Saunders Hygiene/ Sleep & Rest exam 2

The nurse is encouraging a client to participate in recreational therapy. The client states that it is best to stay alone and not bother others. Which statement is an appropriate response from the nurse? 1."Can you tell me more about your feelings?" 2."I understand you are feeling negative, tell me more." 3."Your primary health care provider (PHCP) has prescribed this so please go." 4."I can't make you go, but you need to think of getting better and this is one way."

1."Can you tell me more about your feelings?

The nurse is encouraging an older client who has difficulties with incontinence to participate in recreational therapy. Which nursing interventions should the nurse consider performing before assisting the client to go to the recreational therapy session? Select all that apply. 1.Make sure the client is wearing a clean undergarment. 2.Hold all fluids for 4 hours before the scheduled activity. 3.Encourage the client to use the restroom just before the activity. 4.Explain to the client that others participating also have problems. 5.Administer the prescribed diuretic, which will not be effective for another hour.

1.Make sure the client is wearing a clean undergarment. 3.Encourage the client to use the restroom just before the activity.

The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply. 1.A soft toothbrush 2.Irrigation syringe 3.Bite stick or a padded tongue blade 4.Mouthwash of full strength peroxide 5.Suction with oral suction catheter attached

1.A soft toothbrush 2.Irrigation syringe 3.Bite stick or a padded tongue blade 5.Suction with oral suction catheter attached

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply. 1.Wear sterile gloves. 2.Provide a soft toothbrush. 3.Check oral mucous membranes. 4.Provide alcohol-based mouthwash. 5.Check for missing teeth and cavities. 6.Provide abrasive toothpaste to remove plaque.

2.Provide a soft toothbrush. 3.Check oral mucous membranes 6.Provide abrasive toothpaste to remove plaque.

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider? 1.Garlic 2.Valerian 3.Lavender 4.Glucosamine

2.Valerian

The nurse is discussing the care needs with an unlicensed assistive personnel (UAP) who is preparing to bathe a client who has mild dementia and requires minimal help with hygiene. The nurse identifies which client need as the highest priority when giving the instructions? 1.Protect client privacy. 2.Maintain client safety. 3.Promote social interaction. 4.Develop a therapeutic relationship with the client.

2.Maintain client safety

The nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. The nurse should instruct the UAP to prepare to assist which client first? 1.A client who had left foot amputation 2 days ago 2.A client who was admitted 2 days ago with a pelvic fracture 3.A client who has mild dementia and is occasionally incontinent 4.An ambulatory client who is receiving intravenous antibiotics for a postoperative wound infection.

2.A client who was admitted 2 days ago with a pelvic fracture

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply. 1."I swim three times a week." 2."I have stopped smoking cigars." 3."I drink hot chocolate before bedtime." 4."I read for 40 minutes before bedtime." 5."I plan out my goals for work for the next day"

3."I drink hot chocolate before bedtime." 5."I plan out my goals for work for the next day"

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply. 1.A beef taco 2.A small glass of wine 3.A glass of warm milk 4.A cube of Swiss cheese 5.A chocolate chip cookie 6.A cup of caffeine-free tea

3.A glass of warm milk 4.A cube of Swiss cheese 6.A cup of caffeine-free tea

A client on the medical unit tells the nurse of back discomfort but does not want any pain medication. Which nonpharmacological interventions should the nurse offer the client to help reduce the pain? Select all that apply. 1.Placebo 2.Distraction 3.Acupuncture 4.Back massage 5.Relaxation breathing 6.Transcutaneous electrical nerve stimulation (TENS)

2.Distraction 4.Back massage 5.Relaxation breathing

The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding clients' hygiene needs. Based on the client needs, the nurse instructs the UAP to bathe which client first? 1.A client who is on bed rest after multiple traumas 2.A confused client who is incontinent of stool and urine 3.A client who was admitted for dehydration and failure to thrive 4.A client who is independent with ADLs (activities of daily living)

2.A confused client who is incontinent of stool and urine

The nurse is providing eye care to an unconscious client. Which interventions are included in the procedure? Select all that apply. 1.Cleanse each eye moving from the inner canthus to the outer canthus. 2.Cleanse each eye moving from the outer canthus to the inner canthus. 3.Administer a cleansing solution in the conjunctival sac before providing eye care. 4.Use a clean wet cotton ball or different area of a clean wash cloth for each eye. 5.Use a small amount of very mild soap with water to cleanse the outer aspect of each eye.

1.Cleanse each eye moving from the inner canthus to the outer canthus 4.Use a clean wet cotton ball or different area of a clean wash cloth for each eye