Nokea
To promote self-care, the nurse is planning to teach a client in skeletal leg traction about measures to increase bed mobility. Which item is most helpful for this client for achievement of this goal?
- A. Fracture bedpan
- B. Overhead trapeze
- C. Isometric exercises
- D. Range-of-motion exercises
Correct Answer: B
Rationale: The use of an overhead trapeze is extremely helpful for assisting a client with moving about in bed and getting on and off the bedpan. This device has the greatest value for increasing overall bed mobility. A fracture bedpan is useful for reducing discomfort with elimination. Isometric exercises will not increase bed mobility and could be harmful for a client in skeletal traction. Range-of-motion exercises can also be harmful to a client in skeletal traction and should not be initiated unless there are specific prescriptions to do so.
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The nurse has taught the client with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood the information if the client states the need to follow which instruction?
- A. Try to take only small, shallow breaths.
- B. Take as much pain medication as possible.
- C. Lie on the affected side as much as possible.
- D. Splint the chest wall during coughing and deep breathing.
Correct Answer: D
Rationale: The client with pleurisy should splint the chest wall during coughing and deep breathing. Taking small, shallow breaths promotes atelectasis. The client should take medication cautiously so that adequate coughing and deep breathing are performed and an adequate level of comfort is maintained. The client may also lie on the affected side to minimize the movement of the affected chest wall.
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
- A. Avoid caffeine in your diet.
- B. Take your temperature every day.
- C. Limit your fluid intake to 1000 mL per 24 hours.
- D. Catheterize yourself every 2 hours as needed to prevent spasm.
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement?
- A. I need to eat foods low in potassium.
- B. I need to check the color of my stools.
- C. I need to check the temperature of my legs twice a day.
- D. I need to take aspirin rather than acetaminophen for a headache.
Correct Answer: B
Rationale: Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.
The nurse is precepting a student nurse on the medical-surgical unit who is caring for a client with a T-tube. Which statement by the student nurse regarding the care of the tube indicates a need for further teaching?
- A. I should report a sudden increase in bile output.
- B. The client should be in a semi-Fowler's position to promote drainage.
- C. The drainage system should be kept below the level of the gallbladder.
- D. I will clamp the tube if the client becomes nauseated or begins to vomit.
Correct Answer: D
Rationale: Clamping the T-tube during nausea or vomiting risks pressure buildup; it should be reported instead. Other statements are correct.
Which factors increase the risk for hypothermia in an older client? Select all that apply.
- A. Burns
- B. Anemia
- C. Alcohol abuse
- D. Hypoglycemia
- E. Hyperthyroidism
- F. Poor thermoregulation
Correct Answer: A,B,C,D,F
Rationale: The median oral temperature of an older client is 96.8^{\circF}\left(36^{\circC}\right) . Environmental temperatures below 65^{\circF}\left(18^{\circC}\right) may cause a serious drop in core body temperature to 95^{\circF}\left(35^{\circC}\right) or less in the older client. Numerous factors increase the risk of hypothermia in the older client, including conditions that increase heat loss (e.g., burns); conditions that decrease heat production such as hypothyroidism, hypoglycemia, or anemia; medications or substances that interfere with thermoregulation, such as alcohol; or thermoregulatory impairment (failure to sense cold).