fundamental skills HESI
An older adult in an acute care setting is experiencing emotional stress because of a recent surgery. Which intervention would be most appropriate for the client?
A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps to induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps to bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help a client in a confused state.
During a home visit, the nurse finds that a healthy elderly person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. What does the nurse infer from these findings?
An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy upon suggestion or pressure created by other individuals.
Caring Process - Being With
Being emotionally present to the other; being there; conveying ability; sharing feelings; not burdening
A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?
CALCIUM
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? cushings crohns end stage renal Gerd
ESRD One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.
Caring Process - Enabling
Facilitating the others passage through life transitions (ex - birth, death) and unfamiliar events; informing/explaining; supporting/allowing; focusing; generating alternatives; validating/giving feedback
The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? 91 degrees farenheit 85 degrees farenheit 89 degress farenheit 96 degrees farenheit
Hypothermia is classified as mild hypothermia (body temperature of 34 °C to 36 °C/93.2 °F to 96.8 °F), moderate hypothermia (body temperature of 30 °C to 34 °C/86 °F to 93 °F), and severe hypothermia (body temperature below 30 °C/86 °F). Client B, with a body temperature of 85.3 °F, is in need of rewarming through cardiopulmonary bypass because his or her body temperature is less than 86 °F. Clients A, C, and D do not have a temperature less than 86 °F; therefore, they may not need rewarming through cardiopulmonary bypass.
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?
In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Therefore restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk for thrombophlebitis.
Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply
Interventions such as restoring tissue integrity, optimizing neurologic functions, and providing care before, during, and immediately after surgery are classified under physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy [1] [2]. Interventions to manage restricted body movements are classified under the simple physiologic domain. Interventions to promote comfort using psychosocial techniques are classified under the behavioral domain.
After reviewing a patient's reports, the primary healthcare provider suggests palliative care for the patient. Which conditions would qualify the patient for this type of care? Select all that apply. COPD CHRONIC KIDNEY FAILURE CONGESTIVE HEART FAILURE
Palliative care aims to minimize patient suffering and reduce the undesirable effects resulting from an incurable disease or condition. Disease conditions such as severe chronic renal failure, congestive heart failure, and chronic obstructive lung disease cannot be cured completely with medications, but palliative care may reduce patient suffering from the beginning of the therapy to the end stages. Conditions such as peptic ulcer and cognitive impairment can be completely reversed by medications; therefore, these patients do not require palliative care.
Which intervention reflects the nurse's approach of "family as a context"? MEET CLIENTS COMFORT EVAL FAMILY COPING SKILLS EVAL FAMILY ENERGY LEVEL TRY TO MEET FAMILY NUTRITIONAL NEEDS
TRYING TO MEET THE CLIENTS COMFORT
Caring in Nursing Practice
Providing presence; touch; listening; knowing the patient; spiritual caring; relieveing pain and suffering; family care
Caring Process - Knowing
Striving to understand an event as it has meaning in the life of the other; avoiding assumptions; centering on the one cared for; assessing thoroughly; seeking cues; engaging the self or both
Caring Process - Maintaining Belief
Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning; believing in/holding in esteem; maintaining a hope-filled attitude; offering realistic optimism; "going the distance"
A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to do what?
The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known as transplant; surgery to relieve or reduce symptoms is known as palliative; and surgery to remove or excise an organ or tissue is known as resection.
What is the most important skill of the nurse leader?
clinical care coordination
Swanson's Theory of Caring
defines caring as a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility; supports claim that caring is a cetnral nursing phenomenon but not necessarily unique to nursing practice
Caring Process - Doing For
doing for the other as he or she would do for self if it were at all possible; comforting; anticipating; performing skillfully; prtecting; preserving dignity
Swanson's Theory of Caring - 5 processes
knowing, being with, doing for, enabling, maintaing belief
The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly?
perseverance
Which action made by the patient indicates that they are in the precontemplation stage of Transtheoretical Model of Change?
refuses to think about changing.... The Transtheoretical Model of Change model defines changing patterns in an individual in five stages based on beliefs of readiness to change. The phases are precontemplation, contemplation, preparation, action, and maintenance. The patient refuses and does not think about the change in the precontemplation stage. The patient intends to change in next 60 days in the preparation stage. The patient recognizes the beneficial effects of the change and thinks about the change within 6 months in the contemplation stage. In the maintenance stage, the patient sustains the changed action for 6 months and follows preventive measures to prevent relapse.
Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?
right communication
What type of functional health pattern would the nurse explain describes values and goals?
value and belief pattern Value-belief pattern describes a pattern of values, beliefs, and goals. These guide the client for making choices or decisions. The role-relationship pattern includes the description of the client's patterns in role engagements and relationships. In the self-perception-self-concept pattern, the nurse may describe the client's self-concept pattern and perceptions of self. It involves self-concept/worth, emotional patterns, and body image. Health perception-health management pattern is associated with the description of the client's self report of health and well-being.
