basic care and comfort

Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit? a. make the client mop the floor b. restrict the client's fluids for the rest of the day. c. toilet the client more frequently with supervision d. withhold the client's privileges each time the client voids on the floor

The nurse would toilet the client more frequently with supervision. The client is voiding on the floor not to express hostility but because of confusion. Taking the client to the toilet frequently reduces the risk of voiding in inappropriate places.

Which action would the nurse take to help a female bipolar client in a manic episode meet personal hygiene needs? A. suggest she wear hospital clothing B. guide her to dress appropriately in her own clothing C. allow her to apply makeup in whatever manner she chooses d. keep makeup away from her because she will apply it too freely

B. guide her to dress appropriately in her own clothing the nurse would guide the client to dress appropriately in her own clothing. Having clients who are experiencing a manic episode of bipolar disorder where personal clothing helps keep them more in touch with reality. The client may need direction to dress appropriately. Suggesting that she wear a hospital clothing does not help the client learn to follow the therapeutic Milieu. allow her to apply makeup in whatever manner she chooses may set up the client as a target of ridicule by other clients. The client may use makeup but with supervision.

The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feelings at home . Which client statement indicates effective teaching? a. Before I start the procedure, I will don sterile gloves b. before I start the procedure, I will obtain my body weight c. before I start the procedure, I will measure the residual volume. d. before I start the procedure, I will instill 1 oz [30ml] of a carbonated liquid.

Before I start the procedure, I will measure the residual volume. Measuring the residual volume establishes the absorption amount of the previous feeding. If a residual exceeds the parameter identified by the health care provider or is over 200ML, a feeding may be held. This safety measure prevents adding an excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. The client obtains and reports weekly and or monthly waits, depending on the client's condition and clinical goals. If the tube becomes clogged, the client may instill 30 milliliters of a carbonated beverage; This action is not used routinely

Morning sickness generally disappears by the end of which month? A. five months B. Third month c. 4th month D. second month.

b. third month because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, not the second month, when the chorionic gonadotropin level falls . It is still present in the second month because of high levels of chorionic gonadotropin but has usually diminished by the 5th month.

A child has a respiratory tract infection with a low grade fever. When teaching the parents, which intervention would the nurse emphasize? a. Encouraging high calorie snacks to prevent weight loss b. keeping the toddler wrapped in blankets to prevent shivering c. giving small amounts of clear liquids frequently to prevent dehydration. d. using cool water baths to prevent the child's fever from increasing further.

c. giving small amounts of clear liquids frequently to prevent dehydration fluid is lost through perspiration and the increased metabolic rate associated with the fever; an intake of small, frequent amounts of fluids will replenish lost fluid and prevent dehydration. Although caloric intake is important, it is not a priority. Keeping the taller wrapped in blankets to prevent shivering interferes with the radiation of heat from the body; dressing the toddler in light clothing will help reduce the fever. Cool baths may produce shivering; this will increase the fevera low grade fever is part of the body's adaptive mechanism that limits the multiplication of microorganisms.