The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Collaborate with a registered dietitian for appropriate foods.
b. Inspect the skin and note any areas of ulceration.
c. Keep the room at a comfortably warm temperature.
d. Place a foot cradle at the end of the bed to lift sheets.
e. Remind the client to elevate the head of the bed after eating.
ANS: C, D, E
The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynaud's phenomenon. The UAP can adjust the room temperature for the client's comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.
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Crisis management
a. Is an effective method of resolving problems b. Is preventable by anticipating problems and planning c. Is unavoidable d. Instills a feeling of trust in staff members
The client with bulimia is experiencing anxiety. What action should the nurse take to assist the client to avoid binge eating and purging in response to the anxiety?
1. Assume a matter-of-fact attitude and positive expectations of the client. 2. Project a calm reassuring attitude and provide a quiet non-stimulating environment. 3. Contract for safety since the client is likely to engage in self-injurious behavior. 4. Maintain total control of the environment and project an attitude of authority.
The son of an 80-year-old man has noticed that in recent weeks his father has become incontinent of urine for the first time in his life. The man is later diagnosed with transient urinary incontinence, a condition that is most often attributable to
A) decrease in bladder and sphincter tone. B) bladder outlet obstruction. C) detrusor instability. D) medications.
A child with severe anemia requires a unit of red blood cells (RBCs). The nurse explains to the child that the transfusion is necessary for which reason?
a. Allow her parents to come visit her. b. Fight the infection that she now has. c. Increase her energy so she will not be so tired. d. Help her body stop bleeding by forming a clot (scab).