Fundamental of Adaptive quizzes and answers

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? " "Moderate amount of drainage." " "No change in drainage since yesterday." " "A 10-mm-diameter area of drainage at 1900 hours." " "Drainage is doubled in size since last dressing change." Rationale A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a timeframe. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable. When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? Kidney dysfunction Cardiovascular diseases Eye problems, such as glaucoma Accidents, including their prevention Rationale Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults. A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? Increase fluids. Increase fiber in the diet. Wash hands with soap and water. Wash hands with an alcohol-based hand sanitizer. Rationale Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcoholbased hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile. A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation? Immediately involve pastoral services while caring for the client. Involve the family member in the client’s care instead of pastoral support. Listen to the client’s request for support then carry on with the clinical work. Falsely promise that pastoral services has been contacted and plan to see the client. Rationale The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social, and psychologic needs and the pathophysiology of clients living with advanced diseases. Therefore, the nurse involves pastoral services while caring for the client. Involving a family member may decrease anxiety in the client but may not fulfill the wishes of the client. Just listening to the client’s request without implementation or giving false promises can cause loss of trust in the client. During follow-up visits, the client’s child reports to the nurse, "I tell my parent every day about what may happen if medications aren’t taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client’s motivational level? Not motivated Intrinsically motivated Extrinsically motivated with self-determination Extrinsically motivated without self-determination Rationale If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking their medications on their own rather than because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when they may take medication regularly when reminded to do so or when pressured by others. A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what? Promoting analgesia and circulation Numbing the nerves and dilating the blood vessels Promoting circulation and reducing muscle spasms Causing local vasoconstriction, preventing edema and muscle spasms Rationale Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain. Which skill in critical thinking requires to be orderly in data collection? Analysis Inference Evaluation Interpretation Rationale Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used. When the data collected about the client helps in solving an existing problem, then the skill called inference is being used. Evaluation is used when the results of nursing actions are determined. A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in what? Bubble wrap/packaging wrap A garbage bag in the trash can A cardboard box with a firmly secured lid A plastic liquid detergent bottle with a screw-top lid Rationale Most states (provinces) allow patients to place used needles/pen needles and lancets ( sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks. A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to do what? Restore function and/or appearance Replace an organ or tissue Relieve or reduce symptoms Remove or excise an organ or tissue Rationale The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known as transplant; surgery to relieve or reduce symptoms is known as palliative; and surgery to remove or excise an organ or tissue is known as resection. A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what? Promote gluconeogenesis. Produce an anti-inflammatory effect. Promote cell growth and bone union. Decrease pain medication requirements. Rationale There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. Intake of a high protein diet during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain. A child is being treated with oral ampicillin for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client? Complete the entire course of antibiotic therapy. Herbal fever remedies are highly discouraged. Administer the medication with meals. Stop the antibiotic therapy when the child no longer has a fever. Rationale Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the healthcare provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse should not discourage use of herbal fever remedies; however, the herbal treatment should be reviewed to see if it is contraindicated. Ampicillin should be taken 1 to 2 hours after meals. Antibiotic therapy should be completed as prescribed. The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? Exploring Reflecting Refocusing Acknowledging Rationale Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion. During a home visit, the nurse finds that a healthy elderly person is actively practicing laughing therapy to maintain good health without pressure or insistence from family members. What does the nurse infer from these findings? The patient is not motivated. The patient is intrinsically motivated. The patient is extrinsically motivated with self-determination. The patient is extrinsically motivated without self-determination. Rationale An intrinsically motivated individual participates in an activity because it is inherently interesting or enjoyable rather than because of obligations or outside pressure from family members. If the person is not motivated, he or she would be unlikely to participate in the activity. An extrinsically motivated individual with or without self-determination may practice laughing therapy upon suggestion or pressure created by other individuals. A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what? Relieve bronchial spasms Increase depth of respirations Loosen pulmonary secretions Expel carbon dioxide from the lungs Rationale Postural drainage and percussion also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs. A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus(MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? No special precautions are required. Cover the infected site with a dressing. Drape the client with a covering labeled biohazardous. Place a surgical mask on the client. Rationale Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Draping the client with a sheet marked biohazardous does not protect the client's privacy. A wound infected with MRSA can be transmitted to others via contact, not the airborne route; thus a mask is unnecessary. Question 16 What is the most important nursing action involved in caring for a client using medications to manage disease? Administering the medications Teaching about the medications Ensuring adherence to the medication regimen Evaluating the client’s ability to self-administer medications Rationale The most important part of the nursing practice regarding medication is administering the medications. Administering medications safely requires an understanding of the legal aspects of healthcare, pharmacology, pathophysiology, human anatomy, and mathematics. Teaching about the medications, ensuring adherence to the medications, and evaluating the client’s ability to self-administer medications are responsibilities of the nurse performed before or after the administration of medicines. Question 17 Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? Instruct the client to position one arm on each shoulder of the nurses. Direct the client to extend the legs and remain still during the procedure. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Rationale Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved. Which caring intervention helps to provide comfort, dignity, respect, and peace to a client?