Nursing care of a client for the first 48 hours after surgery includes all of the following interventions. Which action would enable the client to better participate in the other activities?
a. Assist the client to sit up and ambulate as soon and as often as possible.
b. Encourage coughing and deep breathing every 2 hours.
c. Monitor use of the incentive spirometry every waking hour.
d. Provide adequate pain-relief measures.
D
Measures taken to control a client's pain can allow for participation in other activities.
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A patient's sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patient's discharge education?
A) The patient should drink at least 2 liters of fluid in the next 12 hours. B) The patient can resume a normal routine immediately. C) The patient should expect fecal urgency for several hours. D) The patient can expect some scant rectal bleeding.
A client with a body temperature of 104°F is entering the flush phase of the fever. To assist this client, the nurse will:
1. Cover the client with warm blankets. 2. Restrict fluids. 3. Cover the client with a light sheet. 4. Provide warmed intravenous fluids.
The nurse notes that a 20-month-old child is lagging in stage 6 of Piaget's phases of cognitive development. Which activity did the nurse observe that indicates that this child is struggling at this stage?
1. The child wants the same toy to sleep with during naptime and bedtime. 2. The child merely watches as the other children pretend-play. 3. The child cries when the parents leave the unit. 4. The child does not cooperate with some of the treatments.
The nurse is reviewing the traits of a perpetrator of violence with a community group. Which traits should the nurse include? Select all that apply.
A. Limited ability to cope. B. Social withdrawal. C. Low self-esteem. D. Possessive behavior. E. Reckless behavior.