A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions.

Which of the following responses should the nurse make?

"You can apply counterpressure to your back with each position change."

"You can splint the incision with a pillow when changing positions."

"You should change positions as little as possible."

"You should use patterned-paced breathing when changing positions."

Answer and Explanation

The Correct Answer is B

Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.

"You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.

"You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.

"You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, it may not be the most effective strategy for managing pain when changing positions post-cesarean.

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Correct Answer is A

Explanation

ECT can cause temporary memory loss, particularly for events occurring around the time of the treatment. The client may experience difficulty remembering details of recent events or conversations. This effect is usually temporary and improves over time.

Neck pain is not a typical adverse reaction to ECT. The procedure itself does not involve manipulation or strain on the neck, and significant neck pain following ECT would be unusual. However, it is essential for the nurse to assess and address any discomfort or pain the client experiences after the procedure.

Voice alteration is not a known adverse reaction to ECT. ECT primarily affects the brain and does not directly impact the vocal cords or voice production.

Tingling of the scalp is not a common adverse reaction to ECT. During the procedure, the client receives a brief electrical stimulus, usually applied through electrodes placed on the scalp. Sensations experienced during the procedure are typically related to the electrical stimulation and are transient.

A. Elevated amylase B. Decreased bilirubin C. Elevated lipase D. Elevated ammonia

Correct Answer is D

Explanation

D, Elevated ammonia

Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.

Elevated amylase in (option A) is incorrect because it is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.

Decreased bilirubin levels in (option B) is incorrect because they are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.

Elevated lipase in (option C) is incorrect because it is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.

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A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Nursing Test Bank

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A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions.

Which of the following responses should the nurse make?