The nurse exercises caution during the digital removal of feces for a client with:
A. Heart disease
B. Abdominal pain
C. Urinary infection
D. Diabetes mellitus
A
A. Because of the potential to stimulate the sacral branch of the vagus nerve, clients with a history of dysrhythmia or heart disease have a greater risk of changes in heart rhythm. Be sure to monitor client's pulse before and during procedure. This procedure may be contraindicated in cardiac clients; if in doubt, verify with physician.
B. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency.
C. Symptoms of fecal impaction include urinary frequency, not infection.
D. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency, not diabetes mellitus.
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Which of the following statements about spirituality is TRUE?
a. There is no evidence of a connection between spirituality and health. b. Spiritual nursing requires specialized training in order to perform. c. Spirituality and values are the same. d. Spirituality is the core of a person's being.
The nurse assessing a client who has been diagnosed with Lyme disease in its early stage recognizes the following symptoms as classically seen in that stage: Select all that apply
1. "Bull's eye" rash 2. Stiff neck 3. Forgetfulness 4. Severe headache 5. Painful urination
The mother of a 1-month-old infant calls the nurse at the health clinic. The mother is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant's mother?
1. Bring the infant to the clinic for evaluation. 2. Give the infant at least 2 ounces of juice every 2 hours. 3. Measure the infant's urine output for 24 hours. 4. Provide the infant with 50 mL of glucose water.
An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia?
a. Advanced age b. Environmental exposure c. Nutritional deficit d. Obesity