A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment
The nurse realizes the client's pain was influenced by which type of distraction?
1. Visual.
2. Tactile.
3. Intellectual.
4. Behavioral.
Correct Answer: 1
Rationale 1: Visual distraction includes watching television.
Rationale 2: Tactile distraction includes slow, rhythmic breathing or a massage.
Rationale 3: Intellectual distraction includes crossword puzzles or engaging in hobby.
Rationale 4: Behavioral is not a type of distraction.
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The nurse is caring for an older patient recovering from a total hip replacement. Which intervention will prevent dislocation of the hip prosthesis?
1. Encourage early ambulation. 2. Provide pain medication as needed. 3. Apply intermittent compression devices. 4. Place a wedge between the legs to keep the hip in abduction.
Which of the following is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume?
a. Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation. b. Electrolyte balance restored, as evidenced by sodium returning to normal range. c. Patient demonstrates effective coughing and deep-breathing techniques. d. Fluid balance restored, as evidenced by moist mucous membranes and urinating every 4 hours.
"Crix belly" is a syndrome characterized by: (Select all that apply.)
1. elevated CBCs. 2. elevated triglycerides. 3. elevated cholesterol. 4. fat accumulation.
Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema