The nurse is caring for an older adult client who has fallen and fractured her hip. The client will have hip replacement surgery followed by extensive rehabilitation
The client confides in the nurse, "I feel like I don't have any control over anything anymore now that I am old." What is the nurse's best response? a. "I'll make sure that the physical and oc-cupational therapists see you after surgery to help get your strength back."
b. "It's normal to feel this way, but hopefully you will be back on your feet after a stay in rehab."
c. "It's important to control what you can right now, like making out your menu every day and working with the therap-ists."
d. "I sense that you are feeling depressed about the situation. I will ask the doctor to prescribe an antidepressant for you."
C
The nurse should support the client's self-esteem and increase feelings of competency by en-couraging activities that assist in maintaining some degree of control, such as participation in decision making and performance of tasks that he or she can manage. The nurse should provide immediate control options for the client, rather than waiting until after rehabilitation. The client's desire for control does not indicate depression, so an antidepressant is not indicated. Therapy re-ferrals are appropriate but do not address the client's desire for control.
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A two-month-old infant is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event). The physician is to see the infant to write medical orders
The nurse completes the nursing history and performs an assessment and finds no abnormal findings. While waiting on the physician, which activity can the nurse perform independently? 1. Place the child on an apnea monitor. 2. Place the child on nasal cannula oxygen. 3. Draw blood for arterial blood gases. 4. Place the child on contact isolation.
The nurse is sitting in a chair near the patient's bed, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating?
a. Support b. Caring c. Active listening d. Interest
Which symptoms are expected to be seen in a patient with insomnia? (Select all that apply.)
a. Difficulty falling asleep b. Sleeping too much c. Waking often during the night d. Feeling unrested after sleep e. Uncontrollable urge to sleep f. Sleepwalking at least once per week g. Nightmares most of the night
The nurse providing instructions to the client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds
When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to: 1. Dilate the major bronchi. 2. Maintain inflation of the alveoli. 3. Increase surfactant production. 4. Enhance ciliary action in the tracheobronchial tree.