(1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct—assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated 187. The nurse is caring for clients on the psychiatric unit. Suddenly, a male client’s behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions? 1. Utilize an organized team to place the client in seclusion. 2. Leave the client alone in his room to identify feelings of anger. 3. Redirect the client to a quiet activity to divert his attention and not disturb the other clients. 4. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct—as client’s anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion 188. The nurse is instructing the parents of a child with celiac disease. The nurse knows that teaching has been effective when the parents make which of the following statements? 1. “My child’s diet should include raw vegetables, fruits, and crackers.” 2. “My child’s diet should be high in carbohydrates, high in calories, and high in proteins.” 3. “The only restriction in my child’s diet should be breads and cereals.” 4. “My child’s diet should be high in calories, high in protein, and restrict foods containing rye, oats, wheat, and barley.” Strategy: “Teaching has been effective” indicates you are looking for a correct statement. The topic of the question is unstated. (1) does not reflect appropriate dietary needs for this child (2) does not reflect appropriate dietary needs for this child (3) does not reflect appropriate dietary needs for this child (4) correct—celiac disease is characterized by an intolerance for gluten; foods containing rye, oats, wheat, and barley should be restricted
189. The nurse is transcribing the following physician’s orders. Which of the following orders warrants further clarification? 1. Administer haloperidol (Haldol) 5 mg. 2. Instruct client to use incentive spirometer q1h while awake. 3. D 5 W 1 ∕ 4 NS + KCl 20 mEq/L at 100 mL/h. 4. CBC with differential and platelets at 8 AM .
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