Intro to Adult Health Exam 2 Study Guide
2023
How would you teach a client to walk downstairs using crutches? - Answer-First
crutches, then the
... [Show More] affected leg, then finally the unaffected leg
How would you teach a client with left-sided weakness to use a cane? - Answer--Have
the patient keep the cane on the stronger side of the body.
-For maximum support when walking, the patient places the cane forward 15-25 cm (6-
10 inches), keeping body weight on both legs.
-The patient should move the weaker leg forward to the cane, so their body weight is
divided between the cane and the stronger leg.
-The patient should then advance the stronger leg past the cane so the weaker leg and
their body weight are supported by the cane and weaker leg.
Differentiate pre-interaction phase, orientation phase, working phase, and termination
phase of the nurse-patient relationship. - Answer--Pre-interaction phase: occurs before
meeting the patient
-Orientation phase: when the nurse and the patient meet and get to know each other.
-Working phase: when the nurse and the patient work together to solve problems and
accomplish goals.
-Termination phase: occurs at the end of a relationship.
Therapeutic communication: Provide an example of what a nurse might say to a client
who is experiencing anxiety. - Answer-"Can you tell me more about that?"
"I would like to help, is there something you need or something I can do for you?"
Therapeutic communication: Provide an example of false reassurance expressed by the
nurse towards a patient experiencing anxiety. - Answer-"Don't worry, everything is going
to be alright."- when pt is seriously ill or distressed
"There is nothing to worry about."- when a pt is reaching for understanding
Identify the factors surrounding patient-controlled analgesia (Hint: who presses the
button to administer a dose of medication? What are the benefits of a PCA? What are
the risks to a PCA? - Answer--Allows the patient to self-administer pain medication with
minimal risk of overdose.
-Goal: maintain a constant plasma level of analgesic to avoid the problems of prn
dosing.
-Benefits: patient gains control over pain, pain relief does not depend on nurse
availability, patients have access to medication when they need it (decreases anxiety
and leads to decreased medication use), small doses of medications are delivered at
short intervals which stabilize serum drug concentrations for allowing for sustained pain
relief.
-Risks: patients need to understand the PCA device and be able to push the button for
medication administration, family members and visitors could push the button for the
patient (a dangerous action known as PCA by proxy)
-The patient is the only person who should be pressing the button.
-Monitor the patient for signs and symptoms of oversedation and respiratory depression.
How often would you instruct a 65-year-old wheelchair-bound client who has redness in
the sacral area to change position in the chair? - Answer-If the patient has redness
already, make sure you are instructing them to turn/adjust/reposition their weight every
hour.
Explain the actions of a nurse who only speaks English when providing wound care
instructions to a client who does not speak English? - Answer-Speak to the patient in a
normal tone of voice, establish a method for the patient to ask for assistance (call light
or bell), provide a professional interpreter as needed, avoid using family members
(especially children) as interpreters, use communication board with pictures or cards,
translate words from the native language into English list for the patient to make basic
requests, have a dictionary (ex: English/Spanish) available if the patient can read.
What would be an appropriate action by the nurse who observes the client laughing
along with their friends but the patient then turns to the nurse and tells him he is in pain
and is requesting pain meds. What would be an appropriate action by the nurse in the
above scenario (hint: there could be several correct actions). - Answer-If the patient is
telling the nurse that they are having pain, then assess the patient with an appropriate
pain scale/tool, and then provide the patient with pain relief based on your assessment
findings (medications, repositioning, etc).
Accept the patient's report of pain and act based on the nurse's scope of practice.
Pain is what the patient says it is; pain is very individualized and we need to treat their
pain.
The nurse is about to perform a dressing change on a patient who recently underwent
abdominal surgery. What would the nurse do specific to body mechanics prior to doing
this procedure? - Answer-Raise the bed to a comfortable working height
Identify the interventions the nurse would do to keep a client on seizure precautions
safe in case a seizure was to occur. - Answer-Keep suction set up in the patient's room,
pad the side rails for the patient's protection, keep the bed in the lowest position when
not working with the patient and locked, keep oxygen accessible in the room at all
times, keep Ambu bag at the bedside, 4 side rails up and padded, keep clothing and
linens loose to prevent strangulation.
What interventions should the nurse do for an elderly client who is placed on fall
precautions? -
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