midterm fundamentals (chapter 32, 28)
The nurse is caring for a client with a knee sprain. Which client statement regarding use of an ice pack indicates that nursing teaching has been effective?
"I will put a washcloth between my knee and the ice pack."
The nurse in a medical unit is collecting a client's history and asks the client about the use of complementary and alternative therapies. The client asks why the nurse needs to know about this. What is the nurse's best response?
"It's important that we list all your home care needs for the hospital." Nurses need to include complementary and alternative therapy in assessment of the client's current treatments to ensure an understanding of the safety and effectiveness of the treatments, particularly if the client is also receiving allopathic treatment. The nurse would want to be positive with this questioning so that the client is not defensive regarding any complementary and alternative treatments.
The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?
"Necrotic tissue is devitalized tissue that must be removed to promote healing."
The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?
"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."
The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.
"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other." (wounds made by primary intention are well aproximated)
A client is diagnosed with pancreatic cancer and states to the nurse that he or she would like to use integrative care as a health care choice. What is the best response by the nurse?
"Your health care provider will plan a combination of allopathic medicine and complimentary health approaches."
A nurse uses healing touch to care for clients. For which clients would this practice be most appropriate? Select all that apply.
-A client with a surgical wound -A client who has unrelenting pain -A client whose energy field is unbalanced -A client who is being prepared for a surgical procedure
A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.
-Administer analgesia before changing the dressing around the drain, if needed. - Use a gauze pad to clean the drain outlet after emptying it. -Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.
The nurse is educating a client on how to use herbs and supplements as part of an integrated treatment plan. Which teaching points would the nurse include? Select all that apply.
-Buy herbs and supplements that are standardized. -Give the product adequate time to work. -Be knowledgeable about the product and its therapeutic actions.
A client comes to a clinic for a checkup. The clinic practices integrative care. During the visit, the client reports a "runny nose" accompanied by sinus pressure, cough and mild fever. The client states, "I think I have a cold." Which intervention would the nurse include for this client as part of integrative care? Select all that apply.
-Using echinacea or zinc for prevention of colds -Undergoing acupressure to appropriate sites for nasal congestion relief -Using an over-the-counter nasal decongestant spray - Drinking lots of fluids throughout the day -Practicing good hand washing to prevent the risk for transmission
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?
A Penrose drain promotes passive drainage into a dressing. (penrose empties into absorptive dressing material. It promotes drainage passively, with the drainage moving from the area of greater pressure, in the wound or surgical site, to the area of less pressure, the dressing.)
sitz bath
A bath in which only the buttocks and hips are immersed In water. en una vasenilla
A client is asking for the nurse to explain acupuncture. What would the nurse tell the client?
Acupuncture is used to correct disharmony.
An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor?
Adipose tissue is poorly vascularized.
The nurse explains to the client which statement is true regarding the difference between allopathic therapy and complementary and alternative therapy?
Allopathic therapy emphasizes treatments for diseases. Complementary and alternative therapy emphasizes treatments for health.
The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform?
Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.
A nurse can best help a client who is undergoing chemotherapy and using guided imagery with this by doing which of the following?
Assisting the client to find an appropriate imagery tape to use.
Which of the following is an important aspect of Ayurveda?
Balancing of the doshas.
A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document?
Black classification This wound requires debridement.
Allopathic medicine is less effective in the care of clients with:
Chronic illnesses this hasn't been totally effective in dealing with persistent symptoms related to chronic pain illness and patient quality of life.
In prenatal classes, the nurse teaches pregnant clients to use meditation during labor contractions to ease the pain. Which elements of meditation are important for the nurse to emphasize? Select all
Comfortable position Quiet environment Focus of attention
A client is in the last stage of labor. During each contraction, she is focusing on her husband's voice and a picture brought from home. She is demonstrating which type of meditation?
Concentrative Concentrative meditation is probably the most familiar. The person focuses on an internal or external object.
Which action should the nurse perform when applying negative pressure wound therapy
Cut foam to the shape of the wound and place it in the wound.
The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?
Document the findings. The nurse should document the findings and continue to monitor the dressing. As it is a small amount of drainage, there is no need to contact the physician or the wound care nurse. The nurse should not change the dressing, as the dressing is still the surgical dressing and most often the surgeon will change the first surgical dressing within 24 to 48 hours.
Which nurse theorist developed Therapeutic Touch (TT)?
Dolores Krieger
A nurse is part of a team looking at incorporating complementary health practices as part of the services being provided at the health center. The nurse is gathering information about these approaches. Based on information gathered about natural products, which product would the nurse most likely identify as being most commonly used?
Fish oil
A client is following a Mediterranean diet to increase heart health. The nurse would offer which items as a snack? Select all that apply.
Fruit Whole grain crackers Carrots with humus
A client who is receiving chemotherapy and experiencing significant nausea asks the nurse about using aromatherapy to help alleviate the nausea. Which essential oil would the nurse most likely suggest to address the client's nausea?
Ginger ginger and peppermint are used for nausea
The nurse is educating a client on how to use herbs and supplements as part of an integrated treatment plan. Which teaching points would the nurse include? Select all that apply.
Give the product adequate time to work. Buy herbs and supplements that are standardized. Be knowledgeable about the product and its therapeutic actions.
A client asks the nurse about the use of healing touch. Which statement regarding healing touch is accurate?
Healing touch does not use injections.
The nurse is caring for a client whose treatment has been based on the Ayurveda medical system. Which nursing intervention incorporates this client's beliefs into the nursing plan?
Helping the client to balance his or her dosha
A nurse is teaching a client experiencing stress about how relaxation helps to reduce the effects of stress on the body. Which underlying concept would the nurse integrate into the explanation about how relaxation works?
Helps to increase the effects of parasympathetic nervous system on the mind and body
The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.
Hemostasis Inflammatory Proliferation(fibroblastic) Maturation
A home care nurse delivers care that incorporates a philosophy that focuses on connections and interactions between parts of the whole. Which term best describes this philosophy? a)Integrative care b)Holism c)Homeopathy d)Complementary therapy
Holism
The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students?
Holism perspective
Which of the following has been known to achieve benefits for clients with cancer through the use of the mind to visualize a positive physiologic effect?
Imagery
What is the best nursing diagnosis to describe a minor laceration to finger sustained when a client was cutting fruit with a knife in the kitchen?
Impaired Skin Integrity related to open wound Impaired skin integrity best describes the minor laceration. Pain, knowledge deficit, and risk for infection are all sustained as a result of the laceration.
A nurse practitioner is conducting a presentation at a local community center about complementary health approaches. One of the participants asks the nurse practitioner, "Everybody is talking about relaxation. Just how does relaxation help a person?" The nurse responds, integrating which effect as being associated with relaxation? Select all that apply.
Improved sense of well-being Reduced muscle tension Better sleep and rest Less anxiety
Ayurvedic medicine has its roots in which of the following areas?
India originated in the Vedic civilization of India. Its one of the worlds oldest medical system)
Massage therapy is being used on clients during chemotherapy treatments. How does massage therapy help these patients?
It relaxes muscles to increase circulation and release tension.
mechanical debridement
Physical removal of debris by irrigation, hydrotherapy or wet-to-dry dressing application
A client uses meditation as part of treatment for a neuromuscular disease. How can the nurse best facilitate continuation of this treatment while the client is hospitalized?
Provide a quiet uninterrupted period for meditation
A nurse is interviewing a client at the clinic. During the interview, the client tells the nurse about participating in a practice that involves postures, exercises, breathing techniques, and visualization. The nurse correctly identifies this as:
Qi gong. is a system of postures, exercises, breathing and visualization.
Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan?
Record the quantity of drainage once per shift and document on the intake and output record.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?
Reduce the time interval between dressing changes.
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen. (avoid touching the swab to intact skin at the wound edges)
A client receiving a sitz bath complains of light-headedness to the nurse. What is the nurse's most appropriate action?
Stop the sitz bath, call for help, and help the client to the toilet to sit down.
A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?
Supports the area around the wound
The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?
The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. (positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. ex: standard pillow placed under the length of the calves raises the heels off the bed and alleviates pressure)
The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?
The nurse works outward from the wound in lines parallel to it
how to clean a black wound?
This wound requires debridement. often care for by an advance practice nurse.
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?
To splint the area when engaging in activity A splint is a device used for support or immobilization (entablillar)
The nurse is caring for a client in a hospice facility and uses healing touch. A family member asks the nurse, "What good is touching going to do with cancer?" What is the best response by the nurse? Select all that apply.
To stimulate wound healing To decrease pain To promote health To support end-of-life
During a client interview, the client tells the nurse about using ginkgo biloba to improve memory. When reviewing the client's medication history, which medication if used by the client would be a cause for concern?
Warfarin Ginkgo biloba is the most widely sold herb in Europe and used by many to improve memory, affects platelet function and thus shouldn't be used currently with WARFARIN or ASPIRIN
According to survey results, who are the most prevalent users of complementary or alternative therapies?
Women, ages 35-50, with college degree, former smoker
A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform?
Wound irrigation explanation: to clean these wounds, nursing intervention include the use of wound cleansers and irrigation.
The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply.
a client who is obese a client who is taking corticosteroid drugs an older adult who is confined to bed a client with a peripheral vascular disorder
A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:
a rash related to a yeast infection. Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.
A client's risk for the development of a pressure injury is most likely due to which lab result?
albumin 2.5 mg/dL (normal albumin level is 3.4 to 5.4 g/dL)
What term is defined as "those practices that do not form part of the dominant system for managing health and disease"?
alternative medicine
splint
appliance used for fixation, support, and rest of an injured body part
A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding?
avulsion
A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?
biosurgical debridement Biosurgical debridement uses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases.
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?
cleanse with a new gauze for each stroke
allopathic medicine
conventional western medicine
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?
elevating and supporting the stump The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.
The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?
evisceration Evisceration is the most serious complication of dehiscence. It occurs primarily with abdominal incisions. The abdominal wound completely separates, with protrusion of viscera through the incisional area.
The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? a) circular turn b)spiral-reverse turn c)spica turn d)figure-of-eight turn
figure-of-eight turn It is effective for use around joints, such as the knee, elbow, ankle and wrist.
how do we clean red wounds?
gentle cleansing, use moist dressing, and change dressing only when necessary.
A nurse is educating a client on meditation techniques to provide mental calmness and physical relaxation. Which nursing intervention facilitates this process?
helping the client to assume a specific, comfortable posture
The mind and body are connected in the provision of care. This statement describes:
holistic care.
Enzymatic debridement
involves the application of commercially prepared enzymes to speed up the body's autolytic process
A client comes to the clinic for an evaluation. The client reports that "I been having such problems with getting to sleep and then staying asleep. But I don't want to take any medicines." After a discussion of possible complementary health approaches, the client decides to try aromatherapy. Which essential oil would the nurse most likely suggest to address the client's problem?
lavender and chamomile are used for insomnia
A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?
mechanical debridement
debridement
removal of foreign material and dead or damaged tissue from a wound
On the advice of friends, a client on a palliative care unit has requested acupuncture. What it is the goal of this form of CAM?
restoring a healthy flow of energy along the meridians of the body (acupuncture either increases or decreases the flow of chi along the meridian, restoring the balance of yin and yang. This change in the flow of energy contributes to healing)
A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound?
secondary intention
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?
secondary intention
A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?
tertiary intention explanation: Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.
autolytic debridement
using body's enzymes to break down tissue
