Solution Manual for Fundamental care and comfort
A nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse
implement for the client's night sweats and fever.
Select all that apply
1. Keep water by the bedside
2. Place a plastic cover over the pillow
3. Administer an antipyretic every 4 hours
4. Keep a change of linen in the room
5. Position the client in a semi-fowlers position - Answers 1., 2., & 4. Correct: The nurse should
encourage the client to consume liquids to replace insensible water loss and sweating. The plastic cover
will protect the pillow from contact with perspiration. A time management technique for caring for a
client with frequent fever episodes is to keep a change of linen in the room.
3. Incorrect: Antipyretics should be administered to reduce a client's fever. Antipyretics are usually
prescribed as needed, not every 4 hours.
5. Incorrect: Placing a client in different positions will not affect the client's fever. Positioning the client
in a semi-fowlers position may be more appropriate for the client, but will not affect the client's
temperature.
The nurse is planning care for four clients with different medical issues. With which diagnosis would a
client benefit most from an integrative medicine healthcare strategy?
1. Chronic fatigue syndrome who has had no relief of fatigue.
2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection
medications.
3. Cholecystitis who wants surgery to treat the symptoms definitively.
4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest
pain. - Answers 1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat
using only traditional medicine and responds well to the use of an integrative medicine healthcare
strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach
to care that puts the patient at the center and addresses the full range of physical, emotional, mental,
social, spiritual and environmental influences that affect a person's health.
2. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional
medicine strategies.
,3. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional
medicine strategies.
4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional
medicine strategies.
An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH).
At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment?
1. 15
2. 30
3. 45
4. 90 - Answers 4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used
as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur
into the hip socket correctly. This is accomplished with 90 degrees of hip flexion.
1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket.
2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket.
3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket.
The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is
important to preserve client's self-esteem as the task is completed?
1. Closes the door for privacy.
2. Introduces self and explains the procedure.
3. Bathes the client without the help of others.
4. Covers the client with a bath blanket. - Answers 4. Correct: The client does not have to be exposed
during the bed change and should be covered with a bath blanket as the top sheet is removed. A bath
blanket covers the client as once section at a time of the body is exposed and bathed. This allows for the
most privacy and protects self-esteem.1. Incorrect: Closing the door is very important but the client's
privacy should be maintained at all times even from the nurse administering the bath. A bath blanket
promotes privacy and protects the self-esteem.2. Incorrect: Introducing yourself to the client and
explain procedures shows respect. These two actions do not provide for privacy and preserve the self-
esteem of the client.3. Incorrect: If help is needed during an occupied bed bath to protect the client and
provide for safety, help should be obtained. The nurse should use measures to protect privacy and
preserve the client's self-esteem.
The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a
plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene?
,1. Lifting the affected leg with the palms of the hands
2. Covering the affected leg with a blanket to avoid chills
3. Placing plastic over the entire cast prior to bathing
4. Elevating the casted leg on two pillows - Answers 2. Correct: Plaster cast take 24-48 hours to
completely dry. During this time they release heat. The new cast should not be covered so that heat
from the cast can evaporate. If the heat is not allowed to dissipate, drying will take longer. 1. Incorrect:
Plaster cast take 24-48 hours to completely dry. During this time the cast should be handled carefully as
to avoid indentations. Handling the cast carefully with the palms and not the fingertips will prevent
indentations. Indentations in the cast could cause skin breakdown inside the cast. 3. Incorrect: Yes, will
keep cast from getting wet. Plaster casts should never get wet. The plaster cast does not hold up well in
water. Wet casts can also irritate the skin underneath.4. Incorrect: Yes, may elevate the leg. Fractures
are prone to swelling. Elevating fractures while casted is a common occurrence. Elevation prevents
swelling.
A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that
procedure. What is the most important action for the nurse to take prior to changing this catheter?
1. Check size of existing catheter and balloon.
2. Ask client when the catheter was last changed.
3. Clamp and empty the present catheter bag.
4. Gather clean gloves and basin of hot soapy water. - Answers 1. CORRECT. It is important to maintain
the same catheter size as the one currently in use since the surgical opening does not increase in size
like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is
too big, urine will not drain properly, leaving residual and the potential for infection.
2. INCORRECT. Though obtaining information directly from the client is often a good choice, the
individual may not be able to recall a precise date or time. When a catheter change is scheduled at
specific time intervals, the nurse needs to verify the correct time line. Generally, the primary healthcare
provider can provide a current order to facilitate the changing of the catheter.
3. INCORRECT. Although the nurse may empty a catheter bag, if the client uses one, there is no need to
clamp a suprapubic catheter. The standard procedure for replacing a suprapubic catheter does not
include clamping since the catheter does not require long tubing like a regular catheter. Also, urine bags
are generally emptied at scheduled times each shift.
4. INCORRECT. Replacing a suprapubic catheter requires the use of sterile gloves both while cleaning and
inserting the new catheter. Also, care of the insertion site is completed with sterile normal saline before
and after the reinsertion.
, The family of an elderly client are concerned about emotional well-being since the loss of the spouse
two years ago. What alternative therapy could the nurse recommend for this client?
1. Massage
2. Bioelectromagnetics
3. Accupressure
4. Animal-assisted therapy - Answers 4. Correct: Animal-assisted therapy is the use of specifically
selected animals as a treatment modality in health and human service settings. It has been shown to be
a successful intervention for people with a variety of physical or psychological conditions. The
contributions companion animals make to the emotional well-being of people include providing
unconditional love and opportunities for affection; achievement of trust, responsibility, and empathy
toward others; a reason to get up in the morning, and a source of reassurance.
1. Incorrect: Massage therapy is the scientific manipulation of the soft tissues of the body. It is believed
to aid the body to heal itself.
2. Incorrect: This uses electromagnetic fields to affect the functioning of cells, tissues, organs and
systems.
3. Incorrect: Acupressure is a treatment rooted in the traditional Eastern philosophy of life energy, that
flows through the body along pathways. It opens up blocked pathways to relieve pain.
A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome.
What points should the nurse include to help the clients control symptom flare-ups?
Select all that apply
1. If you are constipated, try to make sure you have breakfast.
2. Avoid low fat foods.
3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks.
4. Drinks containing caffeine are likely to contribute to symptoms.
5. Foods such as broccoli and cabbage are good sources of fiber. - Answers 1., 3. & 4. Correct: If you are
constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the
colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your
diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one
causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems
are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts
2. Incorrect: Avoid meals that over-stimulate the gut, like large meals or high fat foods.
A nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse
implement for the client's night sweats and fever.
Select all that apply
1. Keep water by the bedside
2. Place a plastic cover over the pillow
3. Administer an antipyretic every 4 hours
4. Keep a change of linen in the room
5. Position the client in a semi-fowlers position - Answers 1., 2., & 4. Correct: The nurse should
encourage the client to consume liquids to replace insensible water loss and sweating. The plastic cover
will protect the pillow from contact with perspiration. A time management technique for caring for a
client with frequent fever episodes is to keep a change of linen in the room.
3. Incorrect: Antipyretics should be administered to reduce a client's fever. Antipyretics are usually
prescribed as needed, not every 4 hours.
5. Incorrect: Placing a client in different positions will not affect the client's fever. Positioning the client
in a semi-fowlers position may be more appropriate for the client, but will not affect the client's
temperature.
The nurse is planning care for four clients with different medical issues. With which diagnosis would a
client benefit most from an integrative medicine healthcare strategy?
1. Chronic fatigue syndrome who has had no relief of fatigue.
2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection
medications.
3. Cholecystitis who wants surgery to treat the symptoms definitively.
4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest
pain. - Answers 1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat
using only traditional medicine and responds well to the use of an integrative medicine healthcare
strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach
to care that puts the patient at the center and addresses the full range of physical, emotional, mental,
social, spiritual and environmental influences that affect a person's health.
2. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional
medicine strategies.
,3. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional
medicine strategies.
4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional
medicine strategies.
An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH).
At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment?
1. 15
2. 30
3. 45
4. 90 - Answers 4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used
as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur
into the hip socket correctly. This is accomplished with 90 degrees of hip flexion.
1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket.
2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket.
3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket.
The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is
important to preserve client's self-esteem as the task is completed?
1. Closes the door for privacy.
2. Introduces self and explains the procedure.
3. Bathes the client without the help of others.
4. Covers the client with a bath blanket. - Answers 4. Correct: The client does not have to be exposed
during the bed change and should be covered with a bath blanket as the top sheet is removed. A bath
blanket covers the client as once section at a time of the body is exposed and bathed. This allows for the
most privacy and protects self-esteem.1. Incorrect: Closing the door is very important but the client's
privacy should be maintained at all times even from the nurse administering the bath. A bath blanket
promotes privacy and protects the self-esteem.2. Incorrect: Introducing yourself to the client and
explain procedures shows respect. These two actions do not provide for privacy and preserve the self-
esteem of the client.3. Incorrect: If help is needed during an occupied bed bath to protect the client and
provide for safety, help should be obtained. The nurse should use measures to protect privacy and
preserve the client's self-esteem.
The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a
plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene?
,1. Lifting the affected leg with the palms of the hands
2. Covering the affected leg with a blanket to avoid chills
3. Placing plastic over the entire cast prior to bathing
4. Elevating the casted leg on two pillows - Answers 2. Correct: Plaster cast take 24-48 hours to
completely dry. During this time they release heat. The new cast should not be covered so that heat
from the cast can evaporate. If the heat is not allowed to dissipate, drying will take longer. 1. Incorrect:
Plaster cast take 24-48 hours to completely dry. During this time the cast should be handled carefully as
to avoid indentations. Handling the cast carefully with the palms and not the fingertips will prevent
indentations. Indentations in the cast could cause skin breakdown inside the cast. 3. Incorrect: Yes, will
keep cast from getting wet. Plaster casts should never get wet. The plaster cast does not hold up well in
water. Wet casts can also irritate the skin underneath.4. Incorrect: Yes, may elevate the leg. Fractures
are prone to swelling. Elevating fractures while casted is a common occurrence. Elevation prevents
swelling.
A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that
procedure. What is the most important action for the nurse to take prior to changing this catheter?
1. Check size of existing catheter and balloon.
2. Ask client when the catheter was last changed.
3. Clamp and empty the present catheter bag.
4. Gather clean gloves and basin of hot soapy water. - Answers 1. CORRECT. It is important to maintain
the same catheter size as the one currently in use since the surgical opening does not increase in size
like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is
too big, urine will not drain properly, leaving residual and the potential for infection.
2. INCORRECT. Though obtaining information directly from the client is often a good choice, the
individual may not be able to recall a precise date or time. When a catheter change is scheduled at
specific time intervals, the nurse needs to verify the correct time line. Generally, the primary healthcare
provider can provide a current order to facilitate the changing of the catheter.
3. INCORRECT. Although the nurse may empty a catheter bag, if the client uses one, there is no need to
clamp a suprapubic catheter. The standard procedure for replacing a suprapubic catheter does not
include clamping since the catheter does not require long tubing like a regular catheter. Also, urine bags
are generally emptied at scheduled times each shift.
4. INCORRECT. Replacing a suprapubic catheter requires the use of sterile gloves both while cleaning and
inserting the new catheter. Also, care of the insertion site is completed with sterile normal saline before
and after the reinsertion.
, The family of an elderly client are concerned about emotional well-being since the loss of the spouse
two years ago. What alternative therapy could the nurse recommend for this client?
1. Massage
2. Bioelectromagnetics
3. Accupressure
4. Animal-assisted therapy - Answers 4. Correct: Animal-assisted therapy is the use of specifically
selected animals as a treatment modality in health and human service settings. It has been shown to be
a successful intervention for people with a variety of physical or psychological conditions. The
contributions companion animals make to the emotional well-being of people include providing
unconditional love and opportunities for affection; achievement of trust, responsibility, and empathy
toward others; a reason to get up in the morning, and a source of reassurance.
1. Incorrect: Massage therapy is the scientific manipulation of the soft tissues of the body. It is believed
to aid the body to heal itself.
2. Incorrect: This uses electromagnetic fields to affect the functioning of cells, tissues, organs and
systems.
3. Incorrect: Acupressure is a treatment rooted in the traditional Eastern philosophy of life energy, that
flows through the body along pathways. It opens up blocked pathways to relieve pain.
A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome.
What points should the nurse include to help the clients control symptom flare-ups?
Select all that apply
1. If you are constipated, try to make sure you have breakfast.
2. Avoid low fat foods.
3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks.
4. Drinks containing caffeine are likely to contribute to symptoms.
5. Foods such as broccoli and cabbage are good sources of fiber. - Answers 1., 3. & 4. Correct: If you are
constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the
colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your
diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one
causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems
are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts
2. Incorrect: Avoid meals that over-stimulate the gut, like large meals or high fat foods.
