NCLEX Prep: Client Needs: Basic Care & Comfort

A nursing instructor asks a nursing student about tips for examining a 4-year-old sick child. Which statements made by the nurse indicate adequate teaching? Select all that apply.

"I should give the child time to play around." "I should start the examination with the child's fingers and hands. "I should gather all information related to the child's sickness from the parents." While examining a 4-year-old, the nurse should let the child play for some time so that the child may get acquainted to the new surroundings. This action will increase child's cooperative behavior. The nurse should start the examination with nonthreatening areas like the fingers or hands. Information related to the child's sickness is gathered from the parents or guardians. The nurse should call the child by his or her first name and address the parents as "Mr.," "Ms.," or "Mrs." The nurse should refrain from passing judgment when parents explain about their child's illness.

While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?

G5 T1 P1 A2 L2 The client is gravida (G) 5: the current pregnancy, the 41-week pregnancy, the 35-week pregnancy, the 9-week pregnancy, and the 18-week pregnancy. She has had one term (T) pregnancy (one that lasts 40 weeks plus or minus 2 weeks): the 41-week pregnancy. The 35-week pregnancy is considered preterm (P). Pregnancies that end before 20 weeks are considered abortions, so the losses at 9 and 18 weeks would be scored as A2. The other options do not consider the present pregnancy or the correct definitions of term and preterm or do not include the abortions

The nurse is providing care to a client who has had a transurethral resection of the prostate (TURP). Which goal is the priority?

Maintain patency of the indwelling catheter. Indwelling catheter patency promotes bladder decompression, which prevents distention and bleeding; continuous flow of an irrigant limits clot formation and promotes hemostasis. Maintaining patency of the cystostomy tube is not associated with a TURP; a cystostomy tube is a catheter that is placed directly into the bladder through a suprapubic incision. No abdominal incision is made because the resection is performed via the urethra. Although hemorrhage and infection may occur, no wound is observed because the surgery was performed via the urethra.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day. Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.

The nurse is teaching a client about caring for a hearing aid. Which statements made by the patient indicates the need for further learning? Select all that apply.

"I should always keep my hearing aid on." "I can use hair sprays and hair oil while wearing a hearing aid." A hearing aid is a small electronic amplifier which assists clients with conductive hearing loss. The hearing aid should be turned off when not in use. Hair sprays and hair oils can cause damage when they come in contact with the hearing aid. The volume of the hearing aid can be adjusted to prevent feedback squeaking. Batteries should be checked and replaced frequently. The ear mold of the hearing aid can be cleaned with soap and water; excessive wetting should be avoided.

The registered nurse is evaluating the actions of a nursing student who is providing care to a client with compartment syndrome. Which action of the nursing student does the registered nurse think needs correction? Select all that apply.

Applying cold compresses Elevating the extremity above heart level Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) presses on and compromises the function of blood vessels, nerves, and tendons that run through that compartment. Applying cold compresses on the affected area results in vasoconstriction and worsens the condition. Elevating the extremity above heart-level may lower venous pressure and slow arterial perfusion. Bivalving the cast decreases pressure. Evaluating the client's level of pain is helpful to administer suitable medication. Loosening the bandage decreases pressure.

A nurse who works in a mental health facility determines that what is the priority nursing intervention for a newly admitted client with bulimia nervosa?

Check on the client continually Bulimic clients often hide food or force vomiting; therefore they must be carefully observed. Observing the client during meals is insufficient, because these clients may induce vomiting after eating. Fluid and electrolyte balance can become a problem for these clients, and monitoring is required, but at this time it is the responsibility of the nurse, not the client, to measure intake and output. These clients will not become involved in planning meals; this is a long-term goal.

Which of these teaching methods are suitable to a preschooler? Select all that apply.

Encouraging questions and offering explanation Using role play, imitation, and play to make learning fun Preschoolers should be encouraged to ask questions and nurses should provide answers through simple explanations and demonstrations. The nurse should instruct parents to include role play and imitations to make learning fun for preschoolers. Independent learning should be encouraged in young and adult clients. School-aged children should be taught about psychomotor skills necessary to maintain health. An adolescent should be allowed to make decisions about his or her health and health promotion.

What is a priority intervention for the infant undergoing phototherapy?

Exposing as much skin as possible by turning the infant every 2 hours Turning the infant permits optimal skin exposure to the phototherapy lights. The infant's face should not be covered; only the eyes should be covered. Glucose water does not promote excretion of bilirubin in the stools. The supine position would expose only the front of the infant to the lights.

What developmental nursing intervention should the nurse provide to promote safety among adolescents? Select all that apply.

Helping parents minimize risks to their adolescents' safety Teaching parents to serve as role models by guiding expectations and providing education

A nurse is assessing a client in the outpatient clinic who complains of excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep. Which sleep disorder is the client experiencing?

Narcolepsy Narcolepsy is a chronic neurologic disorder that results in irregular sleep and wake states. A client with narcolepsy may experience problems such as excessive daytime sleepiness, sudden muscle weakness during intense emotions, and an inability to walk just after waking or before going to sleep. Nocturia is urination at night that interrupts the sleep and sleep cycle. Sleep apnea is the absence of airflow through the nose and mouth for periods of 10 seconds or more during sleep. Sleep deprivation can cause fever, difficulty breathing, and pain among other things

A toddler receives a gastrostomy tube feeding every 4 hours. What is the priority nursing intervention for this child?

Positioning the child on the right side after the feeding Positioning the child on the right side after feeding facilitates digestion because the pyloric sphincter is on this side and gravity aids emptying of the stomach. The feeding may be started immediately after the tube is opened. Keeping the child lying flat during the feeding may result in aspiration; the child's head and torso should be elevated. If the gastrostomy tube is flushed before or after a feeding, water, not normal saline, is used.

What interventions should the nurse perform while caring for an actively dying patient? Select all that apply.

Provide patient and family reassurance. Perform symptom management in the patient. The nurse should provide comfort care in an actively dying patient. In comfort care, the nurse should reassure the patient and family to reduce their emotional anxiety. The nurse should perform symptom management to improve the patient's quality of life. The patient should not be admitted into hospice care if he or she is actively dying. A patient is admitted to hospice care if death is expected within 6 months. The patient may not require aggressive laboratory tests when death is imminent. He or she should be repositioned as needed for comfort.