A client has returned from the postanesthesia care unit after a vaginoplasty. What comfort measure does the nurse provide for this client?
a. Apply ice to the perineum.
b. Elevate the legs on pillows.
c. Position the client on the left side.
d. Raise the head of the bed.
ANS: A
Ice is applied to the perineum to reduce pain and discomfort. Elevating the legs on pillows is not recommended after a lengthy procedure in the lithotomy position, which predisposes the client to venous thromboembolism. Positioning the client on the left side and raising the head of the bed are not comfort measures related to this procedure.
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The NANDA-I classification is a:
a. standardized classification of patient/client outcomes. b. set of nursing diagnoses of actual problems, risks, and health enhancement needs. c. standardized classification of interventions. d. unified nursing language system into which nursing terminologies can be cross-mapped.
The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back?
1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible.
A 10-year-old child wins the science fair competition and is chosen as a cheerleader for the basketball team. A nurse should recognize that this child is in the process of successfully accomplishing which stage of Erikson's developmental theory?
A. Industry versus inferiority B. Identity versus role confusion C. Intimacy versus isolation D. Generativity versus stagnation
A pregnant patient asks you to describe the differences between monozygotic and dizygotic twins. Which statement should you include in your teaching?
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