A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

The client draws his legs up into a fetal position.

The facial muscles relax.

The respiratory rate increases.

The shoulders droop.

The pulse is within the expected range

Answer and Explanation

Correct Answer : B,D,E

A.   Drawing legs up into a fetal position may indicate discomfort or agitation.
B.   Facial muscle relaxation is indicative of a therapeutic response to the massage.
C.   An increased respiratory rate may suggest distress or discomfort.
D.   Drooping shoulders suggest relaxation and a positive response to the massage.
E.   Maintaining an expected pulse rate indicates that the massage is not causing undue stress or discomfort.

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Correct Answer is B

Explanation

A. Continuous passive motion (CPM) machines are typically used after joint surgeries, not thoracic surgeries.
B. A chest tube is often used postoperatively after a lobectomy to drain excess air, fluid, or blood from the pleural space.
C. A three-way urethral catheter may be used for urinary drainage, but it is not specific to thoracic surgery.
D. Electroencephalography (EEG) monitoring wires are used for monitoring brain activity and are not typically used in the postoperative care of a client following a lobectomy.

A. Allow the client to choose free-time activities B. Post a written schedule of daily activities. C. Provide a consistent daily routine. D. Use an overhead loudspeaker to announce events

Correct Answer is C

Explanation

Individuals with dementia often benefit from routine, but too many choices can be overwhelming.
B: While a written schedule can be helpful, a consistent routine is generally more beneficial for clients with dementia.
C: Providing a consistent daily routine helps decrease anxiety and confusion for clients with dementia.
D: Overhead loudspeakers may cause agitation and confusion in clients with dementia.

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A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has lung cancer and is scheduled for a lobectomy. The nurse should instruct the client to expect the use of which of the following equipment postoperatively?

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for a client who has dementia. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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