Basic Care and Comfort
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? -Encourage the client to close their eyes. -Alternatively patch one eye every 2 hours. -Turn out the lights in the room. -Instill artificial tears.
A: Alternatively patch one eye every 2 hours. Rationale: Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.
The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take? -Have the client breathe into a paper bag. -Instruct the client to put the head between the knees. -Give the client a low concentration of oxygen by nasal cannula. -Tell the client to take several deep, slow breaths and exhale normally.
A: Have the client breathe into a paper bag. Rationale: The best way to ease symptoms caused by hyperventilation is to have the client breathe into a paper bag. This helps to raise carbon dioxide level, which encourages deeper, slower breathing. The symptoms of hyperventilation will not be alleviated by having the client put the head between the knees, giving the client low concentrations of oxygen, or having the client take deep, slow breaths and exhaling normally.
In evaluating a client's response to nutrition therapy which laboratory test would be of highest priority to examine? -serum potassium level -lymphocyte count -albumin level -CBC differential
A: albumin level Rationale: Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge their nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.
After the nurse teaches the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching? -application of powder to the skin under the cast -inspection of the cast edges for smoothness -application of plastic film to cover the perineal cast area -inspection of areas inside the cast
A: application of powder to the skin under the cast Rationale: Powder should not be applied to the skin beneath the cast because powder can cause irritation and skin breakdown. The mother would need further teaching about avoiding this measure. Checking the smoothness of the cast edges, covering the cast around the perineum, and inspecting inside the cast are all appropriate actions for the child with a spica cast to help prevent skin breakdown.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? -Talk slowly and enunciate each word. -Switch topics frequently to keep the client's attention. -Talk in a louder than normal voice. -Face the client and establish eye contact.
A: Face the client and establish eye contact. Rationale: When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. Enunciating each word is unnecessary. The nurse should allow the client at least 30 seconds to respond to questions or follow a command. Clients with aphasia may need more time to process and understand information. Nurses should use short, simple sentences and avoid frequently changing topics. It is unnecessary to speak in a louder or softer voice than normal.
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? -Take a mild laxative such as magnesium citrate when necessary. -Take a stool softener such as docusate sodium daily. -Administer a tap-water enema weekly. -Administer a phospho-soda enema when necessary.
A: Take a stool softener such as docusate sodium daily. Rationale: Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.
When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: -ascites. -contractures. -fluid overload. -dry mouth.
A: contractures Rationale: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications.Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.
A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do? Select all that apply. -Change the feeding apparatus every 24 hours. -Use a higher volume of formula because the formula may be too hypotonic. -Slow the administration rate. -Use a diluted formula, gradually increasing the volume and concentration. -Anticipate changing to a lactose-free formula.
A: -Change the feeding apparatus every 24 hours. -Slow the administration rate. -Use a diluted formula, gradually increasing the volume and concentration. -Anticipate changing to a lactose-free formula. Rationale: Although about 50% of diarrhea in clients receiving tube feedings is caused by sorbitol-containing medications, the nurse should assess for other possible causes. Diarrhea can occur as a result of bacterial contamination if fresh formula is not used or stored in a refrigerator, or if the feeding apparatus is not changed at least every 24 hours. Lactose intolerance, rapid formula administration, low serum albumin level, and hypertonic solutions may also cause diarrhea. Hypotonic solutions would not be a likely cause of diarrhea, abdominal distention, or cramping.
In setting goals for a client with advanced liver cancer who has poor nutrition, which is a desired outcome for the client? -The client will have normalized albumin levels. -The client will return to ideal body weight. -The client will gain 1 lb (0.5 kg) every 2 weeks. -The client will maintain current weight.
A: The client will maintain current weight. Rationale: An appropriate and realistic outcome would be for the client to maintain current weight or not lose weight. It is unrealistic to expect that the client with advanced liver cancer will have normal albumin levels or will be able to gain weight.
The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client? -Instruct the client to change their dietary intake -Instruct the client about relaxation techniques -Administer prescribed analgesics -Encourage increased fluid intake
A: Administer prescribed analgesics Rationale: Administering prescribed analgesics to relieve pain would be the priority. The other actions are appropriate measures, but aren't the priority.
A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device? -"The splint will not be removed for several weeks." -"The splint supports the spine while you are in traction." -"The splint permits free range of motion of the body area." -"The splint immobilizes the body part in a functional position."
A: "The splint immobilizes the body part in a functional position." Rationale: Contoured splints are used for health issues to immobilize the area and support the body part in a functional position. Splints are easily removed and are not indicated for use in traction. The splint prevents, not permits, free range of motion of the body area.
A client has several patches of vesicles over both arms. Which care should the nurse provide to this client? -Cover the draining areas with sterile gauze. -Prepare for phototherapy treatment. -Apply warm soaks to the areas every 4 hours. -Instruct on the application of an antiparasitic agent.
A: Cover the draining areas with sterile gauze. Rationale: Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Because vesicles contain serous fluid, the areas that are draining should be covered with a sterile dressing. Phototherapy is used to treat psoriasis. Warm soaks would irritate the vesicles and may cause them to burst. An antiparasitic agent is used to treat scabies or lice.
A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch? -"I'll empty my pouch when it is about one-third full." -"I can take my pouch off at night." -"I should change my pouch immediately after lunch." -"I must apply a new pouch system every day."
A: "I'll empty my pouch when it is about one-third full." Rationale: The pouch should be emptied when it is about one-third full to prevent the pouch's weight from breaking the seal.The client with an ileostomy must wear a pouch at all times to collect stool.The client should change the pouch at a time when the stoma is least likely to function; 2 to 4 hours after a meal is generally the most appropriate time.A pouch can be worn for 3 to 7 days before being changed.
What is the most important nursing intervention when caring for a child with a newly applied wet hip spica cast? -Use the abductor bar to help move the child. -Cover the cast in plastic to keep it clean. -Reposition the child every 1 to 2 hours. -Use the fingertips when handling the cast.
A: Reposition the child every 1 to 2 hours. Rationale: The child in a wet hip spica cast should be turned every 1 to 2 hours to help dry all sides of the cast and prevent skin breakdown. The abductor bar shouldn't be used for turning the child, even after the cast is dry. A wet cast shouldn't be covered with plastic because this will impede drying, reduce air circulation, and allow heat to build up in the cast. A wet cast should be handled using the palms, because fingertips may cause indentations and pressure points.
The nurse is teaching a client with a peptic ulcer about the diet that should be followed after discharge. What types of food should the nurse suggest the client include in the diet? -bland foods -high-protein foods -any foods that are tolerated -a glass of milk with each meal
A: any foods that are tolerated Rationale: Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.
The nurse has instructed the client about the correct positioning of the leg and hip following hip replacement surgery. Which statement indicates that the client has understood these instructions? -"I may cross my legs as long as I keep my knees extended." -"I should avoid bending over to tie my shoes." -"I can sit in any chair that I find comfortable." -"I should avoid any unnecessary walking for about 3 months after my surgery."
A: "I should avoid bending over to tie my shoes." Rationale: Acute flexion and adduction of the hip should be avoided after hip replacement surgery and the client should not bend over to tie the shoes. Slip on shoes that can be positioned with a long handled shoe horn are preferred. The client may not cross (adduct) the legs as this is a risk for dislocating the prosthesis. The client should not sit in low chairs that will require excessive hip flexion to get in or out of. Hip flexion also increases the risk of dislocation.Frequent walks are encouraged to increase muscle strength and provide hip exercises.
A client reports abdominal pain. Which action allows the nurse to investigate this complaint? -using deep palpation -assessing the painful area last -assessing the painful area first -checking for warmth in the painful area
A: assessing the painful area last Rationale: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when the nurse will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.
A client who survived a hemorrhagic stroke now demonstrates a speech disability. What is the best response when the home care nurse observes the spouse speaking for the client and finishing the client's sentences? -"Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." -"Remember to use a regular tone of voice when you help your spouse speak so your spouse can clearly understand the answers." -"I am wondering if you are concerned about your spouse's cognitive ability, as you seem to frequently speak for your spouse." -"Today I noticed that you are speaking for your spouse, and it would be helpful to have practice conversations with your spouse."
A: "Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." Rationale: When a client has a speech disability, it is important to be patient and allow the client time to speak and answer questions, rather than speak for and answer questions directed to the client. The tone of voice does not help the client better understand what is being said. Typical conversations are a part of daily interaction in a relationship, therefore practice conversations are not needed.
A client is experiencing uncontrollable back pain and a physical therapist suggests a back massage. The clients asks the nurse how massage will help the pain. What is the best response by the nurse? -"A massage will relax muscles but does not wrok on ligaments and tendons." -"Massage is widely practice by all hospitalized clients." -"Massage is an alternative therapy that uses herbal supplements." -cc"Massage is point stimulation used for orthopedic and neurological conditions."
A: "Massage is point stimulation used for orthopedic and neurological conditions." Rationale: Massage uses point stimulation of pushing and pulling of the skin to relieve orthopedic and neurological conditions. Massage will realx muscles, ligaments, and tendons. Massage is not widely used by hospitalized clients nor does it include the use herbal supplements.
The parents of an ill child are concerned because the child "is not eating well." Which strategies are appropriate to encourage the child to eat? Select all that apply. -Allow the child to choose meals from an acceptable list of foods. -Let the child substitute items on the tray for other nutritious foods. -Ask the child to say why he or she is not eating. -Remind the child he or she must eat in order to get better. -Request that the parents not be present when the child is eating.
A: -Allow the child to choose meals from an acceptable list of foods. -Let the child substitute items on the tray for other nutritious foods. -Ask the child to say why he or she is not eating. Rationale: Allowing children choices typically helps them feel in control. They also will be more likely to eat foods they have chosen. Letting the child substitute items on the tray for other nutritious foods is another way to allow the child to make choices, thus helping the child to feel in control.It is important to find out why the child is not eating. Children refuse to eat for various reasons, and interventions should be devised that take into consideration the reason for the child's refusal.Although nutrition plays a large part in the healing process, it is not advisable to tell a child that he or she will not get better if he does or does not do a particular activity. Not only is this dishonest, it also makes the child believe that his own actions are causing the illness.Children usually eat better when their parents are present; there is no indication that the parents are contributing to the child's eating problem.
A prenatal client wants to begin a yoga-based exercise class to keep her healthy during pregnancy. What information should the nurse include in the plan of care? Select all that apply. -Drink plenty of water before, during, and after a workout. -Take precaution to prevent overheating. -Avoid jerky, high-impact motions. -Modify any positions that put strain on the abdomen. -Participate only classes specifically designed for pregnant clients.
A: -Drink plenty of water before, during, and after a workout. -Take precaution to prevent overheating. -Avoid jerky, high-impact motions. -Modify any positions that put strain on the abdomen. Rationale: Clients should keep well hydrated with any form of exercise. Dehydration can lead to dizziness and put the client at risk for falls. Later in pregnancy, dehydration can contribute to preterm labor. Becoming overheated can lead to dehydration. In the first trimester heat can act as a teratogen. Ligaments become more relaxed during pregnancy, making joints more mobile. High impact, quick movements can lead to injury. Many yoga poses put pressure on the abdomen and would need to be modified as a pregnancy progresses. It is unnecessary to restrict participation to a prenatal yoga class only; however, the client should be advised to notify the instructor that she is pregnant and discuss if participating in that particular class is appropriate.
On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do? -Ask the primary care provider for a simethicone prescription. -Chew on some ice chips. -Drink some hot coffee. -Ambulate more often.
A: Ambulate more often. Rationale: During the first few days postpartum, the accumulation of gas in the intestines may cause discomfort. This is relieved by measures such as increasing activity, doing leg exercises, avoiding carbonated or very hot or cold beverages, avoiding using ice or straws, and maintaining a high-protein liquid diet for the first 24 to 48 hours. A rectal tube also may be used. A gastric or intestinal tube is sometimes used when other measures fail.Simethicone tablets may provide some relief, but the nurse, not the client, should ask the primary care provider for this medication.Chewing on ice chips or using a straw may actually increase gas accumulation.Drinking hot coffee should be avoided because very hot or cold beverages increase gas accumulation.
The nurse is reading the nurse's note from the previous shift to evaluate the client with a risk for impaired skin integrity due to fluid volume excess. Which aspects would demonstrate this improvement? -Presence of urine output that is amber in color. -Foot of bed elevated 30 degrees for peripheral edema. -Ambulation to the bathroom without noted dyspnea. -Client statement of thirst and request for the cup of water.
A: Ambulation to the bathroom without noted dyspnea. Rationale: The client would have ambulation without dyspnea as a sign of improvement with fluid volume excess. Amber urine is a sign of a continued imbalance of fluid volume and the client's response of thirst is likely due to fluid restriction, not an indication of improvement. The foot of bed elevation would be a treatment and not a sign of improvement with fluid volume excess.
The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? -Reposition the tube in the nares. -Irrigate the tube with a cool solution. -Apply a water-soluble lubricant to the nares. -Have the client change position more frequently.
A: Apply a water-soluble lubricant to the nares. Rationale: Applying a water-soluble lubricant to the nares helps alleviate sore nares when an NG tube is in place. Repositioning the tube does not eliminate the possibility of irritating the nares. Irrigating the tube with a cool solution or changing positions will not relieve the local irritation from the NG tube.
The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain? -Observe the child for behaviors such as crying and restlessness. -Ask the child to describe the way the pain feels. -Ask the child to point to a face drawing that indicates pain intensity. -Ask the child to rate the pain intensity on a scale of 1 to 10.
A: Ask the child to point to a face drawing that indicates pain intensity. Rationale: In this age group, it would be most appropriate to use a nonverbal manner of pain assessment. The pain intensity rating scale consists of six faces with expressions ranging from happy and smiling to sad and tearful. It is highly reliable in children of this age-group. Observing the child for pain behaviors such as crying and restlessness is most appropriate for pain assessment in infants. Asking a child of this age to describe the way the pain feels may give inconsistent data. The numeric pain scale is most reliable in children older than age 8.
The family of a client who was receiving hospice care contacts the facility every week to talk with the nurse who was the client's primary caregiver. What action should be taken to support the family? -Schedule time to visit the family at home. -Contact the hospice agency to provide grief support for the family. -Suggest the family engage in work and leisure activities. -Ask the family to come to the facility to meet with the primary nurse caregiver.
A: Contact the hospice agency to provide grief support for the family. Rationale: If the client was cared for by hospice, the family should be provided grief support for up to a year following the death of the client. The family may require more support than a visit from the nurse. Everyone grieves in one's own way. Suggesting the family engage with work and leisure activities does not take the family's need to grieve and mourn into consideration. Having the family come to the facility to see the primary nurse caregiver may not be sufficient for the family's needs. The best action is for the hospice agency to provide grief support.
For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? -Impaired urinary elimination -Deficient fluid volume -Imbalanced nutrition: Less than body requirements -Excess fluid volume
A: Deficient fluid volume Rationale: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.
During a visit to the clinic, a pregnant 25-year-old woman who began prenatal care at 10 weeks' gestation and is now in her third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful? -Use glycerin suppositories as needed. -Eat at least four pieces of fruit daily. -Avoid highly seasoned foods. -Use milk of magnesia, as needed.
A: Eat at least four pieces of fruit daily. Rationale: Dietary measures such as increasing dietary intake of bulk and roughage (e.g., eating at least four pieces of fruit each day) help to relieve constipation and should be suggested initially. Other nonpharmacologic measures include drinking a glass of hot fluid in the morning, increasing fluid intake, and exercising regularly.It is best not to suggest laxatives or suppositories because a client may become dependent on them. Additionally, the client should avoid taking any medication unless directed to do so by the primary care provider. If the constipation is unrelieved by other nonpharmacologic measures, the primary care provider may prescribe glycerin suppositories.Avoiding highly seasoned foods would have no effect on constipation. However, if the client was experiencing heartburn, this might be an appropriate suggestion.Laxatives, even mild over-the-counter ones, should be used only when diet, fluid intake, and exercise do not relieve the problem and after consultation with the nurse or primary care provider.
A nurse is caring for a client with Alzheimer disease who was admitted to the hospital from a nursing home. The hospital staff is having difficulty managing the client's urinary incontinence because the client wanders around the unit all day. What is the most appropriate action by the nurse to assist with elimination? -Incorporate a toileting schedule into the pattern of the client's wandering. -Ask the health care provider to prescribe sedation to allow the client to rest. -Teach the client Kegel exercises to increase voluntary control over urination. -Have the client wear a pad and a brief to ensure the absorption of incontinent urine.
A: Incorporate a toileting schedule into the pattern of the client's wandering. Rationale: Incorporating the client's toileting schedule into the wandering assists with elimination and increases the chance of continence. Sedation will decrease the client's mobility but does not address the frequent incontinent episodes. The stem indicates the client's incontinence is related to wandering, not a weakened pubococcygeus (PC) muscles. Therefore, teaching Kegel exercises is unnecessary. Additionally, clients with Alzheimer disease have difficulty with thought and memory; therefore, teaching can be challenging. A pad and brief at the same time does not ensure urine absorption nor do they address the incontinence issue.
The nurse is caring for a client during the postoperative period. The client was prescribed thigh high antiembolism stockings and pneumatic compression devices for prevention of deep vein thrombosis. Assessment data reveal +3 pitting edema to the lower extremities bilaterally. What is the priority action by the nurse? -Measure client's thighs and calves to ensure the antiembolism stockings are the correct size. -Discontinue the antiembolism stockings and use the pneumatic compression devices alone. -Discontinue the antiembolism stockings and notify the healthcare provider. -Apply a larger size antiembolism stocking and notify the healthcare provider.
A: Measure client's thighs and calves to ensure the antiembolism stockings are the correct size. Rationale: For the client with antiembolism stockings and pneumatic compression devices in place for prevention of deep vein thrombosis, it is important for the nurse to remove the stockings and assess the client's skin every 8 hours. If the client has a significant change in the size of the legs, such as with postoperative edema, it would be the nurse's priority to measure the client's legs to ensure the stockings are the correct size. If the measurement showed the need for another size stockings, the nurse would apply them at that time. Clients in the postoperative period are at risk for deep vein thrombosis, therefore it is the priority to ensure the appropriate sized antiembolism stockings, not to discontinue them. Applying a larger size would be implemented after measuring the client's legs to ensure the stockings are the correct size. There is no need to notify the healthcare provider if the nurse applies a larger size.
When assessing for pain in a toddler, which method would be the most appropriate? -Ask the child about the pain. -Observe the child for restlessness. -Use a numeric pain scale. -Assess for changes in vital signs.
A: Observe the child for restlessness. Rationale: Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. While the FACES pain scale can be used in young children numeric rating pain scales are more appropriate for children who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed first.
A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings? -Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. -Apply an ice pack to the incision for 15 minutes prior to application. -Cover the incision with a gauze bandage to provide cushion to the incision. -Premedicate the client with prescribed acetaminophen 500 mg PO 15 minutes prior to application.
A: Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. Rationale: The application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application. Oral acetaminophen 500 mg will not likely provide effective pain relief 15 minutes prior to application of the graduated compression stockings. Although an ice pack may reduce pain, the prescribed morphine will be more effective for relieving pain rated 8/10. Placing a gauze pad to the incision prior to applying the graduated compression stockings may be necessary to absorb drainage, but will not provide pain relief during application.
A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis? -a low-protein, high-fiber diet distributed over four to five moderate-sized meals daily -a low-fat, bland diet distributed over five to six small meals daily -a high-calcium, soft diet distributed over three meals and an evening snack daily -a diabetic exchange diet distributed over three meals and two snacks daily
A: a low-fat, bland diet distributed over five to six small meals daily Rationale: A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition. Dietary protein and fiber are not directly related to pancreatitis. Although calcium is important, the low-fat content is more significant. The hyperglycemia of acute pancreatitis is usually transient and does not require long-term dietary modification.
What observation should the nurse instruct the client with an ileostomy to report immediately? -passage of liquid stool from the stoma -occasional presence of undigested food in the effluent -absence of drainage from the ileostomy for 6 or more hours -temperature of 99.8° F (37.7° C)
A: absence of drainage from the ileostomy for 6 or more hours Rationale: Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the health care provider (HCP) immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8° F (37.7° C) is not necessarily abnormal or a cause for concern.
A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of -acupressure. -biofeedback. -meditation. -aromatherapy.
A: acupressure Rationale: The band on the wrist described by the client is an example of acupressure. Biodfeedback involves conncection to electrical sensors provide the person with information about the body so that the person can then focus actions to make small changes in the body to achieve the goal. Meditation involves deep thinking and reflection to focus the mind and body. Aromatherapy involves the use of essential oils to promote well-being
An older adult client who is 5 feet, 4 inches (163 cm) and weighs 145 lb (65 kg) is admitted to the long-term care facility. The client sits for long periods in a wheelchair and has bowel and bladder incontinence. The client can feed themself and has a fair appetite, eating best at breakfast and poorly thereafter. The client does not have family members living nearby and is often noted to be crying and depressed. The client also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer? Select all that apply. -weight -incontinence -sitting for long periods -sedation -crying and depression -eating poorly at lunch and dinner
A: incontinence sitting for long periods sedation Rationale: Inactivity, immobility, incontinence, and sedation are all risk factors for pressure ulcers. The client's weight and poor eating habits at lunch and dinner are not directly related to the risk of developing pressure ulcers. A calorie count should be taken to see if the client is getting adequate calories and fluids because poor nutrition can contribute to pressure ulcers. The fact that the client cries and is depressed has no direct bearing on risk of developing a pressure ulcer. However, clients with depression are commonly not as active, so the client's activity levels should be monitored closely.
A nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in this client's care plan? -meeting all of the client's physical needs -giving the client an opportunity to express concerns -administering lithium carbonate as ordered -providing a quiet environment in which the client can be alone
A: meeting all of the client's physical needs Rationale: Because a client with catatonic schizophrenia can't meet physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. Although this client is incapable of expressing concerns, the nurse should try to verbalize the message the nonverbal behavior conveys. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with the client, not leave the client alone all the time. Although aware of the environment, the client doesn't actively interact with it; the nurse's support and presence can be reassuring.
A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet? The diet will: -act as a diuretic. -reduce demands on the liver. -help maintain urine acidity. -prevent the development of ketosis.
A: prevent the development of ketosis. Rationale: High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.
When percussing a client's chest, what should the nurse expect to hear? -hyperresonance -tympany -resonance -dullness
A: resonance Rationale: Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.
A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? -applying ice -applying a breast binder -teaching how to express the breasts -administering bromocriptine
A: teaching how to express the breasts Rationale: Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.
The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? -high-carbohydrate, high-protein -high-calcium, high-potassium, high-protein -low-protein, low-sodium, low-potassium -low-protein, high-potassium
A: low-protein, low-sodium, low-potassium Rationale: Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? -"Yes, it produces no adverse effects." -"No, it can initiate premature uterine contractions." -"No, it can promote sodium retention." -"No, it can lead to increased absorption of fat-soluble vitamins."
A: "No, it can initiate premature uterine contractions." Rationale: Castor oil can initiate premature uterine contractions and other adverse effects in pregnant women. Castor oil doesn't promote sodium retention and isn't known to increase absorption of fat-soluble vitamins.
A postpartum woman who gave birth vaginally has unrelenting rectal pain despite the administration of pain medication. Which action is most indicated? -administering additional pain medications -assessing the perineum -reassuring the client that such pain is normal after vaginal birth -preparing a warm sitz bath for the client
A: assessing the perineum Rationale: Pain after childbirth is generally well managed with pain control medications; since they did not help this woman, further assessment is necessary. The first nursing action would be to assess the source of the pain; the woman may have sustained a laceration or a hematoma as a result of childbirth. Assessing the perineum may help the nurse to determine the source of the pain and may require follow-up by the health care provider (HCP) . Subsequent nursing interventions may include pain medication, sitz bath, or education regarding the healing process.
A school-age child with burns on the trunk and arms has no appetite. The nurse and the parent develop a plan of care to stimulate the child's appetite. Which suggestion made by the parent would indicate the need for additional teaching? -deciding that the parent will feed the child -withholding dessert and treats unless meals are eaten -offering the child finger foods that the child likes -serving smaller and more frequent meals
A: withholding dessert and treats unless meals are eaten Rationale: Withholding certain foods until the child complies is punitive and rarely successful. Allowing the parent to feed the child, serving smaller and more frequent meals, and offering finger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill.
An adolescent has skeletal traction for a fractured femur. Which is the most appropriate nursing intervention for this client? -Assess pin sites every shift and as needed. -Ensure that the rope knots catch on the pulley. -Add and remove weights at the adolescent's request. -Put all the joints through range of motion every shift.
A: Assess pin sites every shift and as needed. Rationale: Nursing care for a client in traction includes assessing pin sites every shift and as needed and ensuring that the knots in the rope don't catch on the pulley. The nurse should add and remove weights at the physician's order, not at the adolescent's request. All joints, except those immediately proximal and distal to the fracture, should be put through range of motion every shift.
A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises? -Tighten her stomach muscles. -Lift both legs while lying down. -Do pelvic squats. -Stop the flow of urine while urinating.
A: Stop the flow of urine while urinating. Rationale: By stopping urine flow during urination, the pelvic floor muscles are contracted. Tightening the leg or stomach muscles doesn't contract the pubococcygeus muscle. Pelvic squats don't tighten the pelvic floor muscles.
Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? -"Wait until you have breastfed for at least 4 months." -"Eliminate the baby's favorite feeding times first." -"Plan to omit the daytime feedings last." -"Gradually eliminate one feeding at a time."
A: "Gradually eliminate one feeding at a time." Rationale: The client should wean the infant gradually, eliminating one feeding at a time. The baby can be weaned to a bottle (formula) anytime the mother desires; she does not have to breastfeed for 4 months. Most infants (and mothers) develop a "favorite feeding time," so this feeding session should be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is busy.
The nurse instructs a primigravid client about the importance of sufficient vitamin A in her diet. The nurse knows that the instructions have been effective when the client indicates that she should include which foods in her diet? -buttermilk and cheese -strawberries and broccoli -egg yolks and squash -oranges and tomatoes
A: egg yolks and squash Rationale: Egg yolks and squash and other yellow vegetables are rich sources of vitamin A. Pregnant women should avoid megadoses of vitamin A because fetal malformations may occur. Buttermilk and cheese are good sources of calcium. Strawberries, broccoli, citrus fruits (such as oranges), and tomatoes are good sources of vitamin C, not vitamin A.
The nurse gives a pamphlet that describes Kegel exercises to a client with stress incontinence. Which statement indicates that the client has understood the instructions contained in the pamphlet? -"I should perform these exercises every evening." -"It will probably take a year before the exercises are effective." -"I can do these exercises sitting up, lying down, or standing." -"I need to tighten my abdominal muscles to do these exercises correctly."
A: "I can do these exercises sitting up, lying down, or standing." Rationale: The client can perform the Kegel exercises anytime in any position listed. Pelvic muscles, not the abdominal muscles, should be contracted during these exercises. The client can learn to identify these muscles by urinating and stopping the flow.To be most effective, the exercises should be performed at least twice a day for a total of 10 minutes a day.If performed regularly, the client should begin to note changes after about 6 weeks.
A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: -increase the client's fluid intake to 3,000 mL/day. -administer an oil retention enema. -place the client on the bedpan every 3 to 4 hours. -perform passive range of motion to extremities.
A: increase the client's fluid intake to 3,000 mL/day. Rationale: The most appropriate nursing action is to first increase the client's fluid intake to 3,000 mL/day to soften stool.A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool.Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement.While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement.
A child has chickenpox. The parent asks how to care for the lesions. What should the nurse tell the parent? -Soak in a hot tub for 30 minutes three times a day. -Take an antihistamine, and use calamine lotion on the closed lesions. -Take acetaminophen, and use an antibiotic ointment on the lesions. -Remove lesions' crusts as they form.
A: Take an antihistamine, and use calamine lotion on the closed lesions. Rationale: Use of an antihistamine and calamine lotion are recommended to help decrease the itching.The child can have a bath in cool water, but soaking in a hot tub will dry out the skin. Use of oatmeal baths helps decrease itching.Acetaminophen should be used only if the child has a fever. Antibiotic ointment may be used if lesions are infected.The father should only remove loose crusts that rub and irritate the child.
A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should respond to the client by understanding that in the Asian culture which is the intended outcome of acupuncture? Acupuncture: -purges evil spirits. -promotes tranquility. -restores the balance of energy. -blocks nerve pathways to the brain.
A: restores the balance of energy. Rationale: Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.
An anxious client is admitted for treatment of an exacerbation of irritable bowel disease. The client asks the nurse if biofeedback will help after reading about biofeedback online. What is the best response by the nurse? -"Biofeedback will help reduce stress." -"Biofeedback does not work for irritable bowel disease." -"Stress is hard to control and you may need a medication to relax." -"The device is just another expensive electronic toy."
A: "Biofeedback will help reduce stress." Rationale: The nurse should acknowledge that biofeedback is an evidence-based treatment for stress reduction and commend the client for reading and asking about the modality. It is considerate to ask the availability of this device and respectful to ask for more information as needed. It is demeaning to insist that biofeedback does not work, is not a serious treatment, or is not indicated for the client's condition. The nurse should not tell the client that a medication for relaxation is needed.
