Exam 3 Quizzes
Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. "Did something happen with your parents?" "Why do you want to kill yourself?" "Have you been taking drugs and alcohol?" "Do you have access to medications?"
"Do you have access to medications?"
The nurse in the emergency department assists with the care of a 12-year-old diagnosed with appendicitis. The parents ask the nurse why something isn't being done to reduce the child's pain. The nurse's best response states that: "Eliminating pain prevents monitoring for rupture of the appendix." "The child will not obtain pain relief until the appendix is removed." "To prevent toxicity, analgesics cannot be given prior to surgery." "Appendicitis is not very painful, so powerful narcotics are not needed."
"Eliminating pain prevents monitoring for rupture of the appendix."
Which complaint would the nurse expect from a client diagnosed with major depressive disorder? "I only sleep for 4 hours, but it does not affect my energy for the rest of the day" "I get up everyday and shower, but I do not want to go to work" "I can only concentrate at work if I really try hard" "I do not leave my bed for a few days and have no energy to shower
"I do not leave my bed for a few days and have no energy to shower
The nurse is caring for a client diagnosed with Crohn's disease. The nurse realizes the client requires education when the client makes which statement? "I will increase my hydration to replace the fluid loss caused by diarrhea" "I will cleanse my anal area after each bowel movement and apply a barrier cream" "I hope I am a candidate for this surgery so I can be cured of this disease" " I need to change my diet and eat low residue/low fiber foods to reduce diarrhea"
"I hope I am a candidate for this surgery so I can be cured of this disease" *Unlike ulcerative colitis, there is no surgical cure for Crohn's disease, but surgery can be done to manage symptoms of the disease. Bowel resections with anastomosis may be done to assist with symptoms of the disease. However, surgery is avoided due to the potential for the disease to recur in the same area.
A client was admitted and lost her baby at 32-weeks gestation. "I cannot believe I lost my baby so far along in my pregnancy." Which of the following are therapeutic responses by the nurse? Select all that apply. "How many children do you currently have?" "Leave the room and let the patient alone to grieve" "Don't cry. You can get pregnant again" "I know this is a difficult time for you. How are you feeling about the loss of your child?" "Tell me about how you feel about losing your baby"
"I know this is a difficult time for you. How are you feeling about the loss of your child?" "Tell me about how you feel about losing your baby"
A client is depressed over the loss of her child. Which of the following is the best therapeutic response to the client? "It takes time to heal, but in time, you will be okay" "Do you want me to leave the room so you can grieve in private?" "I know this is a difficult time for you. Tell me how you have been coping with the loss" "Everything will be alright. You can always have another baby"
"I know this is a difficult time for you. Tell me how you have been coping with the loss"
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? "I can have exacerbations and remissions with this disease." "I should increase the fiber in my diet." "I'm going to learn some stress reduction techniques." "I will need to avoid caffeinated beverages."
"I should increase the fiber in my diet." *Patients are told to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. Low-fiber diet may be prescribed, especially during periods of exacerbation.
The nurse is evaluating teaching of family members of a client at risk for developing a pressure ulcer. The nurse determines that further teaching is needed if a family member states which of the following? "Putting a foam under the heels or other bony areas can help decrease pressure." "If a skin area gets red and does not go away after turning, I should report it to the nurse." "The skin should be washed with warm water and lotion should be applied while the skin is still moist." "If an individual cannot turn in bed alone, someone should help the individual turn every 4 hours."
"If an individual cannot turn in bed alone, someone should help the individual turn every 4 hours." *Clients who cannot turn in bed alone should have help turning every 2 hours, not every 4 hours. The other answers are correct statements.
A client who underwent colon surgery with a permanent colostomy 4 days ago appears sad and depressed. The client will not empty the pouch or look at the stoma. The client stated, "I hate this thing. I am so sad." What is the best response of the nurse? "Would you like me to call your family to visit?" "Tell me your concerns regarding your new colostomy" "You will feel better in the next few weeks, so do not feel sad" "Many people live with a permanent colostomy and do just fine"
"Tell me your concerns regarding your new colostomy" *Creation of a stoma can cause emotional as well as lifestyle changes. Disturbed body image may be seen so the nurse should ask the client to tell about the client's concerns regarding the new ostomy. The nurse should be empathetic and utilize therapeutic communication with the client allowing the client to vent and express his/her feelings and emotions. The nurse should be supportive and help the client work through his/her feelings.
A client are risk for developing pressure ulcers complains to the nurse about the turning schedule because the client does not rest well when placed in a side-lying position. The nurse teaches the client which of the following to gain compliance? "Pressure causes decreased absorption of Vitamin D." "Turning prevents the breakdown of skin that could eventually cause infection." "Heat loss from pressure areas is prevented when you are not turned." "You will lose sensation in pressure areas if you are not turned."
"Turning prevents the breakdown of skin that could eventually cause infection."
A client with terminal cancer tells the hospice nurse that his son has asked him to have "a feeding tube put in soon". Which of the following is the nurse's best response? "He loves you and wants you to live as long as possible" "What do you think about your son's request? "Your son's wishes are considered but the final choice belongs to you" "We can teach your family how to take care of the feeding tube"
"Your son's wishes are considered but the final choice belongs to you" *he most important concept in end-of-life care is that the client's choices are the final decisions. Family members and the client should be educated on the types and treatments available. It should be clearly stated that family members can provide input into decision-making but it is the client's wishes that are to be honored and carried out.
Which of the following adolescent clients should the nurse screen for depression? A 13-year-old who has had sudden outbursts of anger and vandalism An 18-year-old who is interested in weight lifting lost 10lbs A 12-year-old who only naps once a day A 15-year-old who lost interest in the guitar, and picked up the drums
13-year-old who has had sudden outbursts of anger and vandalism *Depression may occur in both adults and adolescents between the ages of 10 and 19 years old. The diagnostic criteria for depression among adolescents include increased anger, aggressive outbursts, vandalism, skipping class, sudden weight loss or gain, frequent napping during the day, and withdrawal from activities that otherwise would bring joy to the client.
Which nursing intervention is most therapeutic when the nurse is managing the aggressive, disruptive behaviors of a manic patient whose attempts to control the milieu has been rejected by the other patients? Accompanying the patient to a quieter part of the unit Ignoring the patient's outbursts because they are surly related to the mania Advising that the patient to accept the wishes of the group Suggesting that the patient either quiet down or leave the room
Accompanying the patient to a quieter part of the unit
The nurse is taking care of a client with a surgical wound. Which action by the nurse reflects a need for further teaching by the charge nurse? Uses as little tapes as possible if client is bed bound Applies butadiene on surgical incision Uses sterile water to clean surgical incision Signs and dates dressing before leaving the client
Applies butadiene on surgical incision The nurse must know the proper procedure to take care of a surgical wound. Using betadine on a surgical wound can cause skin irritation and hinder the healing process. The wound needs to be cleaned with sterile water and redressed to prevent the wound from infection. Signing and dating the dressing allows the health care staff to know when the dressing was last assessed.
The nurse observes a client being treated for depression sitting with the head down and avoiding conversation with peers. Which nursing intervention is appropriate for this client? Encourage a peer to sit with the client and the nurse. Tell the client that lack of involvement leads to more depression. Ask open-ended questions about the client's feelings. Ask the client close-ended questions.
Ask open-ended questions about the client's feelings.
Which assessment finding should the nurse report immediately while assessing a client reporting right lower abdominal pain? Cool, clammy skin Rebound hypertension Bowel sounds present Round, soft abdomen
Cool, clammy skin *Clinical manifestations of perforation of the appendix includes symptoms of shock, including cool, clammy skin, hypotension, tachycardia. Another obvious symptom of perforation is a board-like abdomen.
Which intervention will the registered nurse (RN) implement who is completing a follow-up home visit with a woman diagnosed with postpartum depression one month ago? Select all that apply. Ask the woman if she has attended weekly counseling sessions prescribed Remain cheerful and avoid any confrontational conversations that will stress the woman Evaluate the woman's ability to perform activities of daily living for self and infant Ask the woman if she has had any thoughts of hurting herself or the infant
Ask the woman if she has attended weekly counseling sessions prescribed Evaluate the woman's ability to perform activities of daily living for self and infant Ask the woman if she has had any thoughts of hurting herself or the infant Determine the woman's compliance to the prescribed antidepressant drug therapy
A client with Crohn's disease is scheduled to receive an infusion of infliximab. what intervention by the nurse will determine the effectiveness of treatment? Checking the frequency and consistency of bowel movements Carrying out a Hematest on gastric fluids after the infusion is completed Checking serum liver enzyme levels before and after the infusion Monitoring the leukocyte count for 2 days after the infusion
Checking the frequency and consistency of bowel movements
A client with a colostomy reports gas buildup in the colostomy bag. The nurse instructs the client that consuming which food items would help prevent this problem? Select all that apply. Crackers Yogurt Cauliflower Broccoli
Crackers Yogurt *Consumption of yogurt and crackers can help prevent gas. Gas-forming foods include broccoli, cauliflower, mushrooms, onions, peas, and cabbage. These foods should be avoided by the client with a colostomy until tolerance to them is determined.
The nurse provides information to a client with a colostomy resulting from treatment for cancer. When discussing measures to help manage colostomy odors, the nurse will encourage the client to regularly consume which foods? Select all that apply. Cranberry Juice Yogurt Buttermilk Cauliflower Cucumbers Parsley
Cranberry Juice Yogurt Buttermilk Parsley *Parsley, yogurt, buttermilk, and cranberry juice will prevent odor. charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will also eliminate odors.
Which of the following conditions may result in an ostomy for the client? Select all that apply. Crohn's disease Perforated colon Cholelithiasis Colon cancer Ulcerative colitis
Crohn's disease Perforated colon Colon cancer Ulcerative colitis *Cholelithiasis is gallstone formation and does not require an ostomy.
An adolescent client is accompanied by his mother who states that her son has been taking frequent naps, getting into fights at school, and skipping class. The client states that he quit the football team, and has had difficulty concentrating in school and does not care about his future. Which of the following is a suspected explanation for the client's behavior? Conduct disorder Depression Separation anxiety disorder ADHD
Depression
An appropriate nursing strategy to assist a patient who was involuntarily admitted after a suicide attempt is: Discussing the impact of suicidal thoughts on the family Supporting patient focus on others rather than self Encouraging patient to verbalize personal feelings Avoiding any focus on the topic of suicide
Encouraging patient to verbalize personal feelings
What are the top 3 risk factors for pressure ulcer formation? Select all that apply. Fecal and Urinary Continence Altered Sensory Perception Skin moisture Immobility
Immobility, Moisture and Altered Sensory Perception are the top 3 risk factors for pressure ulcer formation. Fecal and Urinary continence is not. If they were incontinent this would also be a risk factor.
The nurse is caring for a client who is manic and exhibiting psychomotor agitation. Which nursing action would be most effective? Administer antidepressants as ordered Implement limit setting with the client. Instruct alternative behaviors with the client Explore causes of the manic behavior
Implement limit setting with the client.
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? Intact skin Exposed bone, tendon, or muscle Full-thickness skin loss Partial-thickness skin loss of the dermis
Partial-thickness skin loss of the dermis *Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. This includes intact or ruptured blisters.
Which nursing intervention can help a client maintain healthy skin? Remove adhesive tape quickly from the skin Keep client well hydrated Recommend wearing tight-fitting clothes in hot weather Avoid bathing client with mild soap
Keep client well hydrated *Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. The role of water within the stratum corneum is pivotal to the maintenance of normal skin integrity and turnover. Water allows for the increased flexibility of the tissues and is a crucial component of the enzymatic reactions responsible for cleavage of the corneodesmosome connections between corneocytes during the desquamation process.
The nurse cares for a patient with a clean wound that has formed granulation tissue. Which, if selected by the nurse, would be most appropriate for this patient? Allow the wound to dry by leaving open to air Debride the granulation tissue with a dry dressing Apply an absorption dressing to remove exudate Keep the tissue moist with a transparent film dressing
Keep the tissue moist with a transparent film dressing
You are teaching a client with a new ascending colon colostomy. You are explaining to the patient that the stool will be __________ as it collects into the bag. Which of following is correct? Hard Semi formed Close to normal Liquid
Liquid *Expect liquid stool from an ascending colon colostomy, loose to semi-formed stool from a transverse colon colostomy, or close to normal stool from a descending colon colostomy. Stool will not appear hard with a colostomy.
A client with Crohn's disease requires additional instruction on corticosteroid use. Which information does the nurse give the client prescribed long-term corticosteroid therapy? Select all that apply. You may stop the medication if you have a sore throat Maintain a diet high in protein, calcium, and vitamin D Expect some weight gain Bruising easily Avoid aspirin and OTC drugs
Maintain a diet high in protein, calcium, and vitamin D Expect some weight gain Bruising easily Avoid aspirin and OTC drugs *Because symptoms are caused by inflammation, many clients are prescribed long-term corticosteroid therapy.
Describe the severity of Ulcerative colitis (mild, moderate, severe).
Mild: Bleeding per rectum, fewer than four bowel motions per day. Moderate: Bleeding per rectum, more than four bowel motions per day. Severe: Bleeding per rectum, more than four bowel motions per day, and a systemic illness with hypoalbuminemia
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? Reposition the client and apply a heating pad on the warm setting to the client's abdomen. Call and ask the operating room team to perform surgery as soon as possible. Notify the health care provider (HCP). Administer the prescribed pain medication.
Notify the health care provider (HCP) The patient has already been diagnosed with appendicitis The nurse has completed a full assessment at this point by listening to the patients complaints, assessing the abdomen and listening to bowel sounds. At this point the nurse must contact the health care provider.
An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery? Apply moist heat to the abdomen Teach the client to massage the painful area Place the client in semi-Fowler's position with the knees to the chest Provide distraction with music
Place the client in semi-Fowler's position with the knees to the chest *Appendicitis typically begins with peri-umbilical pain followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney point. To relieve pain prior to surgery, the nurse assists the client to a comfortable position with the knees drawn to the chest and the head of the bed slightly elevated. The nurse may also administer analgesics and ice packs, if prescribed; heat is avoided as heat may precipitate rupture of the appendix. The abdomen is not palpated or massaged more than necessary to avoid increasing the pain.
A 16-year-old client diagnosed with Crohn's disease is hospitalized. Which statement by the client would alert the nurse to a potential developmental problem? "Please tell my friends not to visit, since I'll see them back at school next week." "I'd like my hair washed before my friends get here." "Is it okay if I have a couple of friends in to visit me this evening?" "When my friends get here, I would like to play some computer games with them."
Please tell my friends not to visit, since I'll see them bac at school next week."
A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? Increased muscle tension and anxiety Poor judgment and hyperactivity Vegetative signs and poor grooming Cognitive deficits and paranoia
Poor judgment and hyperactivity
Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? Vigorously massage lotion into bony prominences Slide the client, rather than lifting when turning Turn and reposition client at least once every 8 hours Post a turning schedule at client's bedside
Post a turning schedule at client's bedside *A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Set goals with the patient or significant other for cooperation in activities or exercise and position changes. This enhances a sense of anticipation of progress or improvement and gives some sense of control or independence.
The 3-day postpartum client has tears in her eyes and states, "I am so exhausted and don't want to hold my baby." Based on this data, which does the nurse suspect the client is experiencing? Postpartum psychosis Postpartum blues Postpartum depression Postpartum infection
Postpartum blues
The registered nurse (RN) identifies what diagnosis in the woman who states she is experiencing weepiness and a feeling of letdown two days after the delivery? Postpartum blues Postpartum depression Postpartum detachment Postpartum psychosis
Postpartum blues
The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information? Select all that apply. Pressure redistribution - turn every 1-2 hours Utilize moisturizers and creams after baths/showers daily Use strong deodorant soaps when bathing clients Keep client clean and dry by managing incontinence Rub and massage client's pressure injuries Encourage diet high in protein and calories
Pressure redistribution - turn every 1-2 hours Utilize moisturizers and creams after baths/showers daily Keep client clean and dry by managing incontinence Encourage diet high in protein and calories
The nurse is working with a postoperative client who dehisced a wound after a previous abdominal surgery. The nurse plans interventions to promote wound healing and prevent another dehiscence by: Preventing emesis Keeping the wound dry Assisting the client with weight loss Administering antibiotics
Preventing emesis *The action or process of vomiting would put pressure on the abdominal operative incision. Preventing emesis would help to prevent dehiscence. Weight loss at this time would not help with dehiscence. Antibiotic administration would help prevent or treat an infection. The wound should be kept moist, not dry.
A basic principle of wound management for all open wounds is to: Apply topical antimicrobials to prevent wound infection Use occlusive dressings to prevent wound contamination Remove wound exudate with frequent dressing changes Protect new granulation and epithelial tissue
Protect new granulation and epithelial tissue *A basic principle of wound management for all open wounds is to Protect new granulation and epithelial tissue. Wounds that are clean and granulating and re-epithelializing should be kept slightly moist and protected from further trauma.
A family in the Emergency Department has received news that their 10-month old baby died. Which is the nurse's first action? Inquire if the family would consider organ donation Ask the family which funeral home should be notified Encourage the families to return home to be with other loved ones Provide a quiet place for the family to grieve
Provide a quiet place for the family to grieve
A client with clinical depression states that they have a plan to kill themselves. What is the priority nursing action that must be performed? Encourage board games to distract from suicidal thoughts Provide continuous one-on-one observation of the client Assign client to their own private room Allows clients to have meals with other clients
Provide continuous one-on-one observation of the client
On day 4 of hospitalization after a suicide attempt, the patient tells the nurse, "You don't have to worry about me any longer. Today was the turning point. You can stop the suicide precautions. I feel great!" Which action indicates the nurse's use of intuition in responding to this patient? Suggesting that the level of suicide precautions be lowered from one-to-one supervision to observing the patient every 30 minutes Conferring with the patient's family members to obtain their evaluation of the patient and his behavior and follow their lead Reporting the patient's statements and the nurse's own feelings to the staff and suggest increased vigilance Reporting only the patient's statements and evaluate the outcome, Patient will report lack of suicidal ideation as attained.
Reporting the patient's statements and the nurse's own feelings to the staff and suggest increased vigilance **Suicidal patients who 'suddenly feel great' and state they no longer need precautions and 'feel great' are an increased risk for suicide. Extra vigilance must be taken as they may have decided to commit suicide as their final decision.
A nurse working on a psychiatric unit is caring for a client who has been diagnosed with major depressive disorder (MDD). Upon assessment of the client, which clinical manifestations does the nurse anticipate? Restlessness, fatigue, suicidal ideation, feelings of guilt A depressed mood sporadically for at least 2 years Anxiety, change in appetite, grief, altered nutrition Depressed mood or loss of interest occasionally for at least 1 week
Restlessness, fatigue, suicidal ideation, feelings of guilt
While changing the client's dressing, the nurse observes the wound's drainage is pale red/pinkish. What does the nurse describe the drainage as? Sanguineous Serous Purulent Serosanguineous
Serosanguineous *Serosanguineous drainage is pale red/pinkish. This drainage is an indication of a healing surgical incision. The known signs and symptoms of an infected incision is redness, pain , fever and a thick yellow drainage. When this is present the nurse must notify the health care provider so further treatment can be given to the client. The healthcare provider will order antibiotics to aid in the healing process. When the surgical incision is healing, it is normal to have serosanguineous drainage.
The nurse assesses a client's surgical incision for signs of infection. Which finding by he nurse would be interpreted as a normal finding at the surgical site? Serous drainage Red, hard skin Hot skin temperature Purulent drainage
Serous drainage *Serous drainage is clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing and smaller amounts is considered normal wound drainage.
A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record? Stage 2 pressure injury Stage 1 pressure injury Stage 4 pressure injury Stage 3 pressure injury
Stage 2 pressure injury *A pressure injury is skin damage usually over a bony prominence or from a medical device such as a Foley catheter tubing. A stage 2 pressure injury is skin damage through two layers of skin, the epidermis and the dermis. A stage 2 pressure injury is open, red, and moist extending to the dermis of the skin. Risk factors for pressure injuries include poor nutrition-being NPO for 3-5 days, dehydration, low albumin, chemotherapy, steroids, immobility, contractures, past history of pressure injuries, incontinence, diabetes, poor sensory perception, paralysis, and obesity. The Braden Scale is utilized to identify clients at high risk for pressure injuries. The Braden Scale rates clients by sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer that has broken into the fatty tissue layer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? Stage III Stage II Stage I Stage IV
Stage III *Stage 3 Pressure ulcers are sores that have broken completely through the top two layers of the skin and into the fatty tissue below. An ulcer in this stage may resemble a crater. It may also smell bad. In this stage, it's important to look for signs of infection including: foul odor pus redness discolored drainage
The nurse is explaining wound healing to a client and the family. The nurse states that this type of wound healing involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigation or removal of debris and exudates. What type of Healing intention is the nurse describing? Primary (first) intention Secondary (second) intention Tertiary (third) intention
Tertiary (third) intention *Tertiary intention (delayed primary closure) occurs when a wound is initially left open after debridement of all nonviable tissue. Wound edges may be surgically approximated following a period of open observation, when the wound appears clean and there is evidence of good tissue viability and tissue perfusion
The nurse is caring for a client who is 2 days postoperative from a left hip replacement. The client states the incision is warm to touch, red, with increasing pain. Which assessment is correct? The client is drug-seeking The client has an infection The incision is healing The client has had too much physical therapy
The client has an infection
A nurse is assessing a client with major depressive disorder (MDD). Which of the following findings indicates the client is at risk for suicide? The client is compliant with treatments The client has been giving away his possessions The client has been social with other clients The client says he is better and wants to go home
The client has been giving away his possessions
A client with a past medical history of depression and suicidal ideation has suddenly become more energetic and in a positive mood. Which of the following should the nurse consider? The client is overcoming depression The client may be released to the family The client is suicidal Rewarding the client
The client is suicidal *Clients who have depression and a history of suicidal ideation may suddenly become more energetic and have calmer behavior. The sudden change in energy typically means the client is more suicidal with more energy to follow through with suicide. The change in behavior and energy is especially seen after starting antidepressants such as selective serotonin reuptake inhibitors (SSRIs). Nurses must monitor the client at all times. This is a priority nursing assessment.
Which principle should the nurse apply when planning nursing care for a patient who was voluntarily admitted after a suicide attempt? Patients who attempt suicide and fail do not really want to die. Patients who talk about suicide are less likely to attempt it. Patients who attempt suicide and fail will not try again. The more specific the plan, the greater the risk for suicide.
The more specific the plan, the greater the risk for suicide.
The nurse receives a report at the beginning of shift regarding the surgical client's abdominal incision healing by "primary intention". What does healing by "primary intention" mean? The patient has poor circulation for healing The wound has little drainage with approximated edges Purulent drainage is present at incision sites The wound is still open and not healing
The wound has little drainage with approximated edges *a wound healing with primary intention means that it is well approximated, with little to no drainage, and has no signs of infection. An approximated wound means that the wound edges have come together to close. This is the goal for the client to be making progress in wound healing.
The nurse is caring for a client in crisis who begins shouting during a group therapy session. Which action is most important for the nurse to take first? Place the client in a private room near nurses' station Obtain an order for physical restraints from the HCP Use calm, simple directions to direct the other clients out of the room Administer anxiolytic and antipsychotic medications as ordered
Use calm, simple directions to direct the other clients out of the room *When providing care to the client in crisis, safety for all parties involved is pivotal. Removing other clients quickly and calmly ensures that the nurse can ensure safety and then focus attention directly on the client in crisis. Crisis management interventions should begin with the least invasive measures possible, and then may escalate as needed. Communication is the first level of intervention.
An older client had abdominal surgery that has not healed after several weeks. The client asks the clinic nurse why it is taking so long for the wound to heal. The nurse would explain that which of the following is a factor that negatively affects healing in the older clients? Keloid formation prevents healing Decreased activity levels prevent blood from reaching the area Most older clients are overweight Vascular changes decrease the blood flow to the wound
Vascular changes decrease the blood flow to the wound *Everything slows down during the aging process, including the phases of wound healing. Skin gets thinner and the body shows a decreased inflammatory response as well as vascular changes decreasing blood flow to the wound(s). Older patients skin is predisposed to injury and will heal slower when injury occurs. Proper nutrition is vital to optimal healing.
The nurse is caring for a 14 year old patient with a colostomy. The patient asks, "Will I ever be able to swim again?" The nurse's best response would be: "Yes, you should be able to swim again, even with the colostomy." "You should avoid immersing the colostomy in water." "Don't worry about that. You will be able to live just like you did before." "No, you should avoid getting the colostomy wet."
Yes, you should be able to swim again, even with the colostomy
A client received news that he has colon cancer and will require surgery, radiation, and chemotherapy. The client was very angry and stated, "Why me? Why did I have to get cancer. I have always treated people right and done the right thing." What is the most therapeutic response by the nurse? Treating people right your whole life does not guarantee you will not get cancer" "Why are you so angry at having cancer?" "You sound very discouraged and upset over your current news. Tell me about how you are feeling regarding your cancer" "Have any of your family members had colon cancer?"
You sound very discouraged and upset over your current news. Tell me about how you are feeling regarding your cancer"
When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using which type of therapy? psychoanalytic therapy. cognitive-behavioral therapy. alternative and complementary therapies. desensitization therapy.
cognitive-behavioral therapy. *form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy, abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to ______________. administer IV metoclopramide (Reglan). discontinue the patient's oral food intake administer cobalamin (vitamin B12) injections. teach the patient about total colectomy surgery.
discontinue the patient's oral food intake *bowel rest. When a patient is having an exacerbation with abdominal cramps and bloody stools, the abdomen must take a 'rest.' Discontinuing the patient's oral food intake will rest the abdomen.
A client who had an appendectomy for a perforated appendix returns from surgery with a JP drain inserted in the incisional site. The purpose of the JP drain is to: provide access for wound irrigation decrease postoperative discomfort minimize development of scar tissue promote drainage of wound exudates
promote drainage of wound exudates
Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first? Wash hands thoroughly Slowly removed the soiled dressing Put on latex gloves Assess the drainage in the dressing
wash hands thoroughly
