sufficient. Unless there is reason to believe that a need for medical intervention exists, the nurse may discuss care related to human responses.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. Prayer Hypnosis Medication Aromatherapy Guided imagery

Prayer Hypnosis Aromatherapy Guided imagery Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

The nurse is providing dietary teaching to a 40-year-old client who is receiving hemodialysis. The nurse should encourage the client to include what in the client's dietary plan? Rice Potatoes Canned salmon Barbecued beef

Rice Foods high in carbohydrates and low in protein, sodium, and potassium are encouraged for these clients. Potatoes are high in potassium, which is restricted. Canned salmon is high in protein and sodium, which usually are restricted. Barbecued beef is high in protein, sodium, and potassium, which usually are restricted.

A client that is a heavy smoker has been prescribed a high-calorie, high-protein diet. The nurse should encourage the client to eat foods that are high in: Niacin Thiamine Vitamin C Vitamin B12

Vitamin C Smoking accelerates oxidation of tissue vitamin C. As a result, smokers need an additional 35 mg/day. Niacin is not oxidized more rapidly in the smoker. Thiamine is not oxidized more rapidly in the smoker. Vitamin B12 is not oxidized more rapidly in the smoker.

A nurse in the pediatric clinic is reviewing the health history of a 6-year-old child with celiac disease who has been on the dietary regimen for 6 months. What evaluation criterion does the nurse use to assess the child's adherence to the diet? Formed bowel movements Ability to handle stressful situations Understanding of the disease process Knowledge of foods allowed on the diet

Formed bowel movements Steatorrhea - the excretion of abnormal quantities of fat with the feces owing to reduced absorption of fat by the intestine. Steatorrhea disappears, replaced by formed bowel movements, when the child adheres to the diet. The ability or inability to cope with stressful situations is not a cause of celiac disease; it is caused by a toxic reaction to gluten. Even when the child understands the disease process, adherence to the diet may be relaxed; as a result of this relaxation, signs and symptoms may recur. Although it is important to assess what the child knows about the diet, knowledge does not guarantee that the child will select the foods on the diet.

The nurse provides teaching to a client who will begin to receive tube feedings after a total laryngectomy. The nurse concludes that the teaching was understood when the client states, "I will need tube feedings until: Healing of the incision is complete." The gag reflex returns." The ability to belch is restored." My oral feedings can be digested."

Healing of the incision is complete." Food should be avoided until the area is healed completely; this will keep the area from becoming irritated and contaminated. Because of the alterations in structure, the gag reflex is no longer present. The ability to belch has no bearing on the decision to resume oral feedings. The ability to tolerate oral feedings is not lost; such feedings are withheld to prevent irritation to the surgical site until healing has taken place.

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply. Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse Brown skin discoloration

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse Prolonged lack of oxygen to hair follicles results in hair loss. Prolonged lack of oxygen to the toes results in yellow, thickened toenails. Arterial ulcers are painful because of the interruption of blood supply to peripheral tissues. Inadequate arterial perfusion results in diminished volume of blood flow to the lower extremities. Brown skin discoloration is characteristic of venous ulcers; red blood cells break down and release ferrous sulfate into the interstitial compartment.

A school-aged child with Kawasaki disease is in pain caused by the desquamating rash. What does the primary nurse identify as is the best short-term goal for this child? The rash will diminish after lotion is applied. Analgesics will be administered as prescribed. Pain will be maintained at a level of 3 on a 0-to-10 scale. Diversional activities will help distract the child from the discomfort.

Pain will be maintained at a level of 3 on a 0-to-10 scale. Maintaining pain at a level below 3 on a 0-to-10 scale is client centered, specific, and measurable and has a time frame ("maintained" implies "at all times"). Diminution of the rash after lotion is applied is not a specific or measurable goal. Administration of an analgesic as prescribed is a nursing goal, not a client-centered goal. Diversional activities represent a combination of an intervention and a potential outcome; the outcome is not specific or measurable and does not have a proposed time frame.

A strict vegetarian (vegan) becomes pregnant and asks the nurse whether there is anything special she should do in regard to her diet during pregnancy. What is most the important measure for the nurse to instruct the client to take? Eat at least 40 g/day of protein. Drink at least 1 quart/day of milk. Take a vitamin supplemented with iron every day. Plan to eat from specific groups of vegetable proteins each day.

Plan to eat from specific groups of vegetable proteins each day. A variety of incomplete proteins (vegetable proteins) can be combined to provide all of the essential amino acids. The pregnant client should eat at least 60 g/day of protein. Vegans do not drink milk. Taking a vitamin supplemented with iron each day is not the most important factor in diet planning; other nutrients also must be provided.

A client at 10 weeks' gestation complains of frequent urination. Before explaining this phenomenon to the client in language that she will understand, the nurse remembers that: Glomerular filtration rate and renal plasma flow increase early in pregnancy. The walls of the ureters undergo muscle tone relaxation during the first trimester. Softening and compressibility of the lower uterine segment results in uterine anteflexion. The uterus is taking on a globular shape as the uterine walls strengthen and become elastic.

Softening and compressibility of the lower uterine segment results in uterine anteflexion. Uterine anteflexion allows the uterine fundus to press on the urinary bladder, causing urinary frequency. Increased glomerular filtration rate and renal plasma flow changes do not produce urinary frequency; nor does muscle tone relaxation. The uterus does not become globular until the second trimester.

A client with a cervical injury reports a severe headache and nasal congestion. The nurse should assess for: Suprapubic distention. Increased spinal reflexes. Adventitious breath sounds. Imminent development of shock.

Suprapubic distention. Autonomic Dysreflexia - a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above). Suprapubic distention is a symptom of autonomic dysreflexia, which commonly is precipitated by a distended bladder. Increased spinal reflexes and adventitious breath sounds are not associated with the symptoms of autonomic dysreflexia. The blood pressure increases suddenly with autonomic dysreflexia.

A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease? Avoid exercises to the involved joints Engage in passive exercises to the involved joints Increase isometric exercises to the involved joints slowly Participate in progressive, resistive exercises to the involved joints

Avoid exercises to the involved joints During the acute phase, immobilization of the joints reduces pain and inflammation. Passive exercises are contraindicated during the acute inflammatory phase; joints need to be immobilized. Isometric exercises involve muscles, not joints. Progressive, resistive exercises are contraindicated during the acute inflammatory phase because joints need to be immobilized to reduce pain and inflammation.

A client is admitted to the hospital after falling and fracturing a hip. The health care provider applies a Buck's boot with traction until surgery to replace the head of the femur with a prosthesis can be performed. What action can the nurse take to ensure that the Buck's traction is being applied correctly? Fit the spreader bar snugly around the foot. Position the boot so it extends 3 inches above the ankle Hang the weight to apply traction, but limit it to eight pounds Cover the malleoli with tape to adequately secure the weights to the leg

Hang the weight to apply traction, but limit it to eight pounds Eight pounds of weight commonly is applied to maintain adequate traction. Weight greater than eight pounds causes excessive tension on the skin, leading to damage. The spreader bar should be wide enough to keep materials away from the malleoli. The Buck's boot should extend to the area just below the knee. Tape is unnecessary when a Buck's boot is used.

On which principle should a nurse base client teaching when planning to assist a client to reestablish a regular pattern of defecation? Sedentary activities produce muscle atony. Increased fluid promotes ease of evacuation. Peristalsis is initiated by the gastrocolic reflex. Increased potassium is needed for normal neuromuscular irritability.

Peristalsis is initiated by the gastrocolic reflex. Peristalsis - a series of wave-like muscle contractions that moves food to different processing stations in the digestive tract. gastrocolic reflex - a reflex in which the simple act of eating stimulates movement in the gastrointestinal tract. Because stomach distention after eating results in contractions of the colon (gastrocolic reflex), which promotes defecation, establishing some regularity of meals that include adequate bulk or fiber will help establish routine patterns of defecation. Although exercise and increased fluid facilitate elimination, in general they do not help to establish a pattern of defecation. Increased potassium is not needed for normal elimination.

What should a nurse include in the plan of care for a 9-year-old child with nephrotic syndrome? Providing meticulous skin care Restricting fluids to 4 oz each shift Offering a diet low in carbohydrates and protein Sending blood to the laboratory for typing and crossmatching

Providing meticulous skin care Nephrotic syndrome - A kidney disorder that causes the body to excrete too much protein in the urine. Massive edema, typical of nephrotic syndrome, predisposes the child to skin breakdown. The child requires more fluid than 4 oz each shift to maintain hydration. Carbohydrates and proteins are not restricted. Children with nephrotic syndrome usually do not receive blood transfusions.

A mother introducing cereal into her infant's diet asks the nurse about the sequence she should follow when introducing new foods. What order should the nurse suggest? Vegetables and fruits Table foods Meats

Vegetables and fruits Meats Table foods Vegetables and fruits should be introduced before meats because of the generous amounts of vitamins and minerals they supply; the introduction of meats is delayed until after 6 months of age. Table foods are introduced after the infant can chew or bite (6 to 7 months). This is not the appropriate first choice because meats are more likely to be allergenic. Fruits may be introduced first, but table foods should be introduced last, after the other foods are tolerated.