prepU Nursing Concepts- Nursing Process
The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment? Prepare for a prostate examination. Ask the client to empty the bladder. Assist the client to a Fowler's position. Dim the lights for privacy.
Ask the client to empty the bladder.
A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? Risk for aspiration related to nil orally status. Deficient knowledge related to ventilatory support. Deficient knowledge related to lack of exposure to apnea monitor. Deficient knowledge related to inability to cope.
Deficient knowledge related to lack of exposure to apnea monitor. For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to lack of exposure to apnea monitor is most appropriate. Although the premature neonate may be at risk for aspiration, the question asks about the most appropriate nursing diagnosis for the parents, not the neonate. No ventilatory support is being used, so a diagnosis of Deficient knowledge related to ventilatory support isn't warranted. A diagnosis of Deficient knowledge related to prematurity would be appropriate just after birth but would probably be resolved by the time the neonate is ready for discharge.
A nurse is developing a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention? monitoring the client's vital signs every hour for 4 hours placing the client in Trendelenburg's position encouraging early ambulation reorienting the client to time and place
reorienting the client to time and place Confusion and temporary memory loss are the most common adverse effects of ECT. A nurse should continually reorient a client to time and place as the client wakes up from the procedure. Following ECT, the nurse should monitor the client's vital signs every 15 minutes for the first hour. The nurse should position the client on the side after the procedure to reduce the risk of aspiration. The client should remain on bed rest until fully awake and oriented.
The nurse is caring for a client with hypoparathyroidism. When the nurse taps the client's facial nerve, the client's mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels? Positive Chvostek's sign Positive Trousseau's sign Positive paresthesias Positive Babinski's sign
Positive Chvostek's sign If a nurse taps the client's facial nerve (which lies under the tissue in front of the ear), the client's mouth twitches and the jaw tightens. The response is identified as a positive Chvostek's sign. A positive Trousseau's sign is elicited by placing a BP cuff on the upper arm, inflating it between the systolic and diastolic BP, and waiting 3 minutes. The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Positive Babinski's sign is elicited by stroking the sole of the foot. Paresthesia is not a symptom that can be elicited; it is felt by the client.
A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? Keep the affected leg in a position of adduction. Use measures other than turning to prevent pressure ulcers. Prevent internal rotation of the affected leg. Keep the hip flexed by placing pillows under the client's knee.
Prevent internal rotation of the affected leg. The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.
