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Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
- A. Sleep Pattern Disturbances (related to arthritis)
- B. Fatigue (related to leg pain)
- C. Knowledge Deficit (regarding sleep hygiene measures)
- D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct Answer: D
Rationale: The client's sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like.
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Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. all body assessment, including the feet and nails.
- B. the essential lab work of the client.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only.
Correct Answer: C
Rationale: The nail beds and the tissue surrounding the nails should be assessed for abnormal discoloration, lesions, paronychia (infection of tissue surrounding the nail), tissue dryness, breaks in the skin, pressure areas, or other abnormal appearances.
The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
- A. Inhale slowly and deeply through mouth
- B. Seal lips tightly around mouthpiece
- C. After inhaling, hold breath for 2 to 3 seconds
- D. Sit with the HOB down and bed almost flat
- E. Splint the incision with pillows
- F. Exhale forcefully, fast, and hard
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.
The nurse is taking the client's temperature. What should the nurse do to correctly obtain the temperature with a tympanic thermometer?
- A. Ensure that the probe tip seals the ear canal prior to taking a temperature.
- B. Irrigate the ear canal with sterile saline before obtaining the temperature.
- C. When inserting the thermometer in the adult ear, pull downward on the pinna.
- D. Check to be sure that the client does not have any tympanostomy tubes in place.
Correct Answer: A
Rationale: A: Sealing the ear canal ensures accurate readings. B: Irrigation is unnecessary and affects results. C: The pinna is pulled upward in adults. D: Tympanostomy tubes don't affect readings after initial placement.
People who live in poverty are most likely to obtain health care from:
- A. their primary care physician (family doctor)
- B. a neighborhood clinic
- C. specialists
- D. Emergency Departments or urgent care centers
Correct Answer: D
Rationale: Economic barriers often lead those in poverty to seek care from Emergency Departments or urgent care centers, which are more accessible than primary care or specialists.
In administering NSAID adjunctive therapy to an elderly client with cancer, the nurse must monitor:
- A. BUN and creatinine.
- B. creatinine and calcium.
- C. Hgb and Hct.
- D. BUN and CFT.
Correct Answer: A
Rationale: Elder adults might be more at risk for gastric and renal toxicity, increasing among elder adults.