Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?
Offering the client a bedpan every three hours.
Keeping an emesis basin near the bedside.
Providing oral care every four hours.
Changing the bed linens frequently.
The Correct Answer is D
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis and may not meet the client’s elimination needs.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis and may not be necessary unless the client has nausea or vomiting.
Choice C is wrong because providing oral care every four hours is not enough to prevent dehydration and dry mouth in a client who has been diaphoretic for the past six hours. The client may need more frequent oral care and fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
My spouse will just have to put up with any new irritability. This statement indicates that the client requires further educational reinforcement about the medication because phenelzine is an antidepressant that should improve the mood and reduce irritability. The client may also need to be assessed for possible adverse effects of phenelzine, such as agitation, insomnia, or hypomania.
Choice A is wrong because it is a correct statement. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with foods that contain tyramine, such as cheese and caffeine, and cause a hypertensive crisis.
The client should avoid excessive amounts of these foods while taking phenelzine.
Choice C is wrong because it is also a correct statement. Phenelzine can cause orthostatic hypotension, which is a drop in blood pressure when changing positions.
The client should change positions slowly, as dizziness may occur.
Choice D is wrong because it is partially correct. Phenelzine can cause headaches, which may be a sign of a hypertensive crisis.
Correct Answer is ["B","D","E"]
Explanation
Choice A is wrong because women are more at risk for hip fractures than men.
This is partly because women lose bone density faster than men do, especially after menopause.
Choice C is wrong because an increase in estrogen will not weaken the bones. In fact, estrogen helps protect the bones from osteoporosis, which is a leading cause of hip fracture.
Some other risk factors for hip fracture include:
- Excessive alcohol and caffeine consumption
- Lack of physical activity
- Low body weight
- Tall stature
- Vision problems
- Dementia
- Medications that cause bone loss
- Cigarette smoking
- Institutional living, such as an assisted-care facility
- Increased risk for falls, related to conditions such as weakness, disability, or unsteady gait
Normal ranges for bone density vary by age and sex, but generally, a T-score of -1.0 or above is considered normal, while a T-score of -2.5 or below is considered osteoporotic. A T-score between -1.0 and -2.5 is considered osteopenic, which means low bone mass.
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