更多"When caring for a client who has ha"的相关试题:
[单项选择]Nursing measures for the client who has had an MI include helping the client to avoid activity that results in Valsalva’s maneuver. Valsalva’s maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure, and thrombi dislodgment. Which of the following actions would help prevent Valsalva’s maneuver（ ）
A. Have the client drink fluids through a straw.
B. Have the client avoid holding her breath during activity.
C. Have the client assume a side-lying position.
D. Have the client clench her teeth while moving in bed.
[单项选择]The nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that he doesn’t wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client’s problem is（）
A. hopelessness.
B. powerlessness.
C. disturbed body image.
D. fear.
[单项选择]A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention isn’t appropriate for this client（）
A. Acknowledging the client’s spiritual distress.
B. Inviting the client’s clergyman to visit him.
C. Encouraging the client to discuss religious beliefs and practices.
D. Encouraging the client to discuss concerns with the clergy.
[单项选择]The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has two young children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping（）
A. Tell the client’s spouse or partner to be supportive while she recovers.
B. Encourage the client to proceed with the next phase of treatment.
C. Recommend that the client remain cheerful for the sake of her children.
D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.
[单项选择]When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following provides the most accurate picture of retention with overflow（）
A. Frequent trips to the bathroom with an average output of 200 to 300 mL per void.
B. Intense urge to urinate with an average output of 250 mL.
C. A varying urge to urinate with an average output of 100 mL.
D. Uterus displaced to the right with increased vaginal bleeding.
[简答题]A child who has had his confidence really damaged basically needs a rescue operation.
[单项选择]A 70-year-old woman who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is adamant that she cannot be allowed to die this way and her daughter agrees. An ethics consult has been placed. Who is the appropriate decision maker（ ）
A. Patient
B. Daughter
C. Doctor
D. Ethics consult team
[单项选择]A client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to（）
A. prevent leaning.
B. distribute weight away from the involved side.
C. maintain stride length.
D. prevent edema.
[单项选择]A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary caregiver（）
A. Breast tenderness.
B. Breakthrough bleeding within first 3 months of use.
C. Decreased menstrual flow.
D. Blurred vision and headache.
[单项选择]The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP) （）
A. Suction the airway every hour and as needed.
B. Elevate the head of the bed 15 to 30 degrees.
C. Turn the client and change his position every 2 hours.
D. Maintain a well-lit room.
[单项选择]The nurse is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client（）
A. Increase alcohol intake while taking the drug.
B. Avoid foods that are rich in purine.
C. Take aspirin for pain.
D. Take the drug between meals to promote absorption.
[单项选择]The nurse is caring for a client who has hemoconcentration after fluid loss. Which IV fluids would be the most appropriate fluid replacement therapy for this client（）
A. Distilled water.
B. Dextrose 5% in water (D5W) only.
C. DSW with 40 mEq of potassium chloride.
D. Dextrose 10% in saline.
[单项选择]A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by（）
A. encouraging a discussion of her problems and fears.
B. asking her if she would like to talk to the chaplain.
C. giving her reassurance.
D. recommending a support group.
[单项选择]The nurse is caring for a client who has generalized anxiety disorder. Which statement is true about this client（ ）
A. The client has regular obsessions.
B. Relaxation techniques and psychotherapy are necessary for cure.
C. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder.
D. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months.
[单项选择]A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take（）
A. Clear the client’s airway.
B. Make the client comfortable.
C. Start eardiopulmonary resuscitation.
D. Stop the feeding and remove the NG tube.
[单项选择]A client who has sustained a head injury is to receive mannitol (Osmitrol) by IV push. In evaluating the effectiveness of the drug, the nurse should expect to find
A. increased lung expansion.
B. decreased cerebral edema.
C. decreased cardiac workload.
D. increased cerebral circulation.
[单项选择]The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by（）
A. suctioning the tracheostomy tube frequently.
B. using a cuffed tracheostomy tube.
C. using the minimal air leak technique with cuff pressure less than 25 cmH2O.
D. keeping the tracheostomy tube plugged.
[单项选择]The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he’ll be undesirable to his wife, and he becomes tearful. He expresses that he’s spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes（）
A. Situational low self-esteem.
B. Unilateral neglect.
C. Social isolation.
D. Risk for loneliness.
[单项选择]A client who has been using crutches at home for t week reports that he is having trouble using the crutches because his armpits hurt and his fingers tingle. What would be the nurse’s most appropriate response（）
A. "You need to do more arm exercises. It sounds like your muscles need strengthening. "
B. "That’s normal. As you adjust to the crutches, the discomfort will diminish. "
C. "Be sure to take your pain medication before ambulating. That will help your discomfort. "
D. "Let me watch you ambulate. Your crutches or technique may need some adjustment. "
