Comfort and Motivation Flashcards
An older client who was given lisinopril suddenly exhibits skin wheals and difficulty breathing. After assessing the respiratory status, airway, and oxygen saturation and activating the rapid response team, what action should the nurse do next?
- Prepare to administer epinephrine.
- Initiate chest compressions and rescue breathing.
- Establish an additional IV access.
- Ensure that intubation and tracheotomy equipment is ready.
1
The client is exhibiting signs and symptoms of anaphlaxis. After assessing the respiratory status, airway, and oxygen status, the nurse should immediately call the rapid response team. The client should then be administer epinephrine immediately. Epinephrine is the drug of choice for an anaphylaxis. If the patient is not treated immediately, dysrhythmias, shock, and cardiopulmonary arrest may occur within minutes as intravascular volume is lost and the heart becomes hypoxic.
The nurse is counseling a first-time mother who is nervous about caring for her child while alone at home. Which action by the nurse is most helpful in this situation?
- Offer the client a list of Internet resources on parenting.
- Find out if the client can stay another night in the hospital.
- Arrange for a family member to stay with the client.
- Reassure the client that everything will turn out fine.
1
Anticipatory guidance helps parents know what to expect. Although plenty of literature is made available to new mothers by the time of discharge, it is also helpful to provide a list of reliable Internet resources that the client may refer to after returning home.
The nurse is providing client teaching about the use of a patient-controlled analgesia (PCA) pump. Which statement by the client indicates the need for more instruction about the PCA pump?
- If I am asleep, one of my visitors can push the button for me.
- The PCA is designed so I can try to maintain adequate pain relief.
- I don’t need to be afraid of overdosing because the pump has preset doses to prevent that.
- The nurse will check the PCA pump syringe to check how often I am needing a dose.
1
The only person who should be pushing the dosing button of the PCA pump is the client. The pump has several safety features, including dosing limits.
Which questions would be relevant for a nurse to ask a client who suffers with chronic pain?
- What makes it better or worse?
- Can you show me where it hurts?
- How would you describe the pain?
- How has this pain affected your life?
- Do you think your pain is psychological?
1, 2, 3, 4
The nurse should ask questions about the symptoms and management of pain and how the pain has affected the client’s life.
During an assessment, an infant’s mother asks the nurse at what age her son’s height could predict his adult stature. Which is the most accurate response by the nurse?
- By 13-years-old, most of the boy’s adult height should be reached.
- By 15-years-old, 95% of the boy’s height should have taken place.
- By 10-years-old, a big growth spurt should occur to affect his height.
- By two-years-old, tripling his linear measurement should suggest his adult height.
2
In general, males between the ages of 11- to 16-years-old, will gain anywhere between 10-30cm (4-12 inches). For boys, approximately, 95% of their skeletal height is completed by the age of 15-years-old. For females, this occurs either with the onset of menarche or at 13-years-old.
The nurse is caring for a client with anorexia nervosa. The nurse establishes a contract in which the client agrees to participate in measures specifically designed to promote a specific weekly weight gain. Which statement accurately describes the rationale for this contract?
- Client involvement in decision making increases a sense of control and promotes compliance.
- Client permission is essential due to increased risk of physical problems with refeeding.
- Objective and subjective data must be routinely collected to help assess anxiety issues.
- The client’s family usually does not follow up with the recommended treatment plan.
1
Behavioral contracting is a supportive intervention to elicit desired weight gain or maintenance for individuals with an eating disorder. Encouraging the client’s involvement with decision making will improve self-esteem and help them to feel more invested in the treatment plan, and also provide a sense of control over health issues.
According to Bandura’s Social Cognitive Theory, which are extrinsic factors that can motivate a client’s behaviors?
- Curiosity.
- Rewards.
- Challenge.
- Punishment.
- Reinforcement.
2, 4
According to Bandura’s Social Cognitive Theory, extrinsic factors for motivating one’s behavior are tradition, rewards, reinforcement, and punishment.
The nurse is caring for a client who has just been placed on lisinopril for treatment of hypertension. The nurse should educate the client about what common side effect of this medication?
- Frequent urination.
- Dizziness.
- Dry skin.
- Increased hunger.
2
When administering medications, it is important that the nurse understand side effects that may be either drug- or drug class-specific. Dizziness is a common side effect of the class of antihypertensives known as ACE inhibitors.
A client being treated with monoamine oxidase inhibitor (MAOIs) for post- traumatic stress disorder (PTSD) appears at the clinic reporting a severe headache, nausea and vomiting, and palpitations. The client’s heart rate is 122 beats/minute and BP 190/110 mmHg. What question should the nurse ask first?
- Are there any changes or ongoing stressors happening in your life?
- What foods had you consumed prior to the onset of these symptoms?
- Where were you when you noticed the onset of symptoms?
- Were you doing any strenuous activity when the symptoms appeared?
2
Clients taking monoamine oxidase inhibitor (MAOIs) risk having a hypertensive crisis if they consume foods high in tyramine. Foods that are generally aged and cured such as red wine, cheese, smoked meats, and fish contain high levels of tyramine. Other questions about place of onset, stressors, and activity are not the priority assessment.
