An older client with a fractured left hip is on strict bedrest. Which nursing measure
is essential to the client's nursing care?
Massage any reddened
... [Show More] areas for at least five minutes.
Encourage active range of motion exercises on extremities.
Position the client laterally, prone, and dorsally in sequence.
Gently lift the client when moving into a desired position. - Gently lift the client
when moving into a desired position.
On admission, a client presents a signed living will that includes a Do Not
Resuscitate (DNR) prescription. When the client stops breathing, the nurse
performs cardiopulmonary resuscitation (CPR) and successfully revives the client.
What legal issues could be brought against the nurse?
Assault.
Battery.
Malpractice.
False imprisonment. - Battery.
Civil laws protect individual rights and include intentional torts, such as assault (an
intentional threat to engage in harmful contact with another) or battery (unwanted
touching).Performing any procedure against the client's wishes can potentially
create a legal issue, such as battery, even if the procedure is of questionable benefit
to the client.
A client who is in hospice care reports increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should
the nurse implement?
Give an around-the-clock schedule for administration of analgesics.
Administer analgesic medication as needed when the pain is severe.Provide medication to keep the client sedated and unaware of stimuli.
Offer a medication-free period so that the client can do daily activities. - Give an
around-the-clock schedule for administration of analgesics.
A Sub-Saharan African widowed immigrant woman lives with her deceased
husband's brother and his family, which includes the brother-in-law's children and
the widow's adult children. Each family member speaks fluent English. Surgery is
recommended for this client. What is the best plan to obtain consent for surgery for
this client?
Obtain an interpreter to explain the procedure to the client.
Encourage the client to make her own decision regarding surgery.
Ask the family members to provide a clarification of the surgeon's explanation to
the client.
Tell the surgeon that the brother-in-law will decide after explanation of the
proposed surgery is provided to him and the widow. - Tell the surgeon that the
brother-in-law will decide after explanation of the proposed surgery is provided to
him and the widow.
Customary law in some rural sub-Saharan countries encompasses wife inheritance
and polygamy; the widow becomes the inherited wife of the her husband's brother.
In those rural areas women live in a patriarchal family where decisions are made
by men. Most likely, the brother-in-law will make the decision for his inherited
wife, so it is important to provide the surgeon with culturally sensitive information.
Since all family members speak fluent English, there is no need for a translator. It
is culturally insensitive to encourage the woman to go against her wishes to follow
her cultural worldview.
The nurse is examining a male client who reports itching on his right arm, The
nurse observes a rash made up of multiple flat areas of redness ranging from
pinpoint to 0.5 cm in diameter. How should the nurse record this finding?
Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5
cm.
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. -
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
Macules are localized flat skin discolorations less than 1 cm in diameter. However,
when recording such a finding the nurse should describe the appearance rather than
simply naming the condition. Vesicles are fluid-filled blisters. Papules are solid
elevated lesions and petechiae are pinpoint red to purple skin discolorations that do
not itch.
A male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What
should be the nurse's first response?
"It is important that you continue your medication while learning to meditate."
"Spiritual meditation requires a time commitment of 15 to 20 minutes daily."
"Obtain your healthcare provider's permission before starting meditation."
"Complementary therapy and western medicine can be effective for you." - "It is
important that you continue your medication while learning to meditate."
The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
"If I exercise at least two times weekly for one hour, I will lower my cholesterol."
"I need to avoid eating proteins, including red meat."
"I will limit my intake of beef to 4 ounces per week."
"My blood level of low density lipoproteins needs to increase." - "I will limit my
intake of beef to 4 ounces per week."
The nurse is evaluating a client learning about a low-sodium diet. Selection of
which meal would indicate to the nurse that this client understands the dietary
restrictions?
Multiple choice questionTossed salad, low-sodium dressing, bacon and tomato sandwich.
New England clam chowder, no-salt crackers, fresh fruit salad.
Skim milk, turkey salad, roll, vanilla ice cream.
Macaroni and cheese, diet Coke, a slice of cherry pie. - Skim milk, turkey salad,
roll, vanilla ice cream.
Skim milk, turkey, bread, and ice cream, while containing some sodium, are
considered low-sodium foods. Bacon, canned soups (especially those with
seafood), hard cheeses, macaroni, and most diet drinks are very high in sodium.
Three days following surgery, a male client observes his colostomy for the first
time. He becomes quite upset and tells the nurse that it is much bigger than he
expected. What is the best response by the nurse?
Reassure the client that he will become accustomed to the stoma appearance in
time.
Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
Offer to contact a member of the local ostomy support group to help him with his
concerns.
Encourage the client to handle the stoma equipment to gain confidence with the
procedure. - Instruct the client that the stoma will become smaller when the initial
swelling diminishes.
Provide medication to keep the client sedated and unaware of stimuli.
Offer a medication-free period so that the client can do daily activities. - Give an
around-the-clock schedule for administration of analgesics.
A Sub-Saharan African widowed immigrant woman lives with her deceased
husband's brother and his family, which includes the brother-in-law's children and
the widow's adult children. Each family member speaks fluent English. Surgery is
recommended for this client. What is the best plan to obtain consent for surgery for
this client?
Obtain an interpreter to explain the procedure to the client.
Encourage the client to make her own decision regarding surgery.
Ask the family members to provide a clarification of the surgeon's explanation to
the client.
Tell the surgeon that the brother-in-law will decide after explanation of the
proposed surgery is provided to him and the widow. - Tell the surgeon that the
brother-in-law will decide after explanation of the proposed surgery is provided to
him and the widow.
Customary law in some rural sub-Saharan countries encompasses wife inheritance
and polygamy; the widow becomes the inherited wife of the her husband's brother.
In those rural areas women live in a patriarchal family where decisions are made
by men. Most likely, the brother-in-law will make the decision for his inherited
wife, so it is important to provide the surgeon with culturally sensitive information.
Since all family members speak fluent English, there is no need for a translator. It
is culturally insensitive to encourage the woman to go against her wishes to follow
her cultural worldview.
The nurse is examining a male client who reports itching on his right arm, The
nurse observes a rash made up of multiple flat areas of redness ranging from
pinpoint to 0.5 cm in diameter. How should the nurse record this finding?
Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5
cm.
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. -
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
Macules are localized flat skin discolorations less than 1 cm in diameter. However,
when recording such a finding the nurse should describe the appearance rather than
simply naming the condition. Vesicles are fluid-filled blisters. Papules are solid
elevated lesions and petechiae are pinpoint red to purple skin discolorations that do
not itch.
A male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What
should be the nurse's first response?
"It is important that you continue your medication while learning to meditate."
"Spiritual meditation requires a time commitment of 15 to 20 minutes daily."
"Obtain your healthcare provider's permission before starting meditation."
"Complementary therapy and western medicine can be effective for you." - "It is
important that you continue your medication while learning to meditate."
The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
"If I exercise at least two times weekly for one hour, I will lower my cholesterol."
"I need to avoid eating proteins, including red meat."
"I will limit my intake of beef to 4 ounces per week."
"My blood level of low density lipoproteins needs to increase." - "I will limit my
intake of beef to 4 ounces per week."
The nurse is evaluating a client learning about a low-sodium diet. Selection of
which meal would indicate to the nurse that this client understands the dietary
restrictions?
Multiple choice questionTossed salad, low-sodium dressing, bacon and tomato sandwich.
New England clam chowder, no-salt crackers, fresh fruit salad.
Skim milk, turkey salad, roll, vanilla ice cream.
Macaroni and cheese, diet Coke, a slice of cherry pie. - Skim milk, turkey salad,
roll, vanilla ice cream.
Skim milk, turkey, bread, and ice cream, while containing some sodium, are
considered low-sodium foods. Bacon, canned soups (especially those with
seafood), hard cheeses, macaroni, and most diet drinks are very high in sodium.
Three days following surgery, a male client observes his colostomy for the first
time. He becomes quite upset and tells the nurse that it is much bigger than he
expected. What is the best response by the nurse?
Reassure the client that he will become accustomed to the stoma appearance in
time.
Instruct the client that the stoma will become smaller when the initial swelling
diminishes.
Offer to contact a member of the local ostomy support group to help him with his
concerns.
Encourage the client to handle the stoma equipment to gain confidence with the
procedure. - Instruct the client that the stoma will become smaller when the initial
swelling diminishes. [Show Less]