EAQ 4- Comfort, Pain & Nutrition

The nurse is obtaining a health history from a newly admitted client who has chronic pain in the right knee. Which with the nurse include in the pain assessment? Select all that apply. One, some, or all responses may be correct.

-pain history, including location, intensity, and quality of pain -clients purposeful body movement and arranging the papers on the bedside table -pain pattern, including precipitating and alleviating factors -vital signs, such as increased blood pressure and heart rate -The clients family statement about increases in pain with ambulation Answer: pain history, including location, intensity, and quality of pain & pain pattern, including precipitating and alleviating factors

The registered nurse (RN) Asked the client to read their pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which steps by the nursing student would be included in a physical assessment for pain? Select all that apply. One, Some, or all responses may be correct.

-palpating for tenderness -observing nonverbal cues -inspecting any areas of discomfort -noticing if the pain is localized or radiates -noticing if the client gives nonverbal signs of pain Answer: palpating for tenderness & inspecting any areas of discomfort

A client with suspected kidney disorder reports flank pain. Which nursing interventions would be conducted while performing flank assessment? Select all that apply. One, some, or all responses may be correct.

-percussing the tender flank first -forming both hands into a clenched fist -asking the client to assume a sitting position -placing one hand flat on the costovertebral angle (CVA) -delivering a firm hand thumb over the lower abdomen Answer: asking the client to assume a sitting position & placing one hand on the CVA

After abdominal surgery, a client reports pain. Which action would the nurse take first?

-Reposition the client -Obtain the clients vital signs -Administer the prescribed analgesics -Determine the characteristics of the pain Answer: determine the characteristics of the pain.

Which parental statement would the nurse recognize as indicative of needing further teaching about the nutritional needs of preschoolers?

-"I should give my child a variety of foods" -"I should increase the protein in my child's diet." -"I should be concerned about my child's weight gain." -"I should limit my child's calorie intake to 1200 per day." Answer: "I should limit my child's calorie intake to 1200 per day."

The nurse assesses a client with dry and brittle hair, flaky skin, a beefy red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are a result of which?

-A food allergy -Noncompliance with medications -Side effects from medications -A nutritional deficiency Answer: A nutritional deficiency

Which food with the nurse instruct a client taking diltiazem to avoid? Select all that apply. One, some, or all responses may be correct.

-Alcohol -Grapefruit juice -Cheddar cheese -Summer sausage -Dark Green vegetables Answer: grapefruit juice

Which finding a newborn as a behavioral responses to pain? Select all that apply. One, some, or all responses may be correct.

-Crying -Tachypnea -Diaphoresis -Tachycardia -Hypertension Answer: Crying

Which pain scale is used to measure the intensity of pain in preschoolers?

-FACES scale -visual analog scale -numerical rating scale -verbal descriptor scale Answer: FACES scale

When the nurse obtains vital signs of blood pressure 90/60 mm Hg, pulse 96 beats/minute, and respiratory rate 10 breaths/minute for a postoperative client who is receiving hydromorphone by a patient-controlled analgesia (PCA) pump, which nursing action would be the priority?

-Give naloxone IV per protocol -Assess the clients pain level on a 10-point scale -Document the vital signs in the clients record -Notify the hospital rapid response team. Answer: give naloxone IV per protocol

The parents of an adolescent child are worried about their daughters use of laxatives. Which other behavior of the adolescent would the nurse associate with bulimia nervosa?

-The adolescent is underweight for her age. -The adolescent indulges and binge eating. -The adolescent is obsessed with being thin. -The adolescent prefers to starve to lose weight. Answer: The adolescent indulges in binge eating.

Which action with the nurse take while giving an injection to a preschooler?

-asking the parent to restrain the child -distract the child with conversation -avoid awakening the child if asleep -avoid using lidocaine ointment over the injection site Answer: distract the child with conversation

When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water soluble vitamin? SATA

-biotin -niacin -folic acid -riboflavin -vitamin c Answer: all of the above

A client is recovering from full-thickness burns, and the nurse provides counseling on how to best meet nutritional needs. Which client food selections indicate to the nurse that the client understands the teaching?

-cheeseburger and a milkshake -beef barley soup and orange juice -bacon and tomato sandwich and tea -chicken salad sandwich and soft drink Answer: cheeseburger and a milkshake

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?

-sodium -Gravies -Red Wines -Organ Meat Answer: Sodium

A client was admitted for thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 OB (0.5kg) of weight each day. Which dietary adjustment would the nurse recommend?

-Increase low-sodium milk intake -provide high-protein drinks -increase foods that are low in potassium -provide 10% more calories in the form of fats Answer: Provide high-protein drinks.

Which role does vitamin C have an wound healing?

-It aids in the process of epithelialization. -Vitamin C helps in the synthesis of immune factors. -It increases the metabolic energy required for inflammation. -Vitamin C is required for collagen production by fibroblasts. Answer: Vitamin C is required for collagen production by fibroblasts.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which calcium-rich food would the nurse suggest for clients who do not tolerate milk?

-Oats -Yogurt -Potatoes -Applesauce Answer: Yogurt

Which food would the nurse recommend to a client when instructing to increased potassium intake? Select all that apply. One, Some, or all responses may be correct.

-Oranges -Celery -Onion -Cheese -Oatmeal Answer: Orange

Which methods qualify as alternative therapies for pain? Select all that apply. One, some, or all responses may be correct.

-Prayer -Hypnosis -Medication -Aromatherapy -Guided Imagery Answer: prayer, hypnosis, aromatherapy & guided imagery.