EAQ: Client Needs- basic care and comfort

A client is diagnosed with psoriasis, and the nurse is providing health teaching concerning skin care at home. Which recommendation does the nurse include in the teaching?

"Apply moisturizing lotion several times a day

During an 8-hour shift a client drinks two 6-ounce (180 mL) cups of tea and vomits 125 mL of fluid. Intravenous fluids absorbed equaled the urinary output. What is the client's fluid balance during this 8-hour period? Record your answer using a whole number. ___ mL

235 mL The client's intake was 360 mL (12 oz x 30 mL = 360) and the loss was 125 mL of fluid; 360mL - 125mL = 235 mL

The nurse is assessing four clients with foot disorders. Which client is instructed to use bunion pads to relieve pressure on the bursal sac?

Client A: hallux vaalgus which is a painful deformity of the great toe consisting of lateral angulation towards the second toe, swelling of the bursa and ofrmation of a callus over the bony enlargement.

Which statement is true about the sleep pattern of preschoolers?

On average, a preschooler sleeps about 12 hours a night. The average preschooler sleeps about 12 hours a night. By the age of five, 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 frequent. About 30% of an infant's sleep time is in the rapid eye movement sleep (REM) cycle.

Which action is the least likely to prevent sleep disturbances?

Performing strenuous exercise within an hour before going to bed.

A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. Which instruction is the best description the nurse can provide when teaching a client how to use a walker?

Put the front walker leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward. There are three critical concepts to this instruction: STABILITY, POSITION, and WEIGHT BEARING. Having all four walker leg tips on the floor provides stability. Positioning the front (not the back) walker leg tips at about an arm's length forward is a safe distance ahead to transfer weight. Putting weight on the walker equalizes weight bearing on the upper and lower extremitites.

The registered nurse is evaluating the actions of a nursing student who is providing emergency care to a client with an extremity fracture. Which action of the nursing student does the registered nurse think needs a correction?

Removing the shoes of the client a client with an extremity fractues has severe pain in the affected area. The client's shoes should not be removed because doing so can increase trauma in the client

A nurse needs to perform a postural drainage of both lung apices in a 4-year old child. In what position should the nurse place the child?

Sitting on nurse's lap, leaning forward in order to perform a postural drainage in a 4-year-old child, the nurse should place the child sitting on the nurse's lap, leaning forward against a pillow.

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse add to the client's plan of care?

Small, frequent intake of juices, broth, or milk will provide gradual replacement of both fluid and electrolytes without overloading the intravascular compartment.

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow?

add extra salt to food because of diminished mineralocorticoid secretion, clients with Addison disease are prone to developing hyponatremia. Therefore, the addition of salt to the diet is advised.

A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide?

applesauce provides nutrition without large additional amounts of potassium and sodium.

A healthcare provider prescribes thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?

ask the healthcare provider if an elastic bandage can be used in place of the stockings. an elastic bandage can be adjusted to the varying proportions of the client's legs.

A nurse is helping an adolescent with type 1 diabetes establish a consistent meal pattern. What feedback from the adolescent indicates that further teaching is needed?

avoids complex carbohydrate substitutes complex cszrbohydrates may be substituted, depending on caloric content and amount eaten per serving

A nurse is instructing about nutrition with a client who has inflammatory bowel disease of the ascending colon. Which suggestion by the nurse is most appropriate?

consume scrambled eggs and applesauce low-residue food produce less fecal waste (eggs/applesauce), decreasing bowel contents and irritation; proteins promotes healing and calories provide energy.

After taking spironolactone, the client inquires about foods and fluids that contain potassium. Which juice should the nurse recommend?`

cranberry juice spironolactone is a potassium-sparing diuretic and foods high in potassium should be avoided. Cranberry juice contains the least amount of potassium

A client with severe chronic rheumatoid arthritis reports that pain lasts for 2 to 3 hours after exercising. What should the nurse should teach the client to do?

decrease the total time and number of repetitions of the exercise

A client with acute glomerulonephritis reports thirst. Which is the most appropriate choice that the nurse can offer to relieve the client's thirst?

hard candy sucking on hard candy, will relieve thirst and increase carbohydrates but does not supply extra fluid. the goa is to minimize unnecessary fluid intake.

A client with scleroderma is assessed by a speech therapist after choking and having difficulty with chewing and swallowing. Which dietary information should the nurse reinforce with the client?

ingest semisoft foods for meals scleroderma causes chronic hardening and shrinking of the connective tissues of any organ of the body, including the esophagus and face. Provide semisoft foods, such as mashed potatoes and pudding or custard to faciltate swallowing.

How is the teaching method for a preschooler different from that for a toddler?

preschoolers are encourged to learn together toddlers are not socially developed enough to participate in group learning activities.

An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?

say the child's name and touch the child's arm before starting care letting the child know that the nurse is in the room is vital; vocal and tactile contact will accomplish this.

A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. How should the nurse plan to meet this client's nutritional needs?

stay with the client during meals. active support is demonstrated when the nurse sits with the client during meals. Even if taken to the dining room, a depressed client may lack the physical or emotional energy to eat.

A client is to be on a 1500 calorie diet. For breakfast the client consumes 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat), ¾ cup cornflakes (15 grams of carbohydrate, 2 grams of protein), and half an orange (5 grams of carbohydrate). How many calories will the nurse document that the client has ingested?

258 the client has ingested 258 calories. Carbohydrates and proteins each yield 4 calories per gram, and fat yields 9 calories per gram. The total carbohydrate calories are 32 x 4 = 128. The total protein calories are 10 x 4 = 40. The total fat calories are 10 x 9= 90; 128+40+90= 258 calories.

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? Select all that apply.

1. boiled spinach 2. dried apricots according to the nutritional table, the food sources highest in iron are, "liver and muscle meats, dried fruits, legumes, dark green leafy vegetables, whole grain and enriched bread/cereals, and beans.

A 9-year-old child who has successfully completed the emergency (resuscitative) phase of treatment for a severe burn injury is started on a high-protein, high-calorie diet. Which snacks should the nurse encourage between meals? Select all that apply.

1. crackers and cheese (cheese increases protein intake (tissue repair) and crackers contain carbohydrates that provide calories (increased metabolism)) 2. Banana pudding and whipped cream (banana is high in potassium (tissue repair)) 3. Frozen yogurt (contains both protein and calories)

A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. What does the nurse determine is the probable cause of this response, and what is the treatment?

absence of gastrointedstinal motility; continue to monitor.

A nursing instructor asks a nursing student about the sleep patterns of preschoolers. Which statements made by the student indicate a need for more education? Select all that apply.

1. Daytime naps are very common among preschoolers 2. partial awakening leading to sleeplessness is common i preschoolers

A client weighed 210 pounds (95.2 kg) on admission to the hospital. After 2 days of diuretic therapy, the client weighs 205.5 pounds (93.2 kg). How many liters of fluid has the client excreted? Record your answer using a whole number. ____ L

2 L one liter of fluid weights about 2.2 pounds (1 kg)

A registered nurse teaches a nursing student about dietary modifications that help to decrease systemic symptoms associated with dysmenorrhea. Which statements made by the nursing student indicate effective understanding? Select all that apply.

1. the client should include low-fat milk in the diet 2. the client should include watermelon and peachesw in the diet

A child with celiac disease is prescribed a gluten-restricted diet. Which lunch selection for the child indicates that the parent understands the dietary instruction provided by the nurse?e

Beef taco, corn, canned peaches, chocolate milk Products that contain wheat, rye, barley, and oats are not tolerated by children with celiac disease. Beef tacos, corn, peaches, and milk are acceptable in a gluten-restricted diet; tortillas may be made with corn flour. Most frankfurters have fillers that contain gluten; the roll and most cookies contain wheat flour. Macaroni contains wheat flour. The bread used for the sandwich contains wheat flour, and oatmeal cookies contain oat and wheat flour.

A newborn with an anorectal anomaly undergoes anoplasty. At the 2-week follow-up visit, a series of anal dilations is started. What should the nurse recommend to the parents to help prevent the infant from becoming constipated?

Breastfeed if possible Human milk has a laxative effect that promotes a soft stool; breastfed infants rarely become constipated.

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns?

administer the prescribed intravenous fluid with the added vitamin C Vitamin C is essential for wound healing. It provides a component of intercellular ground substance that develops into collagen and is necessary to build supportive tissue.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?

previous experience and cultural interpretation of pain sensations is highly individual and is based on past experiences which inclue cultural values.

What developmental nursing intervention should the nurse provide to promote safety among adolescents? Select all that apply.

1. Helping parents minimize risks to their adolescents' safety 2. teaching parents to serve as role models by guiding expectations and providing education the nurse should help parents take the initiative in ensuring the adolescent's safety. Adults serve as role models for adolescents; hence the nurse should encourage parents to guide the adolescent's expectations and provide the child with adequate education.

Which interventions are included in the care plan of a postpartum client with a fourth-degree laceration? Select all that apply.

1. pain management with oral analgesics 2. assessment of site every 15 minutes 3. application of an ice pack for 20-minute intervals

Which of the following signs are indications of hydration status during a sickle cell crisis? Select all that apply.

1. turgor of tissue 2. texture of mucous membranes loss of tissue elasticity (decreawsed tissue turgor) indicates dehydration. Skin that takes 30 or more seconds to return to its original position after being pinched (tenting) is a sign of dehydration.

A client comes for an annual physical examination. To provide appropriate nutritional counseling, the nurse calculates the client's body mass index (BMI). The client's weight is 65 kg, and the height is 1.7 meters. What is the client's BMI? Record your answer using one decimal place. ________ BMI

22.5 The formula for BMI is: weight in kg ÷ (height in meters)2. The square of the client's height is 1.7 × 1.7 = 2.89; 65 ÷ 2.89 = 22.5. The desirable BMI for adults is 18.5 to 24.9.

An adolescent experiencing a vaso-occlusive crisis reports right knee pain. What is the most appropriate nursing intervention

applying a warm soak to the knee warmth causes vasodilation, which will lessen the pain of the vaso-occlusive crisis. Applying a compression wrap is not helpful because the problem is sickling of the red blood cells, not a lack of venous return

The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." What does the nurse determine that the client needs to be taught about?

foods that meet basic nutritional needs

A nurse reviews the diet with the parents of a toddler with recently diagnosed celiac disease. What foods selected by the parents indicate that further teaching is needed?

frankfurters and baked beans processed meats such as frankfurters and luncheon meats may contain flour as a filter, baked beans may be eaten if flour is not used to thicken the sauce.

The nurse has provided teaching to a client with impaired balance, who uses a walker when ambulating. The nurse observes the client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client does what?

holds both handles of the walker while rising to the standing position

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation?

length of time this problem has existed first, the nurse should establish when the client last defecated because the client may have perveived constipation.

A nurse is planning the discharge of a 9-year-old child who has undergone tonsillectomy. The nurse informs the parents that their child may have a mouth odor, slight ear pain, and a low-grade fever for a few days. In addition to the prescribed analgesic, what should the nurse recommend to ease their child's pain?

light-colored ice pops

The nurse is caring for a client admitted to the hospital for a rubber band ligation of internal hemorrhoids. Which action should the nurse take to reduce discomfort?

offer sitz baths sitz baths are warm. warm baths dilate the blood vessels and promote circulation, relieving local inflammation and itching.

A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood?

red meat red meat is high in dense saturated fats and should be avoided.

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction?

relieving muscle spasm and pain traction may be used in the treatment of a fractured hip to align the bones (reduction of fracture). If such traction is not employed, the muscles may go into spasm, shifting the bone fragments and causing pain.

When caring for a client in the early postoperative period after a hemorrhoidectomy, to ensure the client's safety, the nurse will place the client in which position?

side-lying this position helps alleviate pressure on the surgical area.

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

yogurt which contains calcium, is digested more easily than milk because it contains the enzyme lactase, which breaks down milk sugar. Yogurt contains approximately 274 to 415 mg of calcium for an 8 oz container.

The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number. ___mL

970 ml 1 ounce = 30 mL: therefore the client ingested 120 mL of orange juice, 180 mL of tea, 60 mL of water, 90 mL of soup, 120 mL of ice cream. received 400 mL of IV fluid for a total of 970mL.

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?

Different cultural groups favor differet essential nutrients the nurse should become informed regarding the cultural eating patterns of clients so that foods containing the essential nutrients that are part of these dietary patterns may be included in the diet.