Question

1.On the third postoperative day,a client who has had hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. Th client denies having any pain. The clients vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply).

A. Apply soft wrist restraints bilaterally

B. Reorient to day and time frequently

C. Administer a PRN dose of lorazepam

D. Turn the television on for distraction.

E. Present a calm, supportive demeanor.

2. An older client who experinced a cerebrovascular accident has difficulty with visual perception and eats only half of the food on the tray. The client family expresses concern about the client nutritional status. How should the nurse respond to the family concern?

A. Demonstrate the use of visual scanning during meals to the client and family.

B. Suggest that the family bring foods from home that the client enjoys eating.

C. Explain that weight loss will be reversed after the acute phase of the stroke has ended.

D. Encourage the family to offer to feed the client when she does not eat her entire meal.

3. A client uses triamcinolone, a corticosteroid ointment to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erthema with purulent exudate at the site. Which action should the nurse implement?

A. Schedule an appointment for the client to see the healthcare provider.

B. Advise the client to apply plastic wrap over the ointment to promote healing

C. Explain that the client needs to complete all prescribe doses of the medication.

D. Instruct the client to continue until all erythema is relieved.

4. The nurse assess a client being treated for herpes zoster. Which assessment should the nurse include when evaluting the effectiveness of treatment. (Select all that apply)

A. Bowel sounds

B. Functional ability

C. Pain scale

D. Skin integrity

E. Heart sounds

Answer 1

1.A patient who is experiencing auditory hallucinations should be calmed down with comfort measures and devices. Administration of medication as per the order to relieve anxiety

Applying restrains needs a concent and doctor's order

Reorient a patient during anxiousness can make them difficult to understand

Television can be disturbing because the patient is need of rest

Ans:C. Administer a PRN dose of lorazepam

E. Present a calm ,supportive demeanor

2.The visual scanning is used in post CVA patient to improve patient's perception to look on the affected side. Concentrating on the things present in that side

It happens because of stroke ,this is even expected in any foods brought from home or any other places

Weight loss as no direct relation to vision

The family can encouraged to feed the patient if they are having problems with cognition

Ans:A.Demonstrate the use of visual scanning during the meals to the client and the family.

3.The  erythema and purulent discharge are side effects of the medication ,so it has to be stopped and seeked for medical help in case if in tolerability only ,other wise this settles down slowly

A plastic wrap should never be applied because this can lead to poor tissue perfusion for oxygen ,moisture and slow the healing

The prescribed dise ti be completed of patient has no serious adverse reactions

Redness, itching and blistering can occur during initial period the course has to be completed to relieve the erythema

AnsSchedule an appointment for the client tos we the healthcare provider

4. A patient with Heroes will experience severe intolerable pain die to the blisters

Their skin are intact other than the presence of blisters

Bowel sounds will be normal

Functional ability can decrease to to pain and improves of pain settles down.

Heart sounds are also normal ti these patients

Ans:C.Pain scale