A 74-year-old client has kyphosis and is reporting discomfort of
the cervical vertebrate. Which nursing intervention is most
appropriate?
contacting the primary health care provider
placing a small towel under the neck
administering a muscle relaxer
positioning the client on the stomach Correct Answer placing a
small towel under the neck
Explanation:
Kyphotic changes can cause pressure on cervical vertebrae when
someone is in a supine position. Effects of this can be minimized
by placing a small towel or cervical pillow under the neck.
Placing the client on the stomach is incorrect, and a muscle
relaxer will not help reduce the pressure caused by the kyphosis.
Contacting the health care provider is unnecessary.
A client expresses concern that there is an increase in urine
output after exercising. How would the nurse address the client's
concern? Select all that apply.
Explain that urination after exercise is a result of increased
circulation to the kidneys and is a normal function
,Assess cardiovascular function and blood pressure
Ask the client to provide details of the exercise regimen
including frequency and type
Perform a 24-hour input and output assessment
Evaluate for diabetes mellitus Correct Answer EXEPT :
Perform a 24-hour input and output assessment
Explanation:
Urination after exercise is a result of increased circulation to the
kidneys and is a normal function. Especially in overweight
individuals, the elevated heart rate from exercise can cause
temporary high blood pressure and one of the body's first
defense mechanisms for high blood pressure is to decrease blood
volume, hence fluid is excreted as urine. Certain exercises can
increase pressure on the bladder causing the sensation that
urination is needed, even if the bladder is not full. While there
are several causes that may be benign reasons for increased
urination, it can also be caused by more significant issues,
including diabetes and urinary tract infections that are not
caused by or related to exercise. Therefore, conducting a
comprehensive assessment of physical activity, cardiovascular
health, and testing for diabetes is needed to determine if
increased urine output is due to exercise
A client is experiencing acute pain following the amputation of a
limb. What nursing interventions would be most appropriate
when treating this client?
,Treat the pain only as it occurs to prevent drug addiction.
Encourage the use of nonpharmacologic complementary
therapies as adjuncts to the medical regimen.
Increase and decrease the serum level of the analgesic as
needed.
Do not provide analgesia if there is any doubt about the
likelihood of pain occurring. Correct Answer Encourage the
use of nonpharmacologic complementary therapies as adjuncts
to the medical regimen.
Explanation:
The client would benefit from the use of nonpharmacologic
complementary therapies as adjuncts to the medical regimen.
The phantom pain is real pain and should be treated as such. The
nurse would not increase and decrease the serum level of the
analgesic as needed. The nurse would not doubt the client's
report of pain and would not withhold analgesia if she doubted
the likelihood of the pain occurring.
A client presents with reports of acute pain. The nurse's
assessment indicates the client is likely experiencing moderate,
superficial acute pain. What assessment finding would
corroborate this conclusion? Select all that apply.
Explanation:
Sympathetic physiologic responses to moderate superficial acute
pain can include increased blood pressure, pulse, and respiratory
rate. Decreased level of consciousness is not typically present
during episodes of pain. Cool, moist skin may be present but this
is associated with many other diagnoses apart from pain.
A client with chronic pain uses a machine to monitor his
physiologic responses to pain. The unit transforms the data into
a visual display and through seeing the pain responses, the client
is taught to regulate his physiologic response and control pain
through relaxation, imagery, or breathing exercises. This
technique for pain control is known as:
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