Read the information below.

Client reports pain at surgical incision site as 5 on a scale of 0 to 10.

Client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.

Client transferring out of bed to chair independently.

Extremities cool and dry with 2+ peripheral pulses.

Client reports abdominal cramping and small, hard, painful bowel movement after lunch.

Ambulating independently in hallway.

Reports pain as 8 on a scale of 0 to 10, Urinary catheter intact with 100 mL/hr of pink urine.

Encourage prolonged dangling before ambulation.

Irrigate indwelling catheter with 500 mL of fluid.

Administer an enema.

Assist the client with a sitz bath.

Encourage oral fluid intake.

Answer and Explanation

The Correct Answer is E

Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.

The other options are not appropriate based on the information provided:

"Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
"Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
"Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
"Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.

Nursing Test Bank

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Correct Answer is A

Explanation

Correct answer: A

Preschool-aged children (around 3 to 5 years old) have a limited understanding of death compared to older children or adults. They may not fully grasp the finality and permanence of death. They often have a more concrete and literal understanding of death.

A. Believing the death is punishment for bad behavior: Preschool-aged children (typically 3 to 5 years old) often have magical thinking and may believe that their thoughts or actions can cause events to happen. They may think that the death of a parent is a punishment for something they did or thought, reflecting their egocentric view of the world.

B. Recognizing the parent will never wake up: This understanding is more commonly seen in older children who have a more mature grasp of death. Preschool-aged children may not fully comprehend that death is irreversible and permanent.

C. While preschoolers might ask questions about the funeral out of curiosity, this is not the primary way they process or react to the death of a loved one. Their questions are often more about trying to understand what is happening rather than a genuine curiosity about the specifics of the service.

D. Understanding that everyone dies eventually: While preschool-aged children may have some understanding that death is a natural part of life, their comprehension of its full implications is limited. They may not fully grasp the universality of death and its inevitability for all living beings.

A. Avoid discussing the client's fears. B. Offer the client several choices at mealtimes. C. Remind the client of the day and time often. D. Alternate daily caregivers.

Correct Answer is C

Explanation

Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.

Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.

Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.

Alternating daily caregivers can disrupt continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month- old infant. Which of the following instructions should the nurse include in the teaching?

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about foot care with a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?