Basic Care and Comfort

A client who is prescribed a 2-gram sodium diet asks for juice. How should the nurse respond? a. "I suggest you have pear nectar." b. "I suggest you have tomato juice." c. "Juice is not permitted on a low-sodium diet." d. "Juice between meals is not calculated into your diet."

a. "I suggest you have pear nectar." Pear nectar is low in sodium and is a better choice for this client. Tomato juice has a high sodium content; it should be avoided to prevent fluid retention. Low-sodium juices are permitted. The client is permitted low-sodium juice between meals.

The parent of a 2-year-old child with just-diagnosed cystic fibrosis expresses concern about the child's frailty and low weight. Which is the most appropriate reply by the nurse? a. "Digestive enzymes will be given to help your child digest food." b. "Your child's appetite will improve once respiratory therapy is started." c. "Your child's coughing and shortness of breath prevent the adequate chewing of food." d. "I suggest that you offer baby foods to your child because they are more easily digested."

a. "Digestive enzymes will be given to help your child digest food." Because the pancreatic ducts are blocked and fibrotic, oral pancreatic enzymes must be given to make the nutrients digestible and absorbable. Children with cystic fibrosis have good, even voracious, appetites despite respiratory impairment. Chewing is adequate despite coughing and shortness of breath; undernourishment results from inadequate nutrient absorption. It is not the consistency of the foods that leads to inadequate digestion and absorption, but the lack of enzymes from the pancreatic duct.

After recovering from gastrointestinal surgery, a client is prescribed a regular diet. To minimize stomach irritation, the nurse would encourage the client to consume which food? a. Fresh fruit b. Baked fish c. Bran cereal d. Whole milk

b. Baked fish Baked fish is a low-residue, low-fat, high-protein, and non-gas-producing food that usually is tolerated well. Fresh fruit has fiber that irritates the gastrointestinal tract. Bran cereal has fiber that irritates the gastrointestinal tract. Whole milk irritates the gastrointestinal tract and stimulates mucus production.

When educating a client with interstitial cystitis, which foods would the nurse mention are bladder irritants? Select all that apply. One, some, or all responses may be correct. a. Milk b. Nuts c. Citrus fruit d. Aged cheeses e. Soy-containing foods f. Green, leafy vegetables

b. Nuts c. Citrus fruit d. Aged cheeses Nuts, citrus fruits, and aged cheeses irritate the bladder of some individuals. Milk, soy-containing foods, and green, leafy vegetables are not likely to irritate the bladder.

When caring for a client in the early postoperative period after a hemorrhoidectomy, the nurse will place the client in which position? a. Supine b. Side-lying c. High-Fowler d. Trendelenburg

b. Side-lying Side-lying position helps alleviate pressure on the surgical area. High-Fowler and supine should be avoided; both positions will put undue pressure on the site. Trendelenburg is not indicated as an effective intervention for hemorrhoidectomy postoperative care.

Which description would the nurse expect when the parents of a child with celiac disease describe their child's stools? a. Large, frothy, green b. Small, pale, mucoid c. Large, pale, foul-smelling d. Moderate, green, foul-smelling

c. Large, pale, foul-smelling Children with celiac disease have a gluten-induced enteropathy and are unable to absorb fats from the intestinal tract, resulting in stools that are large and fatty or frothy, not mucoid. Although the stools are large and frothy, they are pale because of their high fat content. The stools are large and foul-smelling and have little color.

Which reason would the nurse teach parents is the most important influence on the eating habits of early school-aged children? a. Smell and appearance of food b. Availability of food selections c. Food preferences of the peer group d. Example of parents and siblings at mealtimes

d. Example of parents and siblings at mealtimes The early school-aged child has become a cooperative member of the family and will mimic parents' attitudes and food habits readily. Smell and appearance of food do not have a major influence on eating habits. Availability of food selections certainly has some, though not major, influence on eating habits. The peer group does not become influential until later school age and during adolescence.

Which suggestion for coping with morning sickness would the nurse give to a pregnant client? a. "Eat protein before bedtime." b. "Take an antacid before breakfast." c. "Drink water until the nausea subsides." d. "Take an over-the-counter herbal remedy."

a. "Eat protein before bedtime." Nausea and vomiting in early pregnancy can be relieved with a small snack of protein before bedtime to slow digestion. An antacid may affect electrolyte balance, and it will not ease morning sickness. Drinking water until the nausea subsides is contraindicated because both fetus and mother need nourishment. Many medications and herbal remedies in the first trimester are contraindicated because this is the period of organogenesis, and such preparations could have teratogenic effects.

Which questions would the nurse ask when assessing a client diagnosed with acromegaly? Select all that apply. One, some, or all responses may be correct. a. "Have you noticed any changes to your vision?" b. "Have you ever been told that you snore loudly?" c. "Have you had any changes in your menstrual cycle?" d. "Have you noticed any changes to your bowel movements?' e. "Have you noted you consume excessive amounts of cruciferous vegetables?"

a. "Have you noticed any changes to your vision?" b. "Have you ever been told that you snore loudly?" d. "Have you noticed any changes to your bowel movements?' It is reasonable to ask a client with acromegaly if he or she has experienced changes in his or her vision, because pressure on the optic nerve from a pituitary adenoma can occur. Some clients with acromegaly will develop sleep apnea, secondary to upper airway narrowing and obstruction from increased amounts of pharyngeal soft tissues. Clients with acromegaly are at an increased risk of colorectal cancer. It is not necessary to ask the client with acromegaly about her menstrual cycle; acromegaly is the overgrowth of soft tissue and bone in the hands, feet, and face, and does not affect the reproductive organs as some other excesses of tropic hormones do. Intake of cruciferous vegetables will not affect acromegaly; the goitrogens in these vegetables contain thyroid-inhibiting substances and can lead to goiter if eaten in excessive amounts.

The nurse provides teaching to a client who will begin to receive tube feedings after a total laryngectomy. The nurse concludes that the teaching was understood when the client makes which statement about tube feedings? a. "I will need tube feedings until healing of the incision is complete." b. "I will need tube feedings until the gag reflex returns." c. "I will need tube feedings until the ability to belch is restored." d. "I will need tube feedings until my oral feedings can be digested."

a. "I will need tube feedings until healing of the incision is complete." Food should be avoided until the area is healed completely; this will keep the area from becoming irritated and contaminated. Because of the alterations in structure, the gag reflex is no longer present. The ability to belch has no bearing on the decision to resume oral feedings. The ability to tolerate oral feedings is not lost; such feedings are withheld to prevent irritation to the surgical site until healing has taken place.

Which is the best response to a toddler's mother of who is asking about frequent toilet accidents after the birth of their second baby last month? a. "It's common for young children to go through regressions after stressful events." b. "It's important to scold the child after an accident so the child knows not to do it again." c. "The child should be completely trained by 24 months, so I'll need to let the primary health care provider know." d. "Regressions are unusual once the child has been trained. You should consider time-outs to discourage future accidents."

a. "It's common for young children to go through regressions after stressful events." The birth of a sibling is a stressful event for a toddler and can cause regressions in potty training. It is important to avoid scolding or punishing the child after an accident and to help them clean it up. There is no need to refer the child to a primary health care provider; the regression should resolve on its own over time.

Which rationale would the nurse expect for a mother being reluctant to feed her 6-week-old infant who recently had surgery for hypertrophic pyloric stenosis (HPS)? a. Afraid that her baby's vomiting will resume b. Unaware that she is allowed to feed her baby c. Not sure how to feed her baby with a special nipple d. Uncertain whether her baby will tolerate the thickened formula

a. Afraid that her baby's vomiting will resume Previous experiences with projectile vomiting are frightening; the nurse should explain that this should not recur and encourage the mother to resume feeding her baby. The data indicate that the mother knows she is allowed to feed her baby but is reluctant to do so. A special nipple is not required. Thickened formula is not necessary after surgery.

Which emergency response team helps set up shelters for victims who lost their homes due to a disaster? a. American Red Cross b. Disaster Medical Assistance Team (DMAT) c. International Medical-Surgical Response Teams (IMSRTs) d. Disaster Mortuary Operational Response Teams (DMORTs)

a. American Red Cross The American Red Cross sets up shelters for people who have lost their homes or have been evacuated from their homes after an external disaster. A DMAT provides medical equipment that is sufficient for at least 72 hours. IMSRTs establish fully functional field surgical facilities wherever they are needed in the world. DMORTs manage mass fatalities at the disaster site.

A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? a. Apple b. Orange c. Tomato d. Grapefruit

a. Apple Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic; they can decrease the pH of the stomach and irritate the gastrointestinal mucosa.

Which diet would the nurse recommend to a parent of a healthy 8-month-old infant? a. Applesauce, carrots, chicken, and formula b. Pears, green beans, turkey, and whole milk c. Bananas, sweet potatoes, rice cereal with honey, and formula d. Peaches, cottage cheese, corn, and whole milk

a. Applesauce, carrots, chicken, and formula Applesauce, carrots, chicken, and formula are easily digested foods that should be introduced by 6 months of age; breast milk or formula, rather than cow's milk, is recommended for the first year of life. Honey is not recommended before 1 year of age because of the risk of botulism.

Which nursing interventions enhance comfort in a dying client in the hospital? Select all that apply. One, some, or all responses may be correct. a. Frequently repositioning the client b. Maintaining oral hygiene in the client c. Limiting frequent visits of the family members d. Measuring the vital signs of client frequently e. Applying body lotion to the client's skin daily

a. Frequently repositioning the client b. Maintaining oral hygiene in the client e. Applying body lotion to the client's skin daily The nurse provides comfort care to the client who is in the process of dying to ensure client comfort. Prolonged bed rest may cause back pain and skin issues; to reduce the pain, the nurse frequently repositions the client on the bed. Poor oral and skin hygiene may cause discomfort to the client, so the nurse carefully maintains the client's oral and skin hygiene. The nurse does not limit the visitation of family members because these visits may reduce the client's emotional stress. There is no need to measure the vital signs regularly in an imminently dying client, and doing so may increase discomfort in the client.

Which client would the nurse expect to experience the most severe afterbirth pains? a. Grand multipara b. Breast-feeding primipara c. Primipara with a vaginal delivery d. Woman with a cesarean delivery at 43 weeks' gestation

a. Grand multipara A multipara's uterus tends to contract and relax spasmodically, even if the uterine tone is effective, resulting in pain that may require an analgesic for relief. Although breast-feeding increases the contractile state of the postpartum uterus, the breast-feeding primipara will not have the typical afterbirth pains of a multipara. Primiparas are less likely to have afterbirth pains than multiparas. A cesarean birth has no effect on the development of afterbirth pains.

A neonate born at 36 weeks' gestation, weighing 4 lb 8 oz (2041 g), is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/h. Why is it important for the nurse to check the neonate's voidings for specific gravity? a. Infants under open radiant warmers are at risk for dehydration. b. This infusion rate is inadequate to meet a preterm infant's fluid needs. c. Infants are unable to produce adequate amounts of urine at this gestational age. d. Renal dysfunction is the complication that most frequently affects preterm infants.

a. Infants under open radiant warmers are at risk for dehydration. Open radiant warmers cause excessive fluid loss without electrolyte loss. This infusion rate, based on a rate of 100 mL/kg/day for maintenance fluid and an additional 88 mL/kg/day for fluid loss caused by the radiant warmer, is appropriate for an infant of this size. An infant at 36 weeks' gestation is able to produce sufficient quantities of urine but is unable to concentrate urine effectively. Respiratory distress syndrome is the most frequent complication in a preterm infant.

After surgery, a client is prescribed a clear liquid diet. Which items would the nurse offer to the client? Select all that apply. One, some, or all responses may be correct. a. Jell-O b. Broth c. Sherbet d. Ice milk e. Ginger ale

a. Jell-O b. Broth e. Ginger ale Jell-O, broth, and ginger ale are clear liquids and are included with a clear liquid diet. Sherbet and ice milk contain milk and are not permitted with a clear liquid diet; these items are on a full liquid diet.

Compromised nutrition during chemotherapy can contribute to an increased risk of infection and other problems. Which actions would the nurse take to offset nutritional deficiencies? a. Provide oral supplements. b. Offer the client's favorite foods. c. Restrict intake from dairy products. d. Encourage the client to drink low-protein shakes.

a. Provide oral supplements. The client with cancer may experience protein and calorie malnutrition characterized by fat and muscle depletion. Soft, nonirritating, high-protein and high-calorie foods should be eaten throughout the day. Foods suggested for increasing the protein intake and high-calorie foods that provide energy and minimize weight loss are recommended. Teach the client to avoid extremes of temperature of food, spicy or rough foods, and other irritants. Encourage nutritional supplements like nutrition drinks or shakes as an adjunct to meals and fluid intake. Teach the client to use nutritional supplements in place of milk when cooking or baking. Foods to which nutritional supplements can be easily added include scrambled eggs, pudding, custard, mashed potatoes, cereal, and cream sauces. Packages of instant breakfast can be used as indicated or sprinkled on cereals, desserts, and casseroles. Families are an integral part of the health care team. As symptom severity increases, the family's role in helping the client eat becomes increasingly critical. If the malnutrition cannot be treated with dietary intake, it may be necessary to use enteral or parenteral nutrition. Favorite foods may not be offered during chemotherapy because the client's sense of taste has changed. Dairy products are a necessary part of a balanced diet and do not affect chemotherapy. High-protein shakes are used to encourage healing and protein intake.

Which explanation for the use of Buck traction would the nurse give to the client who has a fractured femur? a. Reduces muscle spasms b. Prevents soft tissue edema c. Eliminates the need for a cast d. Prevents nerves damage

a. Reduces muscle spasms Buck extension is used to reduce the fracture, align the bone, and temporarily reduce muscle spasms. Edema occurs because of tissue trauma and will not be prevented by Buck extension. A fractured head of the femur is repaired via internal fixation; a cast is unnecessary. Damage already has occurred at the time of trauma and is not prevented by Buck extension.

An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury? a. Sacrum b. Scapulae c. Ischial spine d. Greater trochanter

a. Sacrum The sacrum is the center of the greatest body mass; an elevated torso exerts pressure toward this area. Although the scapulae are at risk, they do not bear the greatest body weight as when the client is in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an upright sitting position. Greater trochanter is at risk when the client is in a side-lying position.

The nurse provides dietary teaching for a client with calcium oxalate kidney stones. The nurse would instruct the client to limit the intake of which item? a. Sodium b. Gravies c. Red wines d. Organ meat

a. Sodium High sodium intake in clients with calcium oxalate kidney stones will reduce kidney tubular reabsorption of calcium. The nurse should instruct the client to reduce sodium intake. Clients with uric acid kidney stones should decrease their intake of gravies and red wines. Clients with struvite, uric acid, and cystine types of kidney stones should limit their intake of animal proteins such as organ meats.

Which approach would the nurse take for an older adult client who is confused, does not recognize family members, and often soils clothing with feces and urine? a. Toileting the client every 2 hours b. Placing the client in orientation therapy c. Supervising the client's bathroom activities closely d. Explaining to the client how offensive the behavior is to others

a. Toileting the client every 2 hours The approach the nurse would use is to toilet the client every 2 hours. This client needs toileting every 2 hours to prevent soiling; physically seating the client on the toilet often prevents accidents and negates the need for disposable pads or underwear. The client has cognitive impairment, and reality orientation will probably be ineffective. The client who is this severely confused needs more than just supervision. The client may be unable to control the incontinence, and saying that the behavior is offensive is demeaning.

While assessing a client's skin, the nurse notices that the client's skin is dry. Which is the probable cause of this condition? Select all that apply. One, some, or all responses may be correct. a. Use of hard soap b. Frequent bathing c. Use of tanning pills d. Presence of an allergy e. Use of petroleum products

a. Use of hard soap b. Frequent bathing The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

Which would the nurse incorporate into the plan of care for the older adult experiencing chronic pain? a. Exercise b. Distraction c. Heat therapy d. Trigger point massage

a. exercise Exercise and client teaching are important nonpharmacological activities for older adults experiencing chronic pain. Exercise promotes movement of joints and muscle strength, and it can promote relaxation. Trigger point massage is not used for chronic pain. Distraction may be valuable in clients with minor transient pain but is not used when the client is experiencing chronic pain. Heat therapy is not used for all types of chronic pain.

In addition to iron, which nutrients are necessary for red blood cell synthesis? Select all that apply. One, some, or all responses may be correct. a. Protein b. Calcium c. Vitamin C d. Vitamin D e. Carbohydrates

a. protein c. vitamin c Protein is essential for the synthesis of blood proteins, albumin, fibrinogen, and hemoglobin. Vitamin C (ascorbic acid) influences the removal of iron from ferritin (making more iron available for the production of heme) and influences the conversion of folic acid to folinic acid. Calcium, vitamin D, and carbohydrates are not involved in the synthesis of red blood cells.

Which passive warming measures would the nurse use to promote the warmth and comfort of a client experiencing hypothermia? Select all that apply. One, some, or all responses may be correct. a. Warmed socks b. Radiant warmer c. Warm forced air d. Reflective blanket e. Humidified oxygen

a. warmed socks d. reflective blanket A reflective blanket and warm socks are passive warming measures that can be used to promote the warmth and comfort of the client experiencing hypothermia. The use of a radiant warmer, forced warm air, and humidified oxygen are active warming measures.

Which statement by a woman with preeclampsia indicates the need for further teaching about needed dietary changes? a. "I should avoid excess salt." b. "I should limit my fluid intake." c. "I should eat whole grains and raw produce." d. "I should eat 60 to 70 grams of protein each day."

b. "I should limit my fluid intake." Women with preeclampsia should not limit fluid intake and should drink between 6 and 8 cups of water each day. Salt should be limited to 1.5 g of sodium daily. The client also should eat plenty of fiber from whole grains and raw fruits and vegetables as well as 60 to 70 grams of protein each day.

A mother asks the nurse how to keep her child's spica cast clean. How would the nurse respond? a. "Tuck a folded diaper above the perineal opening." b. "Place plastic wrap or duct tape around the perineal edges of the cast." c. "Wipe the cast with a wet cloth and sprinkle it with baby powder." d. "Do the best you can because it will get soiled no matter what you do."

b. "Place plastic wrap or duct tape around the perineal edges of the cast." Suggesting the use of a protective nonabsorbent material is supportive, constructive, practical, and factual. Placing a diaper above the perineal area will not protect the area beneath the perineum. Although water may or may not cause dissolution of cast material, the infant may inhale the baby powder, which can cause respiratory difficulties. "Do the best you can" is a negative response that provides neither a suggestion nor support to the mother.

Which entry in the food journal of a toddler concerns the nurse the most? a. 2 bananas after lunch b. 36 ounces of apple juice throughout the day c. Carrot sticks and ranch dressing before dinner d. String cheese, an orange, and some whole wheat crackers for lunch

b. 36 ounces of apple juice throughout the day Fruit juice is high in calories and sugar and doesn't have much nutritional value. Drinking 36 ounces a day is too much for a toddler, and the nurse would address this with the parents. Two bananas after lunch or carrot sticks with ranch dressing before dinner are fine snacks. String cheese, an orange, and whole wheat crackers provide a balanced meal for a toddler.

The nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. Which condition might this indicate? a. Venous insufficiency b. Arterial insufficiency c. Phlebitis d. Lymphedema

b. Arterial insufficiency Clients experiencing arterial insufficiency present with extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. Clients with venous insufficiency often have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result of impaired flow of the lymphatic system.

Which intervention would be included when counseling a group of parents about ways to improve the sleep of preschoolers? Select all that apply. One, some, or all responses may be correct. a. Avoid all fluids before bedtime. b. Avoid media use in the evening. c. Provide a lovey or favorite blanket at bedtime. d. Establish a soothing and consistent bedtime routine. e. Allow children to set their own bedtime so they learn to go to bed when tired.

b. Avoid media use in the evening. c. Provide a lovey or favorite blanket at bedtime. d. Establish a soothing and consistent bedtime routine. Preschoolers can sometimes struggle with bedtime because they are becoming more aware of their fears and increased sleep disturbances. Avoiding media use at bedtime, providing a lovey or favorite blanket or stuffed animal, and establishing a soothing and consistent bedtime routine can all help a child this age sleep better. Avoiding all fluids at bedtime and allowing preschoolers to set their own bedtime are not appropriate interventions for preschoolers.

Which nursing intervention would the nurse implement for a 1-day-old infant with an imperforate anus who had a pull-through procedure with an anoplasty? a. Withholding oral feedings for several days b. Encouraging continuation of breastfeeding c. Placing the infant in the Trendelenburg position d. Positioning the infant supine with the head of the crib elevated

b. Encouraging continuation of breastfeeding The goal is to prevent constipation to limit trauma to the surgical site. Breast milk produces a softer stool. Oral feedings are started soon after surgery. Placing the infant in the Trendelenburg position will not promote healing in the anal area and may impede respiratory excursion. Positioning the infant supine with the head of the crib elevated will increase pressure in the perianal area, which could compromise healing.

Which nursing action would be implemented during the transition phase of labor? a. Decrease the fluid intake. b. Help the client maintain control. c. Administer the prescribed opioid medication. d. Encourage the client to breathe in simple patterns.

b. Help the client maintain control. The transition phase is the most difficult part of labor, and the client needs encouragement and support to cope. Fluid management does not depend on the stage of labor. An opioid at this time is contraindicated because it will depress the newborn's respiration. The breathing pattern should be complex and should require a high level of concentration to distract the client.

Which intervention would the nurse prioritize to soothe a hospitalized infant who appears to be in pain? a. Feeding the infant b. Holding the infant c. Playing soft music in the room d. Providing a quiet environment

b. Holding the infant Physical contact provides security for a distressed infant. Feeding to provide comfort is not always an option because the infant may have been fed recently, may be anorexic, or may be on nothing-by-mouth status. Music or a quiet environment helps avoid overstimulation of an infant, but may not help soothe.

The nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in the client's diet? Select all that apply.One, some, or all responses may be correct. a. High fat b. Low sodium c. High vitamins d. Moderate protein e. Low carbohydrates

b. Low sodium c. High vitamins d. Moderate protein Low sodium intake controls fluid retention and edema and, consequently, ascites. Vitamins help repair long-standing nutritional deficits associated with cirrhosis of the liver. A moderate protein diet reduces formation of ammonia, which must be degraded by the liver. High fat intake should be avoided because of related cardiovascular risks and a demand for bile that the liver may not be capable of meeting. High, not low, carbohydrate intake is necessary to meet energy requirements for tissue regeneration.

Which principles of body mechanics would the nurse use when providing care for an immobilized client? a. Bending at the waist to provide the power for lifting b. Placing the feet apart to increase the stability of the body c. Keeping the body straight when lifting to reduce pressure on the abdomen d. Relaxing the abdominal muscles while using the extremities to prevent strain

b. Placing the feet apart to increase the stability of the body Placing the feet apart creates a wider base of support and brings the center of gravity closer to the ground. This improves stability. The nurse should avoid bending at the waist because the movement strains the lower back muscles; the muscles of the thighs and buttocks should provide the power of lifting. Prevent pressure on the abdomen by tightening the abdominal and gluteal muscles to form an internal girdle; keeping the body straight does not reduce strain on the abdominal musculature. Relaxing the abdominal muscles with physical activity increases back strain.

The nurse advises a client recovering from a musculoskeletal injury to increase intake of which nutrient? a. Fat b. Protein c. Sodium d. Vitamin A

b. Protein People suffering from a musculoskeletal injury should be advised to increase their intake of protein to promote tissue healing and recovery. Also important are adequate intake of fluids, fiber, and minerals such as calcium, phosphorus, and magnesium. Fat, sodium, and vitamin A are not specifically beneficial for musculoskeletal injuries.

The nurse is teaching parents about the nutritional needs of their 15-year-old child. Which information would the nurse provide? Select all that apply. One, some, or all responses may be correct. a. Increase the child's fat intake. b. Provide iron-rich foods to the child. c. Increase the child's daily protein intake. d. Curb the child's diet to help prevent obesity. e. Provide adequate vitamin supplementation to the child.

b. Provide iron-rich foods to the child. c. Increase the child's daily protein intake. The nurse would instruct the parents to provide an iron-rich diet to the child. This will help prevent anemia. The nurse would instruct the parents to increase the child's protein intake. Fat needs do not increase in adolescents, so the nurse would not ask the parents to increase the child's fat intake. Increasing physical activity is often more important than curbing fat intake in countering obesity. Vitamin and mineral supplements are not required, so the nurse would instruct the parents to avoid them.

A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." Which complication would the nurse explain that could be prevented by daily exercise? a. Paresthesias of the feet b. Shortening of the muscles c. Development of osteoblasts d. Loss of coordination

b. Shortening of the muscles Flexion and extension prevent tightening of muscles and tendons. Abnormal sensations (paresthesias) are related to neurological, not musculoskeletal, alterations. Weight bearing, not exercise, promotes the development of osteoblasts. Loss of muscular coordination is the result of cerebellar changes; it is not related to immobility.

Which positions promote comfort when a client is in active back labor? Select all that apply. One, some, or all responses may be correct. a. Prone b. Sitting c. Supine d. Lateral e. Knee-chest

b. Sitting d. Lateral e. Knee-chest The sitting position relieves back pain because it removes pressure from the back. The lateral position relieves back pain because it removes pressure from the back. The knee-chest position may help relieve back pain because it removes pressure from the back. The prone position is almost impossible to assume because of the size of the uterus; also, it cannot be maintained because it impedes fetal monitoring. Low back pain is aggravated when the client is in the supine position because of increased pressure from the fetus on the lumbar and sacral regions.

The nurse is caring for a client with severe burns 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? a. Milk b. Tea c. Orange juice d. Tomato juice

b. Tea The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.

Which meal on the client's dietary record provides the most calcium? a. breakfast b. lunch c. dinner e. snack

b. lunch Lunch provides the best dietary sources of calcium: 1 oz of cheddar cheese contains 204 mg; two slices of bread contain 64 mg; 1 cup of milk contains 300 mg; and 1 cup of raw, chopped spinach contains 54 mg, for a total of 622 mg of calcium. Breakfast is lower in calcium than lunch: two eggs contain 50 mg, a slice of toast contains 32 mg, and a 6-oz cup of coffee contains 4 mg, for a total of 88 mg. Dinner is lower in calcium than lunch: a half breast of chicken contains 13 mg, 1 cup of sliced cooked carrots contains 41 mg, a baked potato contains 20 mg, and 1 cup of applesauce contains 17 mg, for a total of 91 mg. The snack is lower in calcium than the lunch: 8 oz of strawberry yogurt contains 345 mg and an apple contains 10 mg, for a total of 355 mg of calcium.

The nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement by the client indicates the nurse's teaching is effective?" a. After meals, I will take a 10-minute walk." b. "After meals, I will drink 8 oz [240 mL] of water." c. "After meals, I will rest in a sitting position for 1 hour." d. "After meals, I will lie down in bed for at least 20 minutes."

c. "After meals, I will rest in a sitting position for 1 hour." Gravity (sitting up after meals) facilitates digestion and prevents reflux of stomach contents into the esophagus. Exercise immediately after eating may prolong the digestive process. Water should not be taken with or immediately after meals because it overdistends the stomach. Lying down in bed for at least 20 minutes is not an appropriate action because it promotes the reflux of gastric contents into the esophagus.

A client returns from surgery with a permanent colostomy. During the first 24 hours, the colostomy would not drain. Which would the nurse determine is the probable cause of this response, and which is the corresponding treatment? a. Intestinal edema after surgery; apply ice b. Presurgical decrease in fluid intake; encourage fluids c. Absence of gastrointestinal motility; continue to monitor d. Effective functioning of nasogastric suction; irrigate stoma

c. Absence of gastrointestinal motility; continue to monitor The colostomy starts functioning when peristalsis returns. Intestinal manipulation and the depressive effects of anesthesia and analgesics cause absence of gastrointestinal motility; this is an expected response, so continue to monitor. Edema will not interfere totally with peristalsis; there should be some output. Ice will damage the stoma. A presurgical decrease in fluid intake will not influence gastric motility 24 hours later. A nasogastric tube decompresses the stomach; it would not directly influence intestinal motility at this time. Irrigation is not necessary.

A 3-year-old child with nephrotic syndrome is admitted with ascites, oliguria, respirations of 40 breaths per minute, and a recent weight gain of 10 lb (4.5 kg). Which nursing intervention would the nurse provide to ease the child's respiratory difficulty? a. Providing six small meals daily b. Maintaining a well-ventilated room c. Ensuring bed rest in the low-Fowler position d. Administering oxygen at 2 L/min by way of nasal cannula

c. Ensuring bed rest in the low-Fowler position The low-Fowler position decreases pressure on the diaphragm from the abdominal organs and the ascites, thereby increasing respiratory excursion. Frequent feedings may lead to fatigue and quickened respiration, which will further distress the child. Placing the child in a well-ventilated room will not alleviate the cause of the respiratory problem, which is pressure on the diaphragm from the ascites. Oxygen therapy is not necessary; the dyspnea results from pressure on the diaphragm, not lack of oxygen.

A client who is to have a total hip arthroplasty with an uncemented prosthesis asks, "When will I be able to get up and walk?" Which information would the nurse include in a response? a. Full weight bearing is permitted after 2 weeks. b. Partial weight bearing begins the day after surgery. c. Full weight bearing may begin the day after surgery. d. Partial weight bearing progresses to full weight bearing in 2 weeks.

c. Full weight bearing may begin the day after surgery. Weight bearing on the operative side may be permitted for those with an uncemented prosthesis. Full weight bearing usually is permitted before 2 weeks. Partial weight bearing beginning the day after surgery may be true for cemented, not uncemented, prostheses. Partial weight bearing may progress to full weight-bearing after 2 weeks with cemented, not uncemented, prostheses.

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 a fever; an intake of small, frequent amounts of fluids will replenish lost fluid and prevent dehydration. Although caloric intake is important, it is not the priority. Keeping the toddler 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 fever; a low-grade fever is part of the body's adaptive mechanism that limits the multiplication of microorganisms.

Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? a. Shut the client's door during the night. b. Apply a vest restraint when the client is in bed. c. Leave a dim light on in the client's room at night. d. Administer the client's prescribed as-needed sedative medication.

c. Leave a dim light on in the client's room at night. The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated by closing the door. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.

A client is diagnosed with celiac disease. Which foods would the nurse teach the client to avoid? Select all that apply.One, some, or all responses may be correct. a. Corn b. Cheese c. Oatmeal d. Rye bread e. Fruit juice

c. Oatmeal d. Rye bread Gluten is found in rye, oats, wheat, and barley, which should be avoided because gluten in these grains is irritating to the gastrointestinal mucosa in clients with celiac disease. Gluten is found in oatmeal and rye bread and should be avoided. Gluten is not found in corn. Gluten is not found in milk and dairy products. Gluten is not found in fruit.

The client with a suprapubic prostatectomy for cancer of the prostate has continuous bladder irrigations (CBI) in place after surgery. Which primary goal is the nurse trying to achieve with the CBI? a. Stimulate continuous formation of urine. b. Facilitate the measurement of urinary output. c. Prevent the development of clots in the bladder. d. Provide continuous pressure on the prostatic fossa.

c. Prevent the development of clots in the bladder. A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. Fluid instilled into the bladder does not affect kidney function. Urinary output can be measured regardless of the amount of fluid instilled. The urinary retention catheter is not designed to exert pressure on the prostatic fossa.

Which verbalization by the parents of a child who has cystic fibrosis (CF) provides evidence that they understand the child's dietary needs? a. Restrict fluids during mealtimes. b. Discontinue the use of salt when cooking. c. Provide high-calorie foods between meals. d. Add whole-milk products from the diet.

c. Provide high-calorie foods between meals. The caloric intake should be 150% to 200% more than the expected intake for size and age because absorption of fats and nutrients is compromised by the disease process. Fluids are encouraged to keep bronchial secretions from becoming too thick and tenacious. Salt is added to the diet to compensate for excessive sodium losses in saliva and perspiration. Whole milk may not be tolerated because of its high fat content; skim milk products should be substituted.

A client had the left hand amputated after a traumatic injury. Which information would the nurse provide in explaining the timing for fitting a permanent prosthesis? a. Muscles in the upper arm must be developed. b. Dexterity in the other extremity must be achieved. c. Shrinkage of the residual limb must be completed. d. Adjustment to the altered body image must be accomplished.

c. Shrinkage of the residual limb must be completed. Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the limb and the prosthesis. Although developed muscles in the upper arm and dexterity in the other extremity are desirable, it is the condition of the residual limb that is the most important factor in the fitting of a prosthesis. The prosthesis probably will facilitate an improved body image.

An instructor asks a student to describe teaching methods that are effective for adolescents. Which statement by the student indicates a need for further teaching? a. "Use teaching as a collaborative activity." b. "Use problem-solving to help adolescents make choices." c. "Help adolescents learn about their feelings and need for self-expression." d. "Encourage adolescents to learn together through pictures and short stories."

d. "Encourage adolescents to learn together through pictures and short stories." A preschooler, not an adolescent, is encouraged to learn together through pictures and short stories. Teaching should be used as a collaborative activity in adolescents. A problem-solving approach can also be adopted to help adolescents make choices. Adolescents should receive help learning about their feelings and need for self-expression.

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. Which response by the nurse is accurate? a. "The client will gain excessive weight if sodium is limited." b. "An inadequate intake of potassium contributed to the disease." c. "This type of diet increases emotional stability." d. "Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium."

d. "Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium." Clients with Cushing syndrome or those receiving cortical hormones must limit their intake of sodium and increase their intake of potassium, because the kidneys are retaining sodium and excreting potassium. Limiting sodium will not cause weight gain. An excessive secretion of adrenocortical hormones in Cushing syndrome, not inadequate potassium intake, is the problem. This type of diet has no direct effect on the client's emotional status.

How would the nurse respond to a client who, after the birth of her baby says, "I'm so cold, and I can't stop shaking"? a. "I'm going to take your temperature right now." b. "Let me check your uterus to see whether it's firm." c. "Turn on your side so I can check the amount of lochia." d. "I'll get you some warm blankets to help make the chill go away."

d. "I'll get you some warm blankets to help make the chill go away." A postpartum chill is an expected vasomotor reaction. Covering the client with warm blankets will ease the discomfort. Taking the client's temperature, checking or palpating the uterus, and checking the amount of lochia flow are all parts of the routine postpartum assessment; however, they do not need to be done in response to the sensation of a chill.

A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm and 100% effaced. Which would the nurse say while trying to calm the client? a. "I'll rub your back—that will help ease your pain." b. "You'll get a shot when you reach the birthing room." c. "I'm sure you're in pain, but try to bear with it for the baby's sake." d. "Medication may interfere with the baby's first breaths; keep breathing."

d. "Medication may interfere with the baby's first breaths; keep breathing." Analgesia crosses the placental barrier; when birth is imminent, it can cause respiratory depression in the newborn. The client is exhibiting fear and panic; a backrub at this time will not be effective and will probably be rejected. Stating that the client will get a shot when she reaches the birthing room is incorrect and provides false reassurance. Although acknowledging that the client is in pain is an empathic response, an explanation of why medication cannot be given is more appropriate in this situation.

A client has a shoulder immobilizer after surgical repair of a fractured humerus. Which instruction would the nurse provide to the client about the correct use of the immobilizer? a. "Place the elbow on a pillow when sitting in a chair." b. "Adjust the upper arm and wristbands so they are slack." c. "Loosen the chest band to exercise the shoulder periodically." d. "Release the wristband to exercise the forearm and hand routinely."

d. "Release the wristband to exercise the forearm and hand routinely." Wrist flexion and extension, and forearm pronation and supination while the elbow is maintained against the chest, constitute part of a prescribed exercise program after this surgery; this promotes circulation and prevents musculoskeletal stiffness. Placing the elbow on a pillow when sitting in a chair will create pressure within the shoulder joint and will disturb healing. The shoulder immobilizer and its two bands should fit snugly but at no time should constrict the chest or parts of the arm. The shoulder joint is not released and exercised until specific instructions are given by the primary health care provider during a follow-up visit.

Which intervention would be included in the plan of care for a client diagnosed with hyperthyroidism? a. Monitor for hypoglycemia. b. Protect visitors and staff from radiation exposure. c. Provide foods to increase appetite. d. Arrange for sufficient rest periods.

d. Arrange for sufficient rest periods. Promotion of rest to reduce metabolic demands is a challenging but essential task for a client who has hyperthyroidism. With hyperthyroidism, glucose tolerance is decreased, and the client is hyperglycemic. There is no indication that radioactive iodine has been given; therefore, the client does not emit radiation. The client will have an increased appetite.

A client with a high cholesterol level says to the nurse, "Why can't I take a medication that will eliminate all of the cholesterol in my body so it isn't a problem?" The nurse explains that some cholesterol is needed to perform which body function? a. Blood clotting b. Bone formation c. Muscle contraction d. Cellular membrane structure

d. Cellular membrane structure Cholesterol is an essential structural and functional component of most cellular membranes. The fact that it is associated with atherosclerotic plaques does not detract from its essential functions. Cholesterol is not necessary for blood clotting; calcium and vitamin K are. Cholesterol is not essential for bone formation; calcium, phosphorus, and calciferol are. Cholesterol is not involved in muscle contraction; potassium, sodium, and calcium are

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? a. Skin that is cool to the touch b. Shrinking of the residual limb c. Absence of phantom limb pain d. Evenly darkened skin of the residual limb

d. Evenly darkened skin of the residual limb Even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a proper fit. Cool skin may indicate inadequate tissue perfusion, which may be caused by progression of the disease, inadequate wound healing, or excessive pressure from the prosthesis. Shrinking of the residual limb results in an improper fit. Absence of phantom limb pain is unrelated to a proper fit.

Which intervention would the nurse recommend when a client reports moodiness and anxiety a few days before her period? a. Begin ginseng supplementation. b. Increase foods that are rich in soy. c. Consult a mental health therapist. d. Exercise three to four times a week in the luteal phase.

d. Exercise three to four times a week in the luteal phase. Regular aerobic exercise, especially in the luteal phase of the menstrual cycle has been found to be very effective for premenstrual syndrome (PMS) and other menstrual symptoms. Ginseng supplementation is not an intervention known to be helpful for PMS. Increasing intake of soy-based foods is recommended for women in menopause to decrease menopausal symptoms. Referral to a mental health therapist generally is not necessary for someone with PMS symptoms.

Which meal is most appropriate for a client with a large pressure injury? a. Hamburger with french fries b. Turkey meatloaf with brown rice c. Pasta and tomato sauce with a side salad d. Grilled chicken, steamed spinach, and a side of orange slices

d. Grilled chicken, steamed spinach, and a side of orange slices People with a pressure wound need extra protein and vitamin C to reduce inflammation and promote wound healing. The grilled chicken is a good source of protein, and both spinach and orange slices are rich in vitamin C. The hamburger and turkey meatloaf are both good protein sources, but the meals are lacking in vitamin C. The pasta with tomato sauce contains vitamin C, but it is not a good source of protein.

An infant is found to have developmental dysplasia of the hip 6 weeks after birth. The parents ask the nurse why their infant must be restrained in a harness at such an early age. How would the nurse respond? a. Infants are easier to manage in a harness than toddlers. b. Mobility will be delayed if correction is postponed until later. c. Adduction devices cannot be used as effectively after the toddler age. d. Infants' hip joints are cartilaginous, allowing molding of the acetabulum.

d. Infants' hip joints are cartilaginous, allowing molding of the acetabulum. The cartilaginous nature of infants' hip joints is the basis for the use of abduction devices (e.g., Pavlik harness) when the infant is very young. Although an infant is easier to manage in a harness than is a toddler, the main reason for the use of a harness so early in life is the easy moldability of the bones at this age. Traction may be used before surgery to correct contractures; these treatments are more traumatic than the harness, which is applied before the infant can walk. Hip dysplasia is usually not painful and does not limit ambulation for the young child. Abduction, not adduction, devices are used; abduction devices are ineffective by the time the child reaches the toddler age.

A client with quadriplegia attends tilt table therapy daily and asks why the angle of the table gradually increases each day. Which response would the nurse use? a. The tilt table facilitates client's ability to develop muscle strength to turn from side to side. b. The tilt table assists in preventing the development of pressure injuries. c. The tilt table promotes hyperextension of the spinal column to prevent contractions. d. The tilt table provides therapeutic weight bearing to limit loss of calcium from the bones.

d. The tilt table provides therapeutic weight bearing to limit loss of calcium from the bones. During prolonged inactivity, bone resorption proceeds faster than bone formation, and lack of therapeutic weight bearing on bone results in demineralization. A tilt table provides gradual progressive weight bearing, which counters these effects. Lateral turning is possible and necessary if a client is immobile, but a tilt table does not make this possible. The tilt table use occurs for scheduled periods in physical therapy. The nursing care required to prevent pressure injuries includes consistently and frequently performed interventions throughout the day and night. The tilt table does not cause hyperextension of the spine; the spine remains in functional body alignment.

While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. Which is the rationale behind this? a. To provide comfort to the client b. To minimize trauma to the rectal mucosa c. To reduce transmission of microorganisms d. To ensure adequate exposure to the blood vessels

d. To ensure adequate exposure to the blood vessels The nurse would place the thermometer probe into the anus in the direction of the umbilicus to ensure adequate exposure to the blood vessels. Wiping the client's anal area with a soft tissue and helping the client get into the Sims' position provide comfort. Using a lubricant will help minimize trauma to the rectal mucosa. The nurse would wash his or her hands before and after assessing the temperature to reduce the transmission of microorganisms.

Which laboratory result in a client who has just been admitted with anemia of unknown etiology requires the most rapid action by the nurse? a. Hematocrit 30% (0.30) b. Hemoglobin 10 g/dL (100 g/L) c. Platelet count 120,000 mm 3 (120 × 10 9/L) d. White blood cell count 950 mm 3 (950 × 10 9/L)

d. White blood cell count 950 mm 3 (950 × 10 9/L) The laboratory results indicate pancytopenia (consistent with aplastic anemia) with an extremely low white blood cell count that will increase client risk for infection. The nurse will take actions to prevent exposure of this client to other clients with infectious diagnoses as well as notify the health care provider of the laboratory results. The client's hematocrit is low, but does not require immediate action to correct. The hemoglobin level is low, as would be expected in a client with anemia, but is not critically low. The platelet count is slightly below the normal level but would not increase the risk for spontaneous or prolonged bleeding.

In which position would the nurse place a 1-year-old infant with a distended abdomen admitted with Hirschsprung disease? a. Prone b. Sitting c. Supine d. Lateral

d. lateral In the lateral position the distended abdomen does not press against the diaphragm, facilitating lung expansion. The prone position is difficult to assume with a distended abdomen; also, the weight of the body will limit lung expansion. The sitting position is not conducive to easy breathing and is difficult to assume with abdominal distention. The distended abdomen will press against the thighs and then the diaphragm, which will hinder full lung expansion. The supine position will interfere with respiration because the abdominal distention will exert pressure against the diaphragm.

Which pain scale would the nurse use when assessing a 4-year-old child? a. CRIES b. FLACC c. Numerical d. Wong-Baker

d. wong-baker The Wong-Baker method is a type of faces pain scale best used in children as young as 3 or 4 years. It contains several faces that a child can use to identify his or her pain level. CRIES and FLACC are pain scales typically used with young infants who are unable to verbalize pain. The numerical pain scales are best used in older children, teens, or adults who can accurately assign a number to represent pain level.

Which steps would the nurse take for managing an adolescent who sustained drug poisoning? Select all that apply. One, some, or all responses may be correct. a. Induce gastric lavage. b. Give ipecac syrup to the client. c. Turn the head of the client to the side d. Empty the mouth to clean the residue of the drug. e. Call local poison control center before any intervention.

c. Turn the head of the client to the side d. Empty the mouth to clean the residue of the drug. e. Call local poison control center before any intervention. The nurse would turn the head of the client to the side to avoid aspiration. The nurse would empty the mouth if there is any remaining drug. If the victim is conscious and alert, the nurse would call the local poison control center or the national toll-free poison control center number before attempting any intervention. The nurse would refrain from inducing vomiting in the client because there is a risk of aspiration. Ipecac syrup causes vomiting, so it is no longer recommended for routine treatment of poisoning.

A 20-lb infant has a normal saline enema ordered, at a dose of 10 mL/kg. Which dose would the nurse administer? a. 9 mL b. 90 mL c. 130 mL d. 210 mL

b. 90 mL First, the nurse must convert to kg by dividing 20/2.2 = 9.09 kg. 9.09 × 10 mL/kg = 90 mL dose to be administered.

The nurse is caring for a client with Addison disease. Which dietary instruction would the nurse provide? a. Add extra salt to food. b. Consume high-potassium foods. c. Omit protein foods at each meal. d. Restrict the daily intake of fluids to 1 L.

a. Add extra salt to food. Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to developing hyponatremia. The addition of salt to the diet is advised. Clients with Addison disease are prone to hyperkalemia. High-potassium foods can be restricted. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism and healing. Fluids are not restricted for clients with Addison disease.

A large family that is struggling financially is instructed by the home health nurse about ways to increase their dietary intake of calcium. Which suggestion would the nurse make? a. Collard greens or kale in one meal a day b. Fruit-flavored yogurt every other day c. Bread made with cornmeal each morning e. Eight ounces (240 mL) of milk with every meal

a. Collard greens or kale in one meal a day Leafy green vegetables are an excellent source of calcium, are inexpensive, and can be home-grown; collards and kale are high in calcium. Yogurt does contain calcium, but it is costly for a large, financially struggling family. Cornbread and other bread products provide limited sources of calcium unless specifically enriched, making them more expensive. Although milk contains calcium, serving milk at every meal exceeds the recommended amount of milk for adults and is costly.

Which information would the nurse provide to a client who reports the skin seems soft and has turned white where wet compresses have been applied to an irritated insect bite? a. Discontinue the wet compresses for 2 to 3 days. b. Apply a dry dressing to the area to keep moisture in the skin. c. Use an ointment such as petrolatum after removing the wet compress. d. Schedule an appointment with the health care provider as soon as possible.

a. Discontinue the wet compresses for 2 to 3 days. If the skin softens and turns white when wet compresses are being used, the client should be instructed to discontinue the compresses for 2 to 3 days. Application of a dry dressing or ointment would not be indicated. It is not necessary to schedule an appointment with the health care provider.

Which diet choices by a client who has heart failure indicate that the nurse's teaching about diet has been effective? Select all that apply. One, some, or all responses may be correct. a. Lean steak b. Fruit salad c. Broiled chicken d. Smoked salmon e. Roasted potatoes f. Macaroni and cheese

a. Lean steak b. Fruit salad c. Broiled chicken e. Roasted potatoes The priority dietary change for clients with heart failure is a low-sodium diet. Lean steak, fruit salad, broiled chicken, and roasted potatoes are all low in sodium. Smoked meats such as smoked salmon are high in sodium. Cheese is high in sodium.

By which mechanism do sitz baths aid healing of an episiotomy? a. Promoting vasodilation b. Cleansing perineal tissue c. Softening the incision site d. Tightening the rectal sphincter

a. Promoting vasodilation Heat causes vasodilation and increased blood supply to the area. Cleansing is performed with a perineal bottle and cleansing solution immediately after voiding and defecation. Sitz baths do not soften the incision site. Neither relaxation nor tightening of the rectal sphincter will speed healing of an episiotomy.

Which statement provides the rationale as to the importance of the nurse teaching clients with quadriplegia the use an adaptive wheelchair? a. The client with quadriplegia is unlikely to regain the ability to walk. b. Use of the adaptive wheelchair prepares the client for wearing braces. c. The adaptive wheelchair assists clients in overcoming orthostatic hypotension. d. Clients with quadriplegia have the strength in their upper extremities to self-transfer.

a. The client with quadriplegia is unlikely to regain the ability to walk. Clients with quadriplegia do not have the muscle innervation, strength, or balance needed for ambulation. Bracing and crutch-walking require muscle strength and coordination that an individual with quadriplegia does not have. Prevention of orthostatic hypotension occurs by a gradual assumption of the upright position and does not necessarily require a wheelchair. Quadriplegia refers to paralysis of all four extremities.

A client has a diagnosis of hemorrhoids. Which signs and symptoms would the nurse expect the client to report? Select all that apply. One, some, or all responses may be correct. a. Flatulence b. Anal itching c. Blood in stool d. Rectal bulging e. Pain when defecating

b. Anal itching c. Blood in stool d. Rectal bulging e. Pain when defecating Anal pruritus (itching) occurs as varicosities enlarge and become inflamed. Blood and mucus in the stool occur during bowel movements. Rectal bulging (prolapse) occurs as portal venous pressure increases and varicosities enlarge. Pain occurs when varicosities enlarge and thromboses occur; pain increases on defecation. Flatulence is unrelated to hemorrhoids.

A back brace is prescribed for a client who had a laminectomy. Which information would the nurse include in the client's teaching plan? a. Use the brace when your back feels tired. b. Apply the brace before getting out of bed. c. Obtain a soft mattress for resting when the brace is off. d. Wear the brace when performing twisting exercises.

b. Apply the brace before getting out of bed. Applying the brace before getting out of bed is done while in the supine position before the body is subjected to the force of gravity in the vertical position; anatomical landmarks are easier to locate for correct application of the brace, and intraabdominal organs have not shifted toward the pelvic floor via gravity. Using the brace when the back feels tired is unsafe; it should be worn the entire day for support. A firm mattress or bed board should be obtained rather than a soft mattress to maintain adequate back support. Twisting exercises are contraindicated because they exert excessive pressure on the operative site.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. Which is an important assessment the nurse needs to perform before beginning the pump? a. Checking for the last bowel movement. b. Checking for residual stomach contents. c. Determining the time of the last nausea medication. d. Determining the client's comfort level.

b. Checking for residual stomach contents. Checking for any residual feeding not absorbed in the client's stomach must be done before introducing more feeding. Aspiration can occur if a feeding is started when there is excessive residual. Checking for last bowel movement and the client's comfort level are important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of the bed elevated to at least 30 degrees.

Which intervention would the nurse provide a 3-month-old infant hospitalized with respiratory syncytial virus (RSV)? a. Administering an antiviral agent b. Clustering care to conserve energy c. Administering a bronchodilator every four hours d. Providing an antitussive agent whenever necessary

b. Clustering care to conserve energy Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest. Antiviral therapy is controversial for this age group and is not given unless complications ensue. Bronchodilators are not routinely indicated for RSV. Antitussive agents are not used; nasal secretions are aspirated with the use of a bulb syringe whenever necessary.

When the nurse is caring for several clients on a medical/surgical floor, which task is appropriate to delegate to the unlicensed assistive personnel (UAP)? a. Ask a client about his or her new complaint of chest pain. b. Turn a bed-bound client to prevent pressure injuries. c. Change a surgical dressing for a client who is 7 days postsurgery. d. Administer acetaminophen to a client who is complaining of a headache.

b. Turn a bed-bound client to prevent pressure injuries. It is within the UAP's scope of practice to turn a client who is bed-bound to prevent pressure injuries. A UAP would not administer medications, assess a client, or change surgical dressings; these tasks should be performed by the nurse.

How would the nurse prepare a client for cranial surgery? a. Assist the client with securing a wig onto the head. b. Obtain the client's consent to have the head shaved. c. Shampoo the client's hair with a medicated shampoo. d. Tell the client that head shaving is needed before anesthesia.

b. Obtain the client's consent to have the head shaved. Because of legal and cosmetic concerns, consent for head shaving must be obtained before a client receives anesthesia. Because head shaving is a nursing intervention, the nurse should obtain this consent. The surgeon will obtain the consent for surgery. The client will not be able to wear a wig to surgery because wigs could become a source of infection and should not be worn until healing occurs. Washing the client's hair with a medicated shampoo is unnecessary because the hair will be shaved to help prevent contamination of the surgical site. Shaving of some areas of the head or the entire head is typically performed after the client is anesthetized.

Which sleep pattern would the nurse recognize as normal in preschoolers? b. Daytime naps are very common among preschoolers. b. On average, a preschooler sleeps about 12 hours a night. c. Partial awakening leading to sleeplessness is common among preschoolers. d. About 30% of sleep time in preschoolers is spent in non-rapid eye movement sleep (NREM).

b. On average, a preschooler sleeps about 12 hours a night. The average preschooler sleeps about 12 hours a night. By the age of 5, children rarely take daytime naps except in cultures in which a siesta is the custom. Partial awakening followed by a normal return to sleep is normal in preschoolers. About 30% of an infant's sleep time is in the rapid eye movement sleep (REM) cycle.

An adult client with low-functioning Down syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining this client's level of pain? a. Asking the client's parent b. Using the Wong-Baker FACES Pain Rating Scale c. Observe the client's body language d. Explain and use the 0 to 10 pain scale

b. Using the Wong-Baker FACES Pain Rating Scale An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; the Wong-Baker FACES Pain Rating Scale uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

When teaching about nutrition during pregnancy, which is the change in daily caloric intake the nurse would say the pregnant woman needs? a. A decrease of 100 calories per day b. A decrease of 200 calories per day c. An increase of 300 calories per day d. An increase of 500 calories per day

c. An increase of 300 calories per day An increase of 300 calories per day is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy. A decrease of 100 to 200 calories per day will not meet the metabolic demands of pregnancy and may harm the fetus. An increase of 500 calories per day is the recommended caloric increase for breast-feeding mothers.

Which assessment finding would the nurse report to the health care provider when giving immediate postoperative care to a client with a newly placed ostomy? a. Moderate edema of the stoma b. Excessive gas issuing from the stoma c. Blanching, dark red to purple color of stoma d. Small amount of blood oozing from the stoma

c. Blanching, dark red to purple color of stoma The stoma should be rosy pink to red in color. A blanching, dark red to purple stoma indicates inadequate blood supply to the stoma or bowel and should be reported to the health care provider. Mild to moderate edema is normal initially and will resolve over the first 6 weeks. Excessive gas is common for the first 2 weeks postsurgery. It is normal for a small amount of blood to ooze from the stoma when touched because of its high vascularity.

Which strategies would the nurse teach a client who says, "I have been having trouble sleeping and feel wide awake as soon as I get into bed"? Select all that apply. One, some, or all responses may be correct. a. Eating a heavy snack near bedtime b. Reading in bed before shutting out the light c. Leaving the bedroom when unable to sleep d. Drinking a cup of warm coffee with milk at bedtime e. Exercising in the afternoon rather than in the evening f. Drinking at least 1 glass of wine or other alcoholic beverage at bedtime

c. Leaving the bedroom when unable to sleep e. Exercising in the afternoon rather than in the evening The nurse would teach the client to leave the bedroom when unable to sleep and exercise in the afternoon rather than in the evening. Lying in bed when one is unable to sleep increases frustration and anxiety and further impedes sleep; other activities, such as reading or watching television, should not be conducted in bed. Exercise during the day expends energy and promotes sleep at night; exercise too close to bedtime is stimulating and may interfere with sleep. A heavy meal exerts pressure against the diaphragm that may be uncomfortable and the body is expending energy to digest the food; a light, not heavy, snack is preferred before bedtime. The bed should be used exclusively for sleep, not for reading, so the client's body expects sleep when the client gets into bed. Although milk may promote sleep, coffee contains caffeine, which is a stimulant that should be avoided after midafternoon; otherwise, it may interfere with sleep. The client should avoid caffeine, nicotine, and alcohol at least several hours before bedtime.

Which assessment findings would be expected in a client brought to the emergency department after being found unconscious in frigid weather? Select all that apply. One, some, or all responses may be correct. a. Bradycardia b. Hypertension c. Pale, ashen skin d. Weak, thready pulse e. Fatigue and weakness

c. Pale, ashen skin d. Weak, thready pulse e. Fatigue and weakness The nurse would expect pale, ashen skin, a weak and thready pulse, and fatigue and weakness in a client with hypothermia. Tachycardia and hypotension would be more likely than bradycardia and hypertension.

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? a. "We'll have to start serial casting right away." b. "The casts will have to be changed every week." c. "The baby may have to have surgery if the problem is not fixed in a few months." d. "We'll have to have the baby fitted with prosthetic devices before the baby is able to walk."

d. "We'll have to have the baby fitted with prosthetic devices before the baby is able to walk." Prosthetic devices are generally not needed for this condition. If parents make this statement, they require further teaching. Serial casting with weekly cast changes is the typical treatment for this condition and is usually successful. Surgery may be needed if the serial casting is not effective, therefore those statements indicate that parents understand the treatment plan.

The nurse is providing postoperative care to a client who had a hip prosthesis inserted. When would the nurse remove the abductor splint? a. When the client gets up to sit in a chair b. If the client needs a change of position c. Once the client's edema and pain have decreased d. During the client's skin care and physical therapy

d. During the client's skin care and physical therapy Until the prescription is written to discontinue the abduction splint, it is only removed for mobility such as physical therapy and hygiene; adduction to or beyond the midline is not permitted until allowed by the primary health care provider. When the client gets up to sit in a chair, the splint is needed unless the client can maintain abduction; flexing the hip with a prosthesis cannot be beyond 60 degrees for up to 10 days; from then on it cannot be beyond 90 degrees until permitted by the primary health care provider. If the client needs a change of position, a splint helps maintain position and keep the hip prosthesis in the hip socket. It is inappropriate to remove the splint once the client's edema and pain have ceased; there are no criteria for discontinuing abduction of the affected extremity.

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." Which initial action would the nurse take? a. Notify the primary health care provider. b. Use distraction techniques. c. Medicate the client as prescribed. d. Perform a complete pain assessment.

d. Perform a complete pain assessment. A complete assessment must be performed to determine the location, characteristics, intensity, and duration of the pain. The pain may be incisional, result from a pulmonary embolus, or be caused by neurovascular trauma to the affected leg, and the intervention for each is different. Notifying the primary health care provider, using distraction techniques, and medicating the client as prescribed may be done after a complete assessment reveals that this is the appropriate intervention. Assessment is the priority.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which is appropriate to include in the client's dietary plan? a. Soft-textured foods to reduce the digestive burden b. Low-cholesterol foods to avoid further formation of gallstones c. Increased protein to promote tissue healing and improve energy reserves d. Reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

d. Reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis.

Which item would the nurse use to feed an infant after a cleft lip repair? a. Preemie nipple b. Nasogastric tube c. Gravity-flow nipple d. Rubber-tipped syringe

d. Rubber-tipped syringe A rubber-tipped syringe minimizes sucking and is not irritating to the suture line. Using a preemie nipple is an acceptable method of feeding before surgery. A nasogastric tube is unnecessary; the infant is hungry enough to feed. Using a gravity-flow nipple is another method of feeding before surgery.

Which meal would the nurse select for a preschooler on a low-residue diet? a. A frankfurter on a roll b. Ripe peaches with ice cream c. Peanut butter and jam on white bread d. Scrambled eggs and toasted white bread

d. Scrambled eggs and toasted white bread A low-residue diet should contain minimal roughage; eggs prepared any way but fried are permitted; refined bread and toast also are permitted. Although meat is permitted, spicy, fried, and tough meats are not. Most frankfurters have fillers that interfere with the goal of low residue. Raw fruits and nuts and jams are not permitted because they contain roughage.

Which principle would the nurse emphasize when counseling the pregnant client with type 1 diabetes? a. The advice to increase high-quality protein and decrease fats b. The need to increase carbohydrates to meet energy demands and prevent ketosis c. The benefit of a low-calorie diet that maintains the current insulin coverage and helps prevent hyperglycemia d. The recommendation to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary

d. The recommendation to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary Increased metabolic demands on the body during pregnancy require increased ingestion of calories; appropriate doses of insulin must be provided to permit glucose utilization by the body. The quantities of carbohydrates and fats, as well as of protein, are increased, not decreased, during pregnancy. Simply increasing carbohydrate intake is not sufficient to prevent ketosis. A low-calorie diet is contraindicated; it will not meet the demands of pregnancy on the client's body or the needs of the growing fetus.

Which recommendation would the nurse give to a parent whose preschooler who has frequent nightmares? Select all that apply. One, some, or all responses may be correct. a. "Consider providing a night-light." b. "Consider sleeping with your child." c. "Consider tucking in a soft toy with your child." d. "Consider talking to the child about his or her fears." e. "Consider taking the child to your room to comfort him."

a. "Consider providing a night-light." c. "Consider tucking in a soft toy with your child." d. "Consider talking to the child about his or her fears." The nurse would recommend the parent provide a night-light; it will help the child overcome fears. The nurse would recommend the parent tuck in the favorite soft toy of the child. This will give the child a sense of safety. The parent may enter the child's room and talk to the child about his or her fears. This helps provide a cooling-down period. The nurse would not recommend the parent sleep with the child because this may create bad bedtime habits. The nurse would tell the parent to comfort the child and leave the child in his or her own bed so that the child does not use the fear as an excuse to delay bedtime.

When assisting a client with Parkinson disease to ambulate, which instruction would the nurse provide the client? a. Avoid leaning forward. b. Hesitate between steps. c. Rest when tremors are experienced. d. Keep arms close to the center of gravity.

a. avoid leaning forward The client with Parkinson disease often has a stooped posture because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. One, some, or all responses may be correct. a. Chemotherapy b. Repositioning c. Regular oral care d. Blood transfusion e. Radiation therapy

a. chemotherapy d. blood transfusion e. radiation therapy Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures. Chemotherapy, radiation therapy, and blood transfusions are a part of palliative care meant to alleviate symptoms and promote well-being. These therapies may not be required in a client who is about to die and is receiving end-of-life care. End-of-life care comprises measures to make the client as comfortable as possible. It may include measures such as regular oral care and repositioning.