basic care and comfort graded.docx - Question 1 See full...

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Question 1 See full question Two days after a herniorrhaphy, the client reports that his scrotum is swollen and painful. To promote comfort, the nurse should instruct the client to: You Selected: elevate the scrotum and place ice bags on the area intermittently. Correct response: elevate the scrotum and place ice bags on the area intermittently. Explanation: A swollen, painful scrotum after herniorrhaphy is relatively common. Elevating the scrotum, as on a rolled towel, and intermittently placing ice bags on the area are helpful. Applying an abdominal binder will have no effect on the scrotal swelling. Applying a truss is unlikely to promote comfort when the scrotum is swollen. Having the client lie on his side with a pillow between his legs will not elevate the scrotum; therefore, this will not help reduce swelling and discomfort. Question 2 See full question The nurse is preparing the client with heart failure to go home. The nurse should instruct the client to: You Selected: monitor weight daily. Correct response: monitor weight daily. Explanation: People with heart failure are taught to maintain a target weight and to weigh themselves daily to monitor increasing fluid retention. Fluid retention can lead to decompensation and hospitalization. Monitoring daily urine output is not required of these clients. A week of bed rest is not indicated for most people with heart failure.
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Clients on potassium-wasting diuretics will be taught to include dietary sources of potassium or to take a potassium supplement. However, all clients with heart failure should weigh themselves daily to monitor fluid status. Question 3 See full question To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: You Selected: stay with the client and encourage him to eat. Correct response: stay with the client and encourage him to eat. Explanation: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake. Question 4 See full question The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet the client's needs? You Selected: baked chicken, an apple, and a slice of white bread Correct response: baked chicken, an apple, and a slice of white bread Explanation: Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic.
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