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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Wearing a medical identification wristband is important for children with chronic conditions such as cystic fibrosis. It helps alert others, including healthcare providers, about the child's condition in case of emergencies. The wristband can provide vital information about the child's diagnosis, treatment needs, and emergency contacts, ensuring appropriate care and timely interventions.

The other options mentioned are not appropriate or necessary for the care of a child with cystic fibrosis:

A- It is important to involve the child to an age-appropriate extent in decision-making about their treatment. Encouraging the child to participate in their own care and treatment decisions can promote their independence and self-management skills.

B- The influenza vaccine is generally recommended for children with cystic fibrosis, as they are at increased risk of respiratory infections. The vaccine helps protect against influenza and its potential complications. Therefore, the nurse should emphasize the importance of annual influenza vaccination for the child.

D- Homeschooling may not be necessary solely based on the diagnosis of cystic fibrosis. The decision regarding the child's education should be made based on their individual needs, abilities, and preferences, in consultation with the child's healthcare team and educational professionals.

A. Catatonia B. Acute onset of confusion C. Memory loss that disrupts ADLs D. Illusions

Correct Answer is C

Explanation

Dementia is characterized by progressive memory impairment, including difficulty remembering recent events, names, and familiar faces. This memory loss can significantly impact the client's ability to perform daily tasks independently.

While dementia is typically a chronic and progressive condition, it is not uncommon for individuals with dementia to experience acute episodes of confusion, often referred to as "sundowning." These episodes tend to occur in the late afternoon or evening and can involve increased agitation, restlessness, and disorientation.

Illusions are perceptual distortions where a person misinterprets real sensory stimuli. In dementia, individuals may experience illusions, such as mistaking a coat hanging on a door for a person or misinterpreting shadows as threatening figures.

Catatonia, characterized by immobility and unresponsiveness, is not typically associated with dementia. It is more commonly seen in conditions such as schizophrenia or certain neurological disorders.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?​​​​​​​

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should the nurse make?

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with assistive personnel. Which of the following statements should the nurse include in the discussion?

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?