The nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after having hip surgery. Which ph
... [Show More] ysical factors place the client at risk for injury in the home? Select all that apply.
1. A night-light in the bathroom
2. Elevated toilet seat with armrests
3. Cooking equipment such as a stove
4. Smoke and carbon monoxide detectors
5. A low thermostat setting on the water heater
6. Common household objects such as a doormat
The nurse reviews wound culture results and learns that an assigned client has methicillin resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions does the nurse institute for this client?
1. Enteric precautions
2. Droplet precautions
3. Contact precautions
4. Airborne precautions
Health and Promotion and Maintenance
The nurse is providing instructions to a client and family regarding home care after left-eye cataract removal. The nurse tells the client and family about assuming which position during the postoperative period?
1. Sleep only on the left side.
2. Sleep on the right side or the back.
3. Bend below the waist as often as you are able.
4. Lower the head between the knees three times a day
The nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. The nurse determines that further teaching is needed if the mother indicates that which fluid will acidify the urine?
1. Prune juice
2. Apricot juice
3. Cranberry juice
4. Carbonated drinks
Psychosocial Integrity
A client who has never been hospitalized before, who is in a hospital room with a roommate, is having trouble initiating the stream of urine. Knowing that there is no pathological reason for this difficulty, what nursing interventions should be included when assisting the client? Select all that apply.
1. Catheterizing the client
2. Running tap water in the sink
3. Assisting the client to a commode behind a closed curtain
4. Instructing the client to pour warm water over the perineum
5. Closing the bathroom door and instructing the client to pull the call bell when done
The nurse admits a client who has right sided weakness, aphasia, and urinary incontinence. The woman’s daughter states, “If this is a stroke, it’s the kiss of death.” What initial response should the nurse make?
1. “Why would you think like that?”
2. “You feel your mother is dying?”
3. “These symptoms are reversible.”
4. “A stroke is not the kiss of death.”
The client tells the nurse, “I’m scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I’m afraid. What happens if something goes wrong after I go home?” Which statement by the nurse is therapeutic?
1. “Don’t worry about the details. This procedure is done all the time and generally without any problems. You’ll be fine!”
2. “They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I’ll come.”
3. “Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can’t be too careful.”
4. “You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?”
Physiological Integrity
The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis. The nurse expects to note which early manifestations of the disease? Select all that apply.
1. Fatigue
2. Anorexia
3. Weakness
4. Low-grade fever
5. Joint deformities
6. Joint inflammation
A client with a spinal cord injury is at risk of developing foot drop. What should the nurse use as the effective preventive measure?
1. Foot board
2. Heel protectors
3. Posterior splints
4. Pneumatic boots
The nurse is developing a care plan for a client with urge urinary incontinence. Which interventions would be most helpful for this type of incontinence? Select all that apply.
1. Surgery
2. Bladder retraining
3. Scheduled toileting
4. Dietary modifications
5. Pelvic muscle exercises
6. Intermittent catheter [Show Less]