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Which intervention reflects the nurse's approach of "family as a context"?
1. Trying to meet the client's comfort
2. Evaluating the client family's coping skills
3. Evaluating the client family's energy level
4. Trying to meet the client family's nutritional needs - -ANS: 1
In the "family as context" approach, the focus is on the client. The nursing
care aims at meeting the client's comfort, hygiene, and nutritional needs. The
"family as a client" approach focuses on the family's needs as a whole to
determine their coping skills. This approach also includes assessment of the
family's energy level to determine if the family would be able to meet the
client's needs. In addition, the approach "family as a client" involves
assessment of the family's nutritional needs.
Which therapeutic communication technique is useful when the nurse and a
client have a conversation and the client begins to repeat the conversation to
himself or herself?
1. Focusing
2. Clarifying
3. Paraphrasing
, 2
4. Summarizing - -3
Focusing is a therapeutic communication technique that is useful when
clients begin to repeat themselves. Clarification helps to check whether the
client's understanding is accurate by restating an unclear or ambiguous
message. Paraphrasing involves restating a message more briefly using one's
own words. Summarizing is a concise review of key aspects of an interaction.
When caring for a client with venous insufficiency, the nurse would implement
which nursing measure?
1. Apply abdominal girdle as needed.
2. Remove compression stockings for client ambulation.
3. Elevate the client's legs above heart level.
4.Keep the upper extremities elevated - -3
Venous insufficiency occurs when vascular damage impedes the body's
ability to move blood from the legs toward the heart. This causes blood to pool
in the legs, where it can cause swelling; pain; and, in some cases, leaking fluid
in the skin or ulcers. Elevation of the legs above the level of the heart makes
use of gravitational forces to drain blood through the veins toward the heart.
Clients should not wear tight restrictive pants and should avoid wearing a
girdle or garter, which may impede venous return. Compression stockings
prevent blood pooling. Elevating the upper extremities will not decrease
edema in lower extremities.
A client with a history of hypothyroidism reports giddiness, excessive thirst,
and nausea. Which parameter assessed by the nurse confirms the diagnosis
as heat stroke?