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

ADHD (Attention-Deficit/Hyperactivity Disorder) is characterized by symptoms such as difficulty sustaining attention, impulsivity, and hyperactivity. Methylphenidate is a commonly prescribed medication for ADHD that helps improve focus, attention, and impulse control.

The ability to complete homework on time suggests improved focus and attention, which are positive effects of methylphenidate in managing ADHD symptoms. It indicates that the medication is helping the child stay on task and concentrate better, leading to improved academic performance.

"Our child has lost some weight since his last appointment" suggests a potential side effect of methylphenidate, which can cause appetite suppression and weight loss.

"Our child has increased his daily caloric intake" might be a response to the weight loss side effect, but it does not directly indicate the effectiveness of the medication.

"Our child has a better grasp of reality" is a subjective statement that does not specifically relate to ADHD symptoms or the expected effects of methylphenidate.

A. Provide a stimulating environment for the client B. Use confrontation to manage the client's behavior C. Limit the number of choices for the client D. Use written signs to assist the client with locating the bathroom

Correct Answer is ["A","C","D"]

Explanation

Correct:

A. Creating a stimulating environment helps engage the client and can reduce restlessness and agitation. This can include activities, social interactions, and sensory stimulation tailored to the individual's preferences.

C. Clients with Alzheimer's disease may become overwhelmed and have difficulty making decisions when presented with too many options. By limiting choices, caregivers can help reduce confusion and frustration for the client.

D. Clients with Alzheimer's disease may experience memory impairment and difficulty with orientation. Using written signs can help them navigate their surroundings and locate essential areas, such as the bathroom. Clear and simple signs can be helpful for maintaining independence and minimizing confusion.

incorrect:

B. Confrontation, which involves challenging or arguing with the client, can escalate agitation and distress. Instead, caregivers should use techniques such as redirection, validation, and providing a calm and supportive environment to manage challenging behaviors associated with Alzheimer's disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is A

Explanation

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

Correct Answer is ["A","C","D"]

Explanation

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?