FUNDAMENTALS OF NURSING BASIC PHYSICAL CARE

1. As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take? 2. Recommending warm milk or a warm shower at bedtime 3. Gathering more information about the client's sleep problem 4. Determining whether the client is worried about something 5. Finding out whether the client is taking medication that may impede sleep Correct answer: 2 RATIONALE: The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 32. 1002 A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is appropriate at this time? 1. Documenting that the client is resting quietly and denies pain 2. Calling a family member to obtain information about the client 3. Giving the client the ordered as-needed pain medication 4. Checking vital signs and assessing for nonverbal indications of pain Correct answer: 4 RATIONALE: The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may result in inadequate intervention. Calling the family or giving pain medication isn't warranted at this time because the client denies pain and the nurse needs to obtain more information. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1375. 1003 When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self- administer a prepackaged enema. Which statement by the client indicates effective teaching? 1. "I will administer the enema while sitting on the toilet." 2. "I will administer the enema while lying on my left side with my right knee flexed." 3. "I will administer the enema while lying on my right side with my left knee flexed." 4. "I will administer the enema while lying on my back with both knees flexed." Correct answer: 2 RATIONALE: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins