Nurses' Notes Postoperative Day 3 0900:

The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.

1300:

The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 to 10. Urinary catheter intact with 100 mL/hr. of pink urine.

Select the 2 actions the nurse should prepare to take for the client.

Irrigate the indwelling catheter with 500 mL of fluid.

Assist the client with a seat bath.

Encourage oral fluid intake.

Administer an enema.

Encourage prolonged dangling before ambulation.

Answer and Explanation

Correct Answer : B,C

A. Not indicated and could lead to complications.

B.   The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort.
C.   The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation.
D.   Not necessary or appropriate without further assessment.

E. Not necessary and may not provide any additional benefit in this context.

Nursing Test Bank

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Correct Answer is C

Explanation

Creating a schedule of daily tasks can help provide structure and routine for individuals with Alzheimer's disease. Having a predictable routine can reduce confusion and frustration by providing a sense of familiarity and stability. The schedule should include activities that the client enjoys and can manage within their abilities. It can help the client feel more organized and engaged throughout the day.

Limiting the use of familiar objects is not recommended. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease. They can help trigger memories and create a sense of familiarity in their environment. Removing familiar objects may increase disorientation and frustration.

Asking questions that require more than one answer can be overwhelming for individuals with Alzheimer's disease. Complex questions can lead to confusion and frustration as the person may struggle to recall or process information. It is best to ask simple and direct questions that can be easily understood and answered.

Having several family members visit daily may cause additional stress and confusion for the client with Alzheimer's disease. Too many visitors can be overwhelming and may disrupt the person's routine or environment. It is important to consider the individual's preferences and abilities when planning visits and ensure that they are manageable and supportive for the client's well-being.

A. Limit the client's social interactions. B. Encourage the client to be assertive. C. Assume responsibility for making the client's decisions. D. Maintain a verbal no-harm contract with the client.

Correct Answer is B

Explanation

A. Incorrect. Limiting the client's social interactions would not be helpful and might further exacerbate feelings of dependence.
B. Correct. Encouraging the client to be assertive is an important aspect of promoting independence and self-advocacy. Clients with dependent personality disorder may struggle with asserting themselves, and fostering assertiveness can improve their overall well-being.
C. Incorrect. Assuming responsibility for making the client's decisions would reinforce their dependence, which is not the goal of treatment.
D. Incorrect. Maintaining a verbal, no-harm contract is typically used for clients at risk of self-harm or harm to others and is not directly related to addressing the challenges of dependent personality disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an Incident report. Which of the following examples should the nurse include?

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits Complete the following sentence by selecting words from the choices below to fill in each blank: To further evaluate the client, the nurse anticipates the client will need and .

A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following s is the nurse's priority?