Caring interventions PrepU
The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? Encourage the family members to express their feelings and listen to them in their frank communication. Encourage conversations about the impending death of the client. Be a silent observer and allow the client to communicate with the family members. Encourage the client's family members to spend time with the client. TAKE ANOTHER QUIZ
Encourage the family members to express their feelings and listen to them in their frank communication. Explanation: Family members usually find it difficult to communicate frankly with a dying person. By encouraging family members to express their feelings and listening to them as they frankly communicate, you may help family members feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members to express their feelings.
The nurse is caring for a client with manifestations of dilated cardiomyopathy. When planning care, which consideration would the nurse make? Place bed in a high or semi-high Fowler's position as needed. Assist client to bathroom every 2 hours. Instruct client to avoid strenuous activity. Assess abdominal girth daily. TAKE ANOTHER QUIZ
Place bed in a high or semi-high Fowler's position as needed. Explanation: Dilated cardiomyopathy has clinical manifestations of dyspnea on exertion and when lying down. Depending on level of dyspnea, placing the client in an upright Fowler's position is helpful. Clients with hypertrophic cardiomyopathy have syncopal episodes and can collapse following strenuous activity. Assistance with ambulation to avoid falls is helpful. Restrictive cardiomyopathy includes manifestations of ascites and assessment of abdominal girth.
A client has developed urinary incontinence after having a urinary catheter in place for a few weeks. What is the initial nursing intervention the nurse should use to start the client with bladder training? Immediately after voiding, perform a bladder scan. Instruct the client to drink more fluids at night for a full bladder in the morning. Place client on a timed voiding schedule. Perform straight catheterizations at specific times each day. TAKE ANOTHER QUIZ
Place client on a timed voiding schedule. Explanation: Placing the client on a timed voiding schedule after a catheter removal will promote bladder muscle retraining. The nurse should do a bladder scan immediately after voiding, but this is not the initial action. The nurse does not need to complete urinary catheterization at specific intervals for initial bladder training. The client needs to limit fluids at night.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Suggest applying cool compresses on the face several times a day to tighten the muscles. Inform the patient that the muscle function will return as soon as the virus dissipates. Tell the patient to smile every 4 hours.
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Explanation: After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? 4 6 8 10
4 Explanation: Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.
The nurse caring for a client with Ménière's disease needs to assist with what when the client is experiencing an attack? Sleeping ADLs Coughing URIs
ADLs Explanation: The client with Ménière's disease requires a great deal of emotional support because of the unpredictability of the attacks and the resulting impairments. During an attack, the nurse administers prescribed drugs, limits movement, and promotes the client's safety. He or she assists the client with activities of daily living because the least amount of motion can produce severe vertigo. The nurse cannot assist with sleeping, coughing. Option D is a distractor for this question.
The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? Perform surgery to remove the tumor from the brain. Begin radiation therapy to prevent cellular growth. Obtain a biopsy to analyze the lymph nodes. Add haloperidol to the client's treatment plan. TAKE ANOTHER QUIZ
Add haloperidol to the client's treatment plan. Explanation: Haloperidol may reduce hallucinations. Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Biopsy is used to analyze the lymph nodes or to destroy the tissues surrounding the tumor.
The nurse is working on a telemetry unit, caring for a client who develops dizziness and a second-degree heart block, Mobitz Type 1. What will be the initial nursing intervention? Administer an IV bolus of atropine. Send the client to the cardiac catheterization laboratory. Prepare to client for cardioversion. Review the client's medication record. TAKE ANOTHER QUIZ
Administer an IV bolus of atropine. Explanation: Atropine 0.5 mg given rapidly as an intravenous bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic second-degree heart block. The client may need to be sent to the cardiac catheterization lab for a temporary pacemaker, but atropine should be tried first. Cardioversion is used to treat a fast heart rate. Reviewing the medication record will not help the client initially.
A patient had a renal angiography and is being brought back to the hospital room. What nursing interventions should the nurse carry out after the procedure to detect complications? Select all that apply. Assess peripheral pulses. Compare color and temperature between the involved and uninvolved extremities. Examine the puncture site for swelling and hematoma formation. Apply warm compresses to the insertion site to decrease swelling. Increase the amount of IV fluids to prevent clot formation. TAKE ANOTHER QUIZ
Assess peripheral pulses. Compare color and temperature between the involved and uninvolved extremities. Examine the puncture site for swelling and hematoma formation. After the procedure, vital signs are monitored until stable. If the axillary artery was the injection site, blood pressure measurements are taken on the opposite arm. The injection site is examined for swelling and hematoma. Peripheral pulses are palpated, and the color and temperature of the involved extremity are noted and compared with those of the uninvolved extremity. Cold compresses may be applied to the injection site to decrease edema and pain.
Surgical removal of the thyroid gland is the treatment of choice for thyroid cancer. During the immediate postoperative period, the nurse knows to evaluate serum levels of __________ to assess for a serious and primary postoperative complication of thyroidectomy. Sodium Calcium Potassium Magnesium
Calcium Explanation: Efforts are made to spare parathyroid tissue to reduce the risk of postoperative hypocalcemia with resultant tetany.
A client calls the clinic and asks the nurse if using oxymetazoline nasal spray would be all right to relieve the nasal congestion the client is experiencing due to seasonal allergies. What instructions should the nurse provide to the client to avoid complications? Report white patches in the mouth because the medication can cause a fungal infection. Do not overuse the medication as rebound congestion can occur. Taper the dose when discontinuing the medication. Do not operate machinery or drive while using the medication.
Do not overuse the medication as rebound congestion can occur. Explanation: Overusing oxymetazoline nasal spray can cause rebound congestion. The medication does not cause fungal infection. Corticosteroids should be tapered, but it is not necessary to taper oxymetazoline. Oxymetazoline does not cause sleepiness so the client can operate machinery or drive.
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client? Speaking loudly Establishing eye contact Avoiding the use of hand gestures Speaking in complete sentences TAKE ANOTHER QUIZ
Establishing eye contact Explanation: The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? Optimizing nutrition Managing muscle weakness Explaining hospice care and services Offering family support groups TAKE ANOTHER QUIZ
Explaining hospice care and services Explanation: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.
The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication? A cardiac dysrhythmia Fluid volume deficit Mucous membrane irritation Pulmonary complications TAKE ANOTHER QUIZ
Fluid volume deficit Explanation: Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? Low in fat Restricts protein to 10% of daily caloric intake High in protein and low in carbohydrate At least 50% carbohydrate TAKE ANOTHER QUIZ
High in protein and low in carbohydrate Explanation: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack? Meclizine (Antivert) Furosemide (Lasix) Cortisporin otic solution Gentamicin (Garamycin) intravenously
Meclizine (Antivert) Explanation: Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack (NIDCD, 2010).
The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply For those patients who are incontinent, insert indwelling catheters. Perform hand hygiene prior to patient care. Assist the patients with frequent toileting. Provide careful perineal care. Encourage patients to wear briefs.
Perform hand hygiene prior to patient care. Assist the patients with frequent toileting. Provide careful perineal care. In institutionalized older patients, such as those in long-term care facilities, infecting pathogens are often resistant to many antibiotics. Diligent hand hygiene, careful perineal care, and frequent toileting may decrease the incidence of UTIs.
The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client? Increase mobility. Provide adequate hydration. Promote safety. Encourage adequate nutrition. TAKE ANOTHER QUIZ
Promote safety. Explanation: Safety is paramount because any injury, no matter how slight, can result in a fracture. Mobility, hydration, and nutrition are important, but will not prevent fractures.
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? Cure the cirrhosis. Treat the esophageal varices. Reduce fluid accumulation and venous pressure. Promote optimal neurologic function.
Reduce fluid accumulation and venous pressure. Explanation: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? High-Fowler's Prone Supine Semi-Fowler's
Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
Which is the most common report by clients with pancreatitis? Tarry, black stools and dark urine Increased and painful urination Increased appetite and weight gain Severe, radiating abdominal pain
Severe, radiating abdominal pain Explanation: Clients with pancreatitis most commonly report severe mid- to upper-abdominal pain, radiating to both sides and straight to the back. The client may describe the stools as being frothy and foul smelling, not black or tarry. The client's urine may be dark. The client will not experience increased or painful urination, increased appetite, or weight gain.
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? Arthrodesis Hemiarthroplasty Total arthroplasty Osteotomy
Total arthroplasty Explanation: A total arthroplasty is a replacement of both articular surfaces within one joint. Arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
Despite having been administered prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? Offer small amounts of nourishment frequently Gently massage the arms and legs Use imagery, humor, and progressive relaxation Encourage the patient to sleep
Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication and to reduce dyspnea. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help in potentiate the effects of pain medication.
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? Withhold anticonvulsant medications for 24 to 48 hours before the exam Maintain NPO status for 6 hours before the procedure Sedate the client before the procedure, per orders Instruct the client that a standard EEG takes 2 hours
Withhold anticonvulsant medications for 24 to 48 hours before the exam Explanation: Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the client be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, meals are not omitted, because an altered blood glucose concentration can cause changes in brain wave patterns. The client is informed that a standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
A type of comprehensive care for clients whose disease is not responsive to cure is a terminal illness. palliative care. euthanasia. interdisciplinary collaboration.
palliative care. Explanation: Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care.