Basic Care and Comfort Quiz

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status?

"We allow her to pick out a treat at the grocery store for good behavior." CORRECT. This statement indicates a need for further teaching. This client's mother should be educated about the importance of praising the client's abilities and skills rather than using food as a reward, which may lead to an increased risk for obesity.

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?

. "I will remove the condom 30 minutes after intercourse." CORRECT. To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina.

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client?

. Avoid inadvertently advancing the catheter into the bladder. CORRECT. Accidental advancement of the catheter into the bladder during cleansing increases the risk of introducing bacteria into the bladder. Therefore, avoiding inadvertent advancement of the catheter into the bladder is the priority intervention.

A nurse is calculating the client's intake and output. Based on the information below, which of the following values correctly represents the client's total output? Sipped 8 oz. clear broth. 100 mL ice chips. Voided 450 mL. IV push pain medication 50 mL. Drank 4 oz. juice and 6 oz. hot tea. Vomited 120 mL and voided 600 mL. Jackson Pratt drain emptied 40 mL.

1210 mL 1210 mL output is the correct value. Input includes all liquids taken by mouth, including through nasogastric or jejunostomy feeding tubes, IV fluids, and blood or its components. Output includes urine, diarrhea, vomitus, and drainage from tubes such as through gastric suction and drainage from postsurgical wounds or other tubes.

A nurse is caring for a client who is receiving intermittent tube feedings. What intervention reduces the risk of aspiration?

Assessing gastric residual volume immediately before administering the feeding CORRECT. Measuring the gastric residual volume (GRV) every 4 to 6 hours in clients who are receiving continuous feedings and immediately before the feeding in clients receiving intermittent feedings is an effective way to reduce the risk of aspiration. Nursing measures to reduce the risk of aspiration, such as keeping the head of bed elevated and routine assessment for aspiration, should be implemented for clients who are receiving tube feedings. Feedings should be withheld if the GRV is greater than 200 mL in two successive measurements.

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response?

Awareness of body structures and sensations is normal and expected CORRECT. Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! It should be ignored unless the behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come and do some fun and exciting activity

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching?

Broccoli with cheese sauce CORRECT. Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may be contraindicated include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods.

A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education?

Cheddar cheese CORRECT. Client's with renal failure need to restrict protein and phosphorus which is present in cheese and many milk products.

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education?

Cleansing the peristomal skin with alcohol. CORRECT. This intervention is not appropriate. The peristomal skin should not be cleansed with alcohol.

nurse is caring for a client who is neutropenic. Which of the following foods are appropriate for this client?

Cooked spinach and celery CORRECT. Clients who are neutropenic are at increased risk for the development of infection. The reduced numbers of neutrophils and other white blood cells can limit the presence of common infection manifestations. The focus of care for client with neutropenia is on keeping the client's own normal flora under control and preventing the transmission of organisms. Raw or fresh foods may be a source of bacteria. The client should avoid raw fruits and vegetables, undercooked meats, eggs, or fish.

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported?

Decreased urine output CORRECT. Decreased urine output indicates dehydration and should be reported immediately to the provider. Listlessness, sunken eyes, decreased tears, and dry mucous membranes are other symptoms of dehydration that should be immediately reported.

A nurse is caring for a client after an open radical prostatectomy. Which of the following interventions is the highest priority in the immediate postoperative period?

Encourage use of patient-controlled analgesia (PCA) as needed. CORRECT. Assessment of the client's pain level, along with monitoring the effectiveness of pain management given through patient-controlled analgesia, is the priority intervention in the immediate postoperative period.

A nurse is changing a dressing on a pre-school-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child?

Encouraging the child to watch a favorite cartoon on television. CORRECT. Cartoons would be a very attractive distraction, and distraction is a powerful nonpharmacologic comfort intervention which works well with this developmental age.

A nurse is providing dietary education to a client with a new ileostomy. What foods should the nurse instruct the client to avoid in the first weeks after surgery?

Fresh vegetables CORRECT. Fresh vegetables are high in fiber and therefore, should be avoided in the first weeks after surgery. During the first weeks after surgery, many providers recommend low fiber diets, particularly for clients with ileostomies, because the small bowel requires time to adapt to the diversion. As ostomies heal, clients are able to eat almost any food and high fiber foods are encouraged to help ensure a more solid stool to achieve success at irrigation, but high fiber foods should be avoided in the first weeks after surgery.

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching?

Grilled chicken salad with fresh salsa

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?

Have you noticed any bloody show or fluid coming from your vagina?" CORRECT. Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor.

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions?

I should limit my sodium intake to 4 grams per day." CORRECT. Excessively high protein and sodium diets put clients at risk for glomerulonephritis. Clients with this condition should implement sodium and protein restriction.

A nurse is educating a client on restful sleep. Which of the following statements by the client would alert the nurse that further teaching is necessary?

I watch television until I fall asleep."

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching?

I will increase my fiber intake to stay regular." CORRECT. A full liquid diet is provided immediately after surgery, followed by a low-residue diet to decrease bowel movements and allow time for the incision to heal. Foods that are high in fiber should be avoided until it has been determined that normal bowel function has been regained. Stool softeners should be administered as prescribed to facilitate bowel elimination and prevent stress on stitches.

A nurse is teaching a client with right-sided hemiparesis to ambulate with a quad cane. Which instructions are appropriate?

Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. CORRECT. Place quad cane in left hand, extend left hand with quad cane and right lower extremity followed by left leg. Holding the quad cane on the stronger side of the body and moving the cane in unison with the weaker leg gives support and helps to maintain stability for the client.

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid?

Pork chop and brown rice. CORRECT. Pork chops and brown rice are high in roughage content which will stimulate peristalsis and makes the symptoms of ulcerative colitis worse. Other foods to be avoided include whole grains, nuts, raw fruits and vegetables, caffeine, alcohol, tough meats, pork and highly spiced meats.

A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice?

Rabbit CORRECT. Of the "beasts of the earth" (which basically refers to land mammals with the exception of swarming rodents), clients observing Kosher laws may eat any animal that has cloven hooves and chews its cud. Any land mammal that does not have both of these qualities is forbidden. The Torah specifies that the camel, the rock badger, the hare and the pig are not kosher because each lacks one of these two qualifications. Cattle, sheep, goats, deer and bison are kosher.

A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client?

The infant does not raise his head when placed on his abdomen CORRECT. When placed on the abdomen the 3 month old should attempt to raise his head. Some sources refer to this as "tummy time" which provides the infant with the stimulation to strengthen upper body and neck muscles in preparation for good head control when sitting upright and the some of the muscles required for crawling.

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation?

When the client has the urge to defecate. CORRECT. Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and subsequent constipation. Therefore, the best time to toilet a client to encourage bowel training is when the client has the urge to defecate.

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?

a. "I can give him a tub bath in two days." CORRECT. The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks.

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following?

a. Increase their independence. CORRECT. The drive for independence is expressed by the toddler opposing the desires of those in authority (tantrums) and attempting to do everything for themselves. The Erickson developmental stage for this age is "Autonomy vs. Shame and Doubt."

A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good understanding of how to use a bulb syringe to suction excess mucous from the infant's airway?

b. "I should suction my baby's mouth before the nose." CORRECT. The mouth should always be suctioned before the nose to prevent aspiration during the gasp response that occurs when the nose is suctioned.

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention?

b. The baby is crying inconsolably for more than three hours CORRECT. Inconsolable crying lasting more than three hours and/or seizures within 48 hours of vaccination is a sign of encephalopathy that must be treated immediately.

For which of the following clients would benefit most from use of a walker?

d. An 82-year-old female client post right hip replacement that has had two falls in the past week. Correct - Walkers are needed for clients with balance problems or those that cannot support their own weight.

A nurse needs to determine a client's strength before ambulating. Which of the following should the nurse do?

d. Ask the client to plantar flex the feet against resistance. CORRECT. It is necessary to assess the client for muscle strength (legs and upper arms) as immobile clients have decreased muscle strength, tone, and mass, which affects the ability to bear weight and raise the body.