Week 2: Basic Care and Comfort

The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many milliliters of the full-strength formula with water? Record your answer as a whole number.

375 To determine the amount of formula to use, multiply the 500 ml of full-strength formula by 75% (0.75):500 ml X 0.75 = 375 ml.

he nurse is caring for a client receiving heparin for venous thromboembolism. Which finding should concern the nurse?

After sneezing, the client develops a nose bleed. A client receiving anticoagulant therapy should be monitored for bleeding. Nosebleeds can indicate that the client is experiencing a complication of anticoagulant therapy. The client's aPTT should be 1.5 times the control, the INR should be 2.0 to 3.0, and because the full effect of warfarin takes 3 to 5 days, the client may be on both heparin and warfarin concurrently

A client is experiencing uncontrollable back pain and a physical therapist suggests a back massage. The clients asks the nurse how massage will help the pain. What is the best response by the nurse?

"Massage is point stimulation used for orthopedic and neurological conditions." Massage uses point stimulation of pushing and pulling of the skin to relieve orthopedic and neurological conditions. Massage will realx muscles, ligaments, and tendons. Massage is not widely used by hospitalized clients nor does it include the use herbal supplements.

A client reports abdominal pain. Which action allows the nurse to investigate this complaint?

assessing the painful area last Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when the nurse will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.

A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner?

Hold the cane in the right hand. To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4 to 6 inches (10 to 15 cm) from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, and then move the uninvolved leg.

The nurse has taught a client with a history of chronic upper respiratory infections (URIs) about the appropriate use of Echinacea. Which client statement indicates that the nurse's teaching has been successful?

I will use Echinacea as a tea several times a day." Echinacea can be prepared as a cup of tea and used several times a day. All the other statements are incorrect as Echinacea can be used throughout the year as indicated, it cannot be a substitute for appropriate antibiotic use for a client with chronic URIs, and it should only be used up to 2 weeks as prolonged use is not advised.

A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply.

avoid caffeine, alcohol, and nicotine before bedtime prepare the room for sleep and turn off distracting noise participate in a bedtime routine Caffeine, alcohol, and substances such as nicotine act as stimulants, avoiding them should help promote sleep. Maintaining a cool temperature in the room will facilitate optimal sleep. Excessive fullness or hunger can disrupt or interfere with sleep. A regular sleep-wake time facilitates physiologic patterns, rather than waiting until an individual begins to feel tired. The room should be conducive to sleep. Eliminate distractions such as a television or radio. Participation in a relaxation, prayer, or meditation routine can help prepare an individual for a restful night.

The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse

Some children distract themselves with play while in pain." Some children distract themselves with play or music while in pain and may sleep as a result of exhaustion. Nurses commonly underestimate children's pain when they do not rely on children's self-reports. Narcotics can be used safely with children.

A client who is receiving chemotherapy develops stomatitis. What should the nurse instruct the client to do?

Use a soft-bristled toothbrush after each meal. Stomatitis is an inflammation of the mucous membranes of the mouth resulting from chemotherapy. Using a soft-bristled toothbrush prevents further bleeding and irritation to the already irritated gums and mucous membranes. Hydrogen peroxide can further irritate the mouth. Fluids need to be lukewarm instead of hot; dental floss can be used if it is done gently.

Two days after surgery to amputate their left lower leg, a client states that they have pain in the missing extremity. Which action by the nurse is most appropriate?

administer medication, as ordered, for the reported discomfort. The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. It should be treated with medication. The nurse doesn't need to contact the physician at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the physician.

A client progressing through pregnancy develops constipation. What is the primary cause of this problem during pregnancy?

reduced intestinal motility During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.

A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform which exercise?

tailor sitting Tailor sitting, also referred to as cobbler's or butterfly pose, is an excellent exercise that helps to strengthen the client's back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. Leg lifts are helpful for leg aches. Shoulder circling exercises are helpful for neck and upper backaches. Squatting is not helpful for alleviating lower backaches.

Before a cancer client receiving total parenteral nutrition resumes a normal diet, the nurse teaches them about dietary sources of minerals. Which foods are good sources of zinc?

whole grains and meats Good sources of zinc include whole grains, meats, dairy products, and seafood. Fruits are good sources of vitamin C, and vegetables are a good source of many vitamins and minerals, but not zinc. Yeast is a good source of chromium, and legumes are a good source of copper, manganese, and molybdenum.

The nurse is educating a client who works with chemicals on immediate emergency care in the event of eye exposure. Which statement reflects correct teaching by the nurse?

"You should flush your eyes for about 15 minutes with tap water to remove the chemical." The client who works with chemicals should be taught emergency care of the eyes in the event of chemical exposure. If one or both eyes are exposed, the client should irrigate the eyes for approximately 15 minutes with tap water to try to remove the chemical (sterile water is not required for flushing). Waiting until the client gets to the emergency department would delay care that could prevent more extensive injury to the eyes. There is no need to irrigate both eyes if only one is exposed; the client should be careful to not let the water run into the unaffected eye in case of chemical exposure in this way.

A client has a prescription for an oil retention enema and a cleansing enema. The client asks the nurse to explain the purpose of the enemas. What is the most accurate response by the nurse?

"Oil retention enemas soften stool, and cleansing enemas stimulate a bowel movement The oil retention enema is given first to soften the stool, and then the cleansing enema is given to stimulate peristalsis. This is the most accurate response. The oil retention enema is given first, followed by the cleansing enema. The purpose of the oil retention enema (not the cleansing enema) is to soften the stool, not lubricate the bowel lining. While is common for people to need two different types of enemas, this answer provides no education to the client and therefore is not the most accurate response.

A 10-year-old male is 24 hours post appendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain?

Obtain vital signs with a pain score. The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the client's pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head to toe assessment, but it is not the priority in managing the child's pain.

The health care provider orders documentation of a client's intake and output. Using the following information, calculate this client's intake in milliliters. Record your answer to the nearest tenth.250 ml decaffeinated coffee 125 ml green jello62.5 ml apple juice 125 ml lemon-lime soda250 ml beef broth 300 ml of urine output

812.5 250 ml coffee + 62.5 ml apple juice + 250 ml beef broth + 125 ml jello + 125 soda = 812.5 ml. The 300 milliliters of urine output does not calculate into the client's input

A prenatal client wants to begin a yoga-based exercise class to keep her healthy during pregnancy. What information should the nurse include in the plan of care? Select all that apply.

Drink plenty of water before, during, and after a workout. Take precaution to prevent overheating. Avoid jerky, high-impact motions. Modify any positions that put strain on the abdomen. Clients should keep well hydrated with any form of exercise. Dehydration can lead to dizziness and put the client at risk for falls. Later in pregnancy, dehydration can contribute to preterm labor. Becoming overheated can lead to dehydration. In the first trimester heat can act as a teratogen. Ligaments become more relaxed during pregnancy, making joints more mobile. High impact, quick movements can lead to injury. Many yoga poses put pressure on the abdomen and would need to be modified as a pregnancy progresses. It is unnecessary to restrict participation to a prenatal yoga class only; however, the client should be advised to notify the instructor that she is pregnant and discuss if participating in that particular class is appropriate.

A client receiving chemotherapy is nauseated and has lost 15 pounds (6.8 kg) in one month. Which nutritional instruction would the nurse include in the plan of care?

Eat frequent but small meals. Small quantities of food offered frequently allow the client to ingest food with the best chance of avoiding nausea. Eating two high protein meals per day may increase nausea. Fluids may distend the stomach and can cause nausea. Extremes in temperature can precipitate nausea.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet. A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake is not necessary because chronic pancreatitis is not associated with hyponatremia or fluid loss.

An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do?

Make the bed with the bedsheet on top of the pressure mattress. To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis. Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area. The other actions would not be appropriate actions.

A nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. What instructions would the nurse give to this client?

Take an afternoon nap. Fatigue is a common part of pregnancy. It is worst in the first and third trimesters; first-trimester fatigue is often associated with the many physical and psychosocial changes of being pregnant, and third-semester fatigue is caused by sleep disturbances from increased weight and physical discomforts such as heartburn. If physical causes of the fatigue are ruled out, the client should be arranging her life to permit additional rest periods. Naps should be encouraged. It is best to sleep on the left side, but a position of comfort improves sleep. Sleeping pills should be contraindicated during pregnancy. The client should go to bed to sleep on her natural sleep schedule. If one is used to going to bed late at night, then going to bed earlier doesn't mean the client will fall asleep earlier. The client should sleep and rest when her body tells her

The client is discussing the client's medication history with the nurse. During the discussion, the client pulls out a list of the prescribed medications, which include fish oil and St. John's Wort. What is the nurse's understanding of why these alternative therapies are used by the client?

The client has a history of depression The client has a history of depression. Fish oil and St. John's wort are alternative therapies to treat depression.

Which indicates the client with ulcerative colitis has attained an expected outcome of nursing care?

The client maintains an ideal body weight. An expected outcome for a client with ulcerative colitis is maintaining an ideal body weight.It would not be appropriate to restrict fluid intake; the client should strive to remain well hydrated.Ulcerative colitis produces episodic diarrhea, not constipation.It is not inevitable that the client with ulcerative colitis will need an ileostomy. The decision to perform surgery depends on the extent of the disease and the severity of the symptoms.

A pediatric client has just had a plaster cast placed on his lower left leg. Which action should the nurse take to provide safe cast care?

Use only the palms of the hand when handling the cast. The wet plaster cast should be handled using only the palms of the hands to prevent indentations of the cast surface. Petaling a cast should be done only when the edges of the cast are rough and are causing irritation to the client's skin. The nurse should not keep the child in the same position until the cast is dry. Doing so would prohibit proper toileting and elimination and would produce undue pressure on the coccyx. The cast typically emits heat as it dries, so notifying a health care provider (HCP) is not necessary in this instance. If needed, a fan can be used to circulate the room air

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

by supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

he client with a hearing aid does not seem to be able to hear the nurse. The nurse should first:

check the hearing aid's placement. Inadequate amplification can occur when a hearing aid is not placed properly.The certified audiologist is licensed to dispense hearing aids.The ear mold is the only part of the hearing aid that may be washed frequently; it should be washed daily with soap and water.Irrigation of the ear canal is done to remove impacted cerumen or a foreign body.

For which client(s) does the nurse anticipate the healthcare provider's orders for pneumatic compression devices? Select all that apply.

client who had extended low anterior resection for colonic mass client in the intensive care unit on a ventilator with sepsis client with four vessel coronary artery bypass graft with bilateral chest tubes Pneumatic compression devices may be used with graduated compression stockings or alone to apply sequential pressure to the legs to enhance blood flow and venous return. They require a prescriber's order and are usually prescribed for high-risk surgical clients, clients with decreased mobility, and those at risk for deep vein disorders. Clients with extended low anterior resection and coronary artery bypass graft would be surgical clients at high risk for deep vein thrombosis. The client in the intensive care unit on a ventilator with sepsis has decreased mobility and is also at risk for deep vein thrombosis. Same-day procedures such as endoscopy and laparoscopy would not be considered high risk for deep vein disorders and would not require pneumatic compression devices.

A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?

current medications St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, she can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.

When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet?

high purine To control uric acid calculi, the client would follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.

he nurse is planning the care for a client with risk factors for atherosclerosis. What should the nurse include in the teaching plan for this client as modifiable risk factors? Select all that apply.

e-cigarette use hypertension stress Nicotine use (e-cigarettes), hypertension, and stress are modifiable risk factors for atherosclerosis. Gender and genetics are nonmodifiable risk factors for atherosclerosis

The nurse is teaching a client with stomatitis about managing oral discomfort. Which instruction is most appropriate?

eat a soft, bland diet. Clients with stomatitis (inflammation of the mouth) have significant discomfort, which impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and flossing.

Which intervention should the nurse suggest to a parent to relieve itching in a child with chicken pox?

oatmeal preparation baths Because of their colloidal properties, oatmeal preparation baths typically help relieve the itching associated with chicken pox. Calamine lotion can be also be used if there are no open lesions. Baby powder is unlikely to relieve itching because it acts primarily to absorb moisture. A soft towel moistened with hydrogen peroxide is unlikely to relieve itching. Rather, hydrogen peroxide is used to clean wounds. A cool compress moistened with a weak salt solution is unlikely to relieve itching because it does not have any antipruritic properties.

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of

organ meats. Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output

weighing the diaper before and after micturition Weighing the diaper before applying it to the newborn, infant, or toddler, and then weighing it after micturition will help evaluate the urine output. The difference between the wet diaper and the dry one will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing the child or measuring the formula will not give an indication of evaluating the urine output in this situation.

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. The nurse knows that the client understands the management of the disorder when the client says

"I will eat five or six small meals each day and have some protein with each meal." Digestion of a large meal shunts blood to the gastrointestinal tract, increasing fatigue levels. Clients with this disorder should ingest small, frequent, and nutritious meals five or six times per day. It is not necessary to completely avoid simple carbohydrates. Eating immediately before bedtime can disturb sleep patterns. A pregnant woman with cardiac issues benefits from sound sleep.

A client admitted to the hospital for chemotherapy states that using a peppermint-scented candle at home to helps control nausea. Which interventions would the nurse plan to promote comfort for this client?

Asking the client to try using peppermint oil in place of scented candles Aromatherapy may affect the brain's limbic system, causing relaxation, evoking positive emotional memories, and decreasing the need for antiemetics. Such alternative therapies may increase a client's feeling of control over illness. Because this client associates positive feelings with the scent of peppermint, the nurse should encourage the client to continue using that scent, but should ask the client to use scented oil rather than a candle. Fire of any kind, even a candle, is a hazard in the hospital — especially when oxygen is being used. Increasing the client's nausea medication or ordering a sedative could cause dangerous adverse effects and wouldn't be best practice.

A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when administering an enema? Select all that apply.

Assist the client into the left-lateral Sims' position. Lubricate the distal end of the rectal catheter. Be sure to keep the solution container below 18 inches (45 cm) above bed level. To administer an enema, the nurse should prepare the prescribed type and amount of solution. The standard volume of an irrigating enema for an adult is 750 to 1,000 mL. For an adult, the solution should be warmed to 100° (37.8°C) to 105°F (40.6°C) to help reduce client discomfort. The nurse should help the client into left-lateral Sims' position. After lubricating the distal end of the rectal catheter, the nurse should insert the tube 2 to 3 inches (5 to 7.5 cm). During infusion, the solution bag should not be raised higher than 18 inches (45 cm) above bed level.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?

Change the tube feeding administration set at least every 24 hours. The nurse should change tube feeding administration sets at least every 24 hours. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings.

The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse?

Discontinue the graduated compression stockings and notify the healthcare provider When a client has prescribed graduated compression stockings, the nurse would remove the stockings and inspect the skin at least every 8 hours. If the client has discoloration, markings, or blisters on the heel, the nurse would discontinue the stockings and notify the healthcare provider because sequential compression devices may be used instead to prevent deep vein thrombosis. Applying antibiotic ointment or sterile dressings would require a healthcare provider's order, therefore the healthcare provider should be notified before proceeding with the reapplication of the stockings. Reapplying the stockings may cause further damage to the heel, therefore the healthcare provider should be notified before making a referral to the skin care team.

A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?

Discuss meals that include low-fat high-carbohydrate content. In cirrhosis, the liver's metabolic function is compromised, increasing the client's need for carbohydrates and other energy sources for cellular metabolism. The nurse should limit the client's fat intake to prevent satiation and should restrict protein intake because a cirrhotic liver can't metabolize protein effectively. A client with cirrhosis may have increased edema as a result of reduced plasma albumin, so the client should restrict fluid intake rather than drink 64 oz of water daily. Increasing fiber intake isn't a priority intervention for a client with cirrhosis. A client with cirrhosis doesn't need to eliminate caffeine from their diet

A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which action has the highest priority?

Elevate the head of the bed during and after the PEG tube feedings. A client who is unconscious and receiving PEG tube feedings should be positioned with the head of the bed elevated during and after feedings to decrease the risk of aspiration. Considering client safety is the priority intervention; the others are not the priority

A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?

Increase daily fluid intake to at least 2 to 3 L. A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization. Depending on the composition of the stone, the client also may be instructed to institute specific dietary measures aimed at preventing stone formation. Clients may need to limit purine, calcium, or oxalate. Urine may need to be either alkaline or acid. There is no need to strain urine regularly.

A client reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first?

Inquire about the client's sleeping habits. Assessing the client's sleeping habits may provide information about the causes of the inability to sleep. Sedatives should be given as a last option. A backrub may promote sleep but may not address this client's problem. Moving the client may not address the client's specific problem.

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate?

Offer the client frequent oral hygiene care The most appropriate intervention is to offer the client frequent mouth care to moisten the dry oral mucosa. Reexplaining why the client cannot drink may be helpful but will not relieve the thirst. Ice chips cannot be given to a client who is on NPO status. Diverting the client's attention does not help manage the thirst.

A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which suggestion would be most helpful?

Practice relaxation techniques before bedtime. Insomnia in the later part of pregnancy is not uncommon because the client has difficulty getting into a position of comfort. This is further compounded by frequent nocturia. The best suggestion would be to advise the client to practice relaxation techniques before bedtime. The client should avoid caffeine products such as chocolate and coffee before going to bed because caffeine is a stimulant. Alcohol consumption, regardless of the type or amount, should be avoided. Exercise is advised during the day, but it should be avoided before bedtime because exercise can stimulate the client and decrease the client's ability to fall asleep

The nurse is assisting a client diagnosed with dementia during meal time. Which nursing would best prevent complications?

Serve one course at a time with the appropriate utensil. The client with dementia may be at risk for less than required nutrition. Therefore, food and fluid intake is a priority. One course at a time will prevent the client from becoming overwhelmed. A plate with too many choices, rushing a client with a short meal time, and expecting them to prepare a meal by opening containers may frustrate a client with cognitive deficits

A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises?

Stop the flow of urine while urinating. By stopping urine flow during urination, the pelvic floor muscles are contracted. Tightening the leg or stomach muscles doesn't contract the pubococcygeus muscle. Pelvic squats don't tighten the pelvic floor muscles.

A client with human immunodeficiency virus/acquired immunodeficiency disorder (HIV/AIDS) reports to the nurse a loss of 15 pounds in the past month and asks, "Do you think that I could use marijuana to help get my appetite back?" What is the nurse's best response?

There are medications in addition to medical marijuana that can stimulate your appetite and help you to regain weight." The use of an appetite stimulants is useful in HIV/AIDS clients who have anorexia. There is evidence that medical marijuana is an appetite stimulant that has enabled people to gain weight, as well as relieve nausea. If a client has no appetite, the use of supplements and suggestions to eat more protein may not be very helpful.

Which nursing recommendation is most appropriate for a client to decrease discomfort from hemorrhoids?

Use warm sitz baths. Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids.Fiber in the diet should be increased to promote regular bowel movements.Laxatives are irritating and should be avoided.Decreasing physical activity will not decrease discomfort.

The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is mostessential for the nurse to instruct on which aspect of daily care?

a diet high in protein and nutrients It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bed rest is not common in care and assistive devices are used only in the acute period.

A client has left-sided paralysis. The nurse should document this condition as left-sided

hemiplegia. Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.

When positioning a neonate with an unrepaired myelomeningocele, which position is mostappropriate?

prone with hips in abduction Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler's position, even though the chest and abdomen are elevated.

The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time?

Attend the funeral. It is appropriate for the nurse who took care of a client for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up personal or phone call to the client's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. Flowers may not be desired by the family. The nurse needs to do more than just remove the client's name from the care list.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

A child is prescribed amoxicillin for otitis media. What should the nurse recommend the mother do when the child develops diarrhea?

Offer yogurt several times a day. Diarrhea is a common adverse effect of amoxicillin because the drug kills normal intestinal bacteria. Yogurt with live cultures helps restore the normal intestinal flora. Restricting the child to clear fluids will not help stop the diarrhea or recolonize the intestine. Withholding food and fluids for 2 hours is suggested when a child vomits. Pizza tends to be spicy and aggravates the diarrhea, but restricting its intake will not help the underlying problem.

During a physical examination, the nurse observes a copper bracelet on a client's wrist. The client states that she is wearing it to treat her arthritis. What should the nurse do?

Recognize that the client is wearing a protective object she believes prevents illness. The client might wear objects as a protection against specific medical disorders. Typically, these practices bring no harm to the client and should not be discouraged. The client should continue to be encouraged to follow the medical guidance of her health care provider (HCP). If the practice is not harming the client, it is inappropriate to label it quackery and demand that the client discontinue it. There is no medical evidence to support the wearing of a copper bracelet.

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do?

Use constant, gentle touch. Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands.

A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?

encouraging intake of at least 2 L of fluid daily Encouraging a daily fluid intake of at least 2 L helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence

After the nurse counsels a primiparous, breastfeeding client about diet and nutritional needs during the lactation period, which client statement indicates a need for additional teaching?

"I should drink at least five glasses of fluid daily For the breastfeeding client, drinking at least 8 to 10 glasses of fluid a day is recommended. Breastfeeding women need an increased intake of vitamin D for calcium absorption. A breastfeeding woman requires an extra 500 cal/day above the recommended nonpregnancy intake to produce quality breast milk. Breastfeeding women need adequate calcium for blood clotting and strong bones and teeth.

The nurse is caring for a client prescribed IV heparin for treatment of thromboembolism. The client is prescribed 18 units/kg/hr. The client weighs 145 lb (66 kg). The heparin comes from the pharmacy as 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round to the nearest whole number.

12 The recommended dose of 18 units/kg should be obtained by multiplying the weight in kilograms by 18 units. 66 kg × 18 units = 1188 units/hr. Concentration for the medication is 25,000 units/250 mL. Use the formula Desired/Have × Volume: 1188 units/25,000 units × 250 mL = 11.88 mL/hr or 12 mL/hr.

A client who is being treated for cancer has expressed interest in exploring complementary and alternative therapies. What is the nurse's best action?

All treatments should be encouraged unless there are known and significant contraindications. Unless there is a known safety risk, complementary and alternative treatments should be facilitated. The nurse should make it clear that the client does not have to choose between conventional treatment and alternatives.

The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain?

Ask the child to point to a face drawing that indicates pain intensity. In this age group, it would be most appropriate to use a nonverbal manner of pain assessment. The pain intensity rating scale consists of six faces with expressions ranging from happy and smiling to sad and tearful. It is highly reliable in children of this age-group. Observing the child for pain behaviors such as crying and restlessness is most appropriate for pain assessment in infants. Asking a child of this age to describe the way the pain feels may give inconsistent data. The numeric pain scale is most reliable in children older than age 8.

The nurse is caring for a client during the postoperative period. The client was prescribed thigh high antiembolism stockings and pneumatic compression devices for prevention of deep vein thrombosis. Assessment data reveal +3 pitting edema to the lower extremities bilaterally. What is the priority action by the nurse?

Measure client's thighs and calves to ensure the antiembolism stockings are the correct size. For the client with antiembolism stockings and pneumatic compression devices in place for prevention of deep vein thrombosis, it is important for the nurse to remove the stockings and assess the client's skin every 8 hours. If the client has a significant change in the size of the legs, such as with postoperative edema, it would be the nurse's priority to measure the client's legs to ensure the stockings are the correct size. If the measurement showed the need for another size stockings, the nurse would apply them at that time. Clients in the postoperative period are at risk for deep vein thrombosis, therefore it is the priority to ensure the appropriate sized antiembolism stockings, not to discontinue them. Applying a larger size would be implemented after measuring the client's legs to ensure the stockings are the correct size. There is no need to notify the healthcare provider if the nurse applies a larger size.

Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?

lamb and peaches Iron-rich foods include lamb and peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply.

weighing and recording all wet diapers obtaining an accurate daily weight obtaining an accurate stool count Accurate intake and output recording includes noting all intake, including IV fluids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive sufficient fluid intake, but having a breast-feeding child switch to bottle-feeding will not promote intake. Restricting fluids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should continue to encourage fluids for this dehydrated child.

The client will have an abdominal hysterectomy tomorrow. Which information will be mostimportant for the nurse to give to the client prior to admission to the hospital?

what she can eat and drink before admission It is a priority that the client knows she will not be able to eat or drink for 8 hours before admission. A client who consumes food and fluid before receiving a general anesthetic is at risk for aspiration, which can lead to aspiration pneumonia, respiratory arrest, and even death. The clothing she should wear to the hospital and the type of medication she will receive are important, but not the priority. Information on exercise and resumption of normal activities can be included in the discharge teaching.

The client is diagnosed with benign fibrocystic breast disease. Interventions to reduce discomfort from this disease include teaching the client to:

avoid caffeine. Avoiding caffeine is reported to alleviate discomfort associated with fibrocystic breast disease for many women, but the rationale is not clearly understood.Activity level is not associated with fibrocystic breast disease.Wearing tighter garments could increase discomfort.

A client tells a nurse that she's going to breast-feed her neonate but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy." The client indicates she needs additional teaching when she states she'll resume taking all the medications she was taking before her pregnancy because most drugs are excreted through breast milk and may affect the neonate. The client should consult with her physician before taking any drugs while breast-feeding. She should increase her daily calories by 500, drink 10 glasses of fluid, and include milk products in her diet to increase her milk production and provide adequate nutrition for her neonate and herself.

The parent of a client who is disabled due to a traumatic amputation states to the nurse, "I am concerned that situations will occur and that I may not know what to do to help my child when we are at home." Which response by the nurse is the most appropriate to address the parent's concern?

"Talk to your child about needs and ask how you can be of assistance There will be times where the best strategy for the parent to use is to ask what the client needs, and request that the client identify how the parent can best facilitate assistance and support in that specific situation. Although written information and the creation of a plan of care can be helpful, it is best to provide the parent with a general guideline to use since not all situations will be addressed in these materials. Focusing on the parent's limitations may limit communication and make the client hesitant to ask for assistance.

A client with pneumonia has a temperature of 102.6° F (39.2° C), is diaphoretic, and has a productive cough. The client is able to ambulate. What should the nurse do?

Change the bed sheets frequently. Frequent changes of the bed sheets are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort, and the client should be kept dry to promote comfort and prevent skin irritation. The client should change position every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. The client can ambulate to the bathroom, but the nurse should offer assistance as needed.

The nurse is caring for a 3-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention?

Have the dietician meet with the child and family to provide foods the child will eat The dietician should be involved to help determine foods appropriate for children in different age groups. The child and family should help select preferred foods and identify cultural beliefs and dining habits. Take advantage of a hungry period and serve small snacks. Encourage parents to relax pressures placed on eating by stressing the legitimate nature of loss of appetite. The other responses do not help to stimulate the child's appetite.

A client tells the nurse that she is concerned because she has not had a bowel movement since the birth of her infant 3 days ago. Which would be the priority intervention by the nurse?

Increase her consumption of fiber to 25 grams per day. The client's diet needs to be high in fiber to promote normal bowel elimination. A diet with 25 grams is an adequate amount of fiber for this client. It is normal not to have a bowel movement for approximately 3 days following birth, especially if the woman had one during labor. Stool softeners may be warranted, but typically laxatives are not recommended until other measures have been pursued. Ambulation will promote peristalsis; therefore, the nurse should encourage ambulation rather than bed rest.

A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:

assess the feet for signs of neurovascular impairment The nurse should assess the client frequently for signs of neurovascular impairment of the feet, such as pallor, coldness, numbness, or tingling. Pillows are not placed under the buttocks because the pillows would alter the alignment of the traction. Weights provide traction and should not be removed. Pulleys help to maintain optimal alignment of the traction and therefore should be left alone.

To prevent back injury, the nurse should instruct the client to

avoid prolonged sitting and standing Prolonged sitting and standing should be avoided because they strain the lower back.Pushing objects rather than pulling them will help decrease back strain.Clients should select a semi-firm to firm mattress to provide back support.When sitting, the client should choose a chair with good support and a straight back. The client should sit with feet flat on the floor.

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?

metabolic alkalosis Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

A nurse is reviewing a pregnant client's nutritional status. To determine whether the client has an adequate intake of vitamin A, the nurse should assess the client's diet for consumption of:

milk. Common food sources of vitamin A include dairy products, liver, egg yolks, fruits, and vegetables. Fish and meat are good sources of protein. Cereals, especially whole grains, are good sources of niacin, vitamin B1, and vitamin B6.

Which night clothes would the nurse recommend for an infant with atopic dermatitis?

one-piece cotton pajamas with long sleeves Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate.A short-sleeved shirt would be inappropriate because the infant could scratch the uncovered arms, exacerbating the condition.Flannel may be too warm, causing the child to perspire, which will aggravate the condition.Because atopic dermatitis is commonly associated with allergies, wool garments should be avoided.

The nurse is caring for a 4-year-old child who is experiencing pain. When evaluating the child's response to pain, which of the following factors are most important for the nurse to assess? Select all that apply.

parental presence personality traits past experiences communication skills The presence of the child's parents, past experiences, personality traits, and communication skills may greatly influence how the child reacts to pain in any given situation. The child's ability to comprehend the meaning of pain is limited due to the developmental level and is therefore less likely to influence the response to pain.

Following nasal surgery, the client has packing in the nose. The nurse should:

perform frequent mouth care Mouth breathing dries the oral mucous membranes. Frequent mouth care is necessary for comfort and to combat the anorexia associated with the taste of blood and loss of the sense of smell.Checking the nares for ulcerations and monitoring the temperature every 4 hours are not necessary.Nose drops are not instilled with packing in place.

A nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse should

remove the warm compress for at least 15 minutes after each 20-minute application. Because heat and cold can injure the skin, either should be applied for only a limited time. Warm compresses increase circulation and promote fluid absorption in the infiltrated area. Removing the compresses every 20 minutes for at least 15 minutes prevents injury to the skin and subsequent rebound vasoconstriction. Cold compresses, which help reduce edema, cause vasoconstriction. Keeping the area covered continuously can lead to skin breakdown.

A client receiving chemotherapy has pruritus. In educating the client about the care plan, the nurse should caution the client against which measure?

taking daily baths with a deodorant soap Use of deodorant soaps is drying to the skin. Cotton clothing is the least irritating to skin. A cool, humidified environment adds to the client's comfort and provides hydration for the skin. Fluid intake of 3,000 mL/day is recommended for adequate hydration.

A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement

teaching how to express the breasts Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.

A 12-year-old client is 2 days postoperative from an open reduction, internal fixation procedure for a fractured femur. The client's chart reads:Breakfast:1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml)1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml)1 bowl of oatmeal (n/a)1 - 6 oz glass of orange juice (6 oz × 30 ml = 180ml)Additional information for 8-hour shift:I.V. of lactated Ringers is running at 125 ml/hr.A 1 g cefazolin injection was administered q8h.The pharmacy sent the cefazolin injection 1 g in 100 ml 50% dextrose.Calculate this client's intake for the 7 am to 3 pm shift. Record your answer using a whole number

1520 Calculate the breakfast intake in milliliters: 1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml) 1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml) 1 bowl of oatmeal (n/a) 1 - 6 oz glass of orange juice (6 oz × 30 ml = 180 ml). Additional information needed: 1,000 (I.V. 125 ml/hr × 8 hr) plus 100 ml (cefazolin injection, one dose). 120 ml + 120 ml + 180 ml + 1,000 ml + 100 ml = 1,520 ml

A client with a nasogastric tube requires irrigation of the tube to maintain patency. Place the steps in the correct order for the nurse performing the procedure. All options must be used.

Perform hand hygiene and apply gloves. Check placement of the nasogastric tube. Draw up 30-60 milliliters of water in a syringe. Clamp and disconnect the nasogastric tube from suction. Connect the irrigating syringe to the nasogastric tube and instill fluid. Reconnect suction to the nasogastric tube. The first step in the procedure is to perform hand hygiene and apply gloves because of the potential for contact with body fluids. Placement of the nasogastric tube should be confirmed next because the nurse would not want to instill fluid into the tube without being sure it is in the stomach. The nurse would then draw up the fluid and clamp the tube by disconnecting from suction. The fluid would be instilled once the syringe is connected and then the suction is reconnected to the nasogastric tube.

he nurse is assessing the ankle-brachial index (ABI) for a client with peripheral vascular disease. The highest systolic pressure for each ankle is 80 mm Hg and the highest brachial pressure is 160 mm Hg. What does this client's ABI indicate?

mild to moderate insufficiency ABI is calculated by dividing the highest systolic pressure for each ankle by the highest brachial pressure. For this client it would be 80/160 mm Hg = 0.50 ABI. This indicates that the client has mild to moderate insufficiency. Clients with ABI of about 1.0 have no arterial insufficiency; clients with ABI of less than 0.50 have ischemic rest pain; and clients with an ABI of 0.40 or less indicates severe ischemia or tissue loss.

A nurse is caring for a group of pediatric clients. The nurse understands that which age group would most likely identify their pain as punishment for past behavior?

preschool or toddler (age 2-5 years) Children in this age group are in Piaget's preoperational stage of cognitive development and relate pain as punishment for past behavior. A priority nursing action is to provide reassurance.

A client at risk for deep vein thrombosis (DVT) is prescribed antiembolism stockings. What should the nurse instruct the client about the purpose of these stockings?

promotes venous blood return from the extremities Antiembolism stockings prevent DVT by helping force blood in the venous system to move back toward the right side of the heart instead of allowing blood to pool in the veins. The stockings are not used to support the leg muscles during ambulation. The stockings may make the lower extremities feel warmer, but this is not their purpose. The stockings will not alter the consistency of the blood.

client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping the client cope with these cramps?

teaching her to dorsiflex her foot during the cramp Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a well-balanced diet, calcium supplements and additional servings of high-calcium foods may be unnecessary.

A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient?

fats Breast milk has a higher fat content than cow's milk. Thirty to fifty-five percent of the calories in breast milk are from fat. Breast milk contains less iron than cow's milk does. However, the iron absorption from breast milk is greater in the neonate than with cow's milk. Breast milk contains less sodium and calcium than cow's milk

A client with diabetes and peripheral neuropathy is being discharged from the hospital. What instruction should the nurse provide to decrease the risk for skin breakdown? Select all that apply.

Always wear socks, and preferably, shoes to protect the feet. Check the feet daily to look for any injuries to the feet. Use lotion on feet to keep skin from becoming dry and cracked. The client with peripheral neuropathy has a risk for skin breakdown due to decreased sensation in lower legs and, particularly, the feet. The client should wear socks and shoes, check the feet daily, and apply lotion to moisten the dry skin, but lotion should not be applied between the toes because lotion can cause skin maceration. The client should use a nail file instead of clippers to prevent injury and should not use a hot water bottle, as this can cause burns due to the client's decreased sensation.

The nurse is caring for a client during a prolonged hospital stay for congestive heart failure. The client has a prescription for thigh high antiembolism stockings. In regard to the antiembolism stockings, what is the priority action by the nurse?

Remeasure the client's legs routinely Using the correct size of antiembolism stockings is critical to their effectiveness. If a stocking is not tight enough, it will not improve venous return effectively. If the stocking is too tight, it may impair circulation. In a client who has had a prolonged hospitalization for congestive heart failure, the potential for changes in leg circumference related to increases or decreases in the amount of lower extremity edema requires the legs be remeasured routinely to ensure the appropriate sized stocking. Laundering the stockings every day is recommended, but not a priority. Lightly dusting the legs with talcum powder may ease the application of the stocking, but is not required. Documenting the size of the stockings used is important to provide a baseline, but remeasuring the legs routinely is the nurse's priority.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to

rest in an air-conditioned room. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.

An older adult client who is 5 feet, 4 inches (163 cm) and weighs 145 lb (65 kg) is admitted to the long-term care facility. The client sits for long periods in a wheelchair and has bowel and bladder incontinence. The client can feed themself and has a fair appetite, eating best at breakfast and poorly thereafter. The client does not have family members living nearby and is often noted to be crying and depressed. The client also frequently requires large doses of sedatives. Which factors place the client at risk for developing a pressure ulcer? Select all that apply.

incontinence sitting for long periods sedation Inactivity, immobility, incontinence, and sedation are all risk factors for pressure ulcers. The client's weight and poor eating habits at lunch and dinner are not directly related to the risk of developing pressure ulcers. A calorie count should be taken to see if the client is getting adequate calories and fluids because poor nutrition can contribute to pressure ulcers. The fact that the client cries and is depressed has no direct bearing on risk of developing a pressure ulcer. However, clients with depression are commonly not as active, so the client's activity levels should be monitored closely.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest

football hold After a cesarean birth, most mothers have the greatest comfort when the neonate is positioned in the football hold with the mother in semi-Fowler's position, supporting the neonate's head in her hand and resting the neonate's body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the neonate easy access to the mother's breast. The scissors hold, where the mother places her hand well back on the breast to prevent touching the areola and interfering with the neonate's mouth placement, is used by the mother to hold the breast and support it during breastfeeding. The cross-cradle hold is done when the mother holds the neonate's head in the hand opposite from the breast on which the neonate will feed and the mother's arm supports the neonate's body across her lap. This position can be uncomfortable because of the pressure placed on the client's incision line. For the cradle hold, the mother cradles the infant alongside the arm at the breast on which the neonate will feed. This position also can be uncomfortable because of the pressure placed on the incision line.

Which night clothes would the nurse recommend for an infant with atopic dermatitis

one-piece cotton pajamas with long sleeves Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate.A short-sleeved shirt would be inappropriate because the infant could scratch the uncovered arms, exacerbating the condition.Flannel may be too warm, causing the child to perspire, which will aggravate the condition.Because atopic dermatitis is commonly associated with allergies, wool garments should be avoided.

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should respond to the client by understanding that in the Asian culture which is the intended outcome of acupuncture? Acupuncture:

restores the balance of energy. Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.

A client who has been using benzodiazepines for anxiety wants to add an alternative therapy. The nurse suggests biofeedback. How will the nurse best describe biofeedback to the clien

It is a way to concentrate on the body's response during a stressful situation. Biofeedback uses the senses such as heart rate and respiratory rate to sensitize the client to ways to find calm. The client uses the responses of the body to relax. This therapy can assist the client in finding alternative ways to deal with stressors. Rather than controlling emotions, biofeedback allows the person to recognize and respond to physical signs of emotional stress before the emotions are fully formed. When biofeedback is not effective or is still being learned, antianxiety medications are useful; however, biofeedback works well alone. This therapy does not balance energies.