Nursing Interventions Assessment Quiz

Questions and Answers

Which nursing interventions are appropriate for a client displaying paranoid behaviors? (Select all that apply)

Use active listening skills to seek information from the client. (correct)

Encourage the client to describe the problem as she sees it. (correct)

Tell the client that she is delusional and you can help her.

Ask the client to tell you exactly what she thinks is happening. (correct)

Reassure the client that you are not with the CIA.

Explain to the client that most people are not investigated by the CIA.

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? (Select all that apply)

Avoid use of donut type devices. (correct)

Position the client directly on the trochanter when side lying.

Avoid uninterrupted sitting in a chair or wheelchair. (correct)

Elevate the HOB no more than 30 degrees when possible. (correct)

When the client is side lying, use the 30-degree lateral inclined position. (correct)

Massage bony prominences.

What are important nursing actions for a client recently diagnosed with primary open angle glaucoma? (Select all that apply)

Discuss with the client the importance of controlling blood pressure to decrease potential loss of peripheral vision.

Review meds the client is currently on to determine whether any of them cause increased intraocular pressure. (correct)

Determine whether the client has any sudden loss of vision accompanied by pain.

Have the client demonstrate the use of eye drops. (correct)

Instruct the client to take analgesics as soon as discomfort occurs in the eye.

Assess the client for chronic diseases such as diabetes. (correct)

Which clinical manifestations of a client with Addison's disease are correct? (Select all that apply)

Nausea Signup and view all the answers

What should be included in teaching about home care and treatment of venous stasis ulcers? (Select all that apply)

Healing will be facilitated by wearing leg compression devices. Signup and view all the answers

What important information should be checked on the initial evaluation of cardiac clients? (Select all that apply)

Presence of diaphoresis. Signup and view all the answers

Which nursing interventions are necessary when preparing a client for cardiac catheterization? (Select all that apply)

Verify consent has been signed. Signup and view all the answers

What important teaching points should the nurse include for a patient with GERD? (Select all that apply)

Take ranitidine (Zantac) at bedtime. Signup and view all the answers

Which assessment findings would cause concern regarding the development of compartment syndrome in a client with a fractured femur? (Select all that apply)

Toes on affected leg cool to touch and edematous. Signup and view all the answers

What are indications for dialysis? (Select all that apply)

Metabolic acidosis. Signup and view all the answers

Which lab results indicate that dialysis was effective? (Select all that apply)

BUN decreases from 110 to 90 mg/dL. Signup and view all the answers

What might cause a patient to experience pain during peritoneal dialysis? (Select all that apply)

Accumulation of dialysate solution under the diaphragm. Signup and view all the answers

Study Notes

Nursing Interventions for Paranoid Client

Use active listening to gather information and build trust with the client.
Encourage the client to express her perception of the issue for better understanding.
Ask open-ended questions to clarify the client's thoughts and feelings.
Avoid direct confrontation of the client’s delusions, as this could hinder therapeutic rapport.

Pressure Ulcer Prevention Strategies

Position clients correctly to avoid pressure on bony prominences; do not place directly on the trochanter.
Avoid using donut-shaped devices to prevent ischemia.
Elevate the head of the bed to no more than 30 degrees to reduce shearing forces.
Encourage a 30-degree lateral incline position when on the side to distribute pressure evenly.
Advise against prolonged sitting in chairs or wheelchairs to minimize pressure.

Nursing Actions for Primary Open Angle Glaucoma

Evaluate current medications for any that may increase intraocular pressure.
Check for sudden vision change and eye pain, which require immediate attention.
Instruct on the proper administration of prescribed ophthalmic eye drops.
Assess for comorbid conditions like diabetes that can affect glaucoma management.

Clinical Manifestations of Addison's Disease

Common symptoms include fatigue, nausea, and skin hyperpigmentation.
Monitor for hypotension, which may result from adrenal insufficiency.
Recognize that symptoms can vary and develop gradually over time.

Home Care Instructions for Venous Stasis Ulcers

Use leg compression devices to enhance healing and reduce venous congestion.
Elevate legs while sitting to promote venous return.
Counsel clients to avoid prolonged standing, which can worsen venous stasis.
Change dressings as needed due to the potential for excessive drainage.

Initial Cardiac Assessment Focus

Essential to assess for cardiac pain and jugular vein distention.
Evaluate heart sounds and apical pulse for immediate physiological insights.
Presence of diaphoresis can indicate stress or poor perfusion.

Preparation for Cardiac Catheterization

Confirm informed consent has been signed prior to the procedure.
Provide a clear explanation of the procedure to the client.
Verify the client is on a clear liquid, no caffeine diet before the procedure.
Obtain a 12-lead ECG to evaluate heart rhythm and function.
Assess for history of shellfish allergy due to potential contrast dye reactions.

Discharge Teaching for GERD Management

Elevate the head of the bed to help prevent acid reflux.
Recommend reducing caffeine intake to minimize acid production.
Discuss weight loss strategies for overweight patients to alleviate symptoms.
Caution against increasing fluid intake during meals and eating before bed.

Indicators of Compartment Syndrome Post-Fracture

Monitor for paresthesia and edema in the affected limb.
Unrelieved leg pain should be reported as a significant concern.
An observable coolness of toes can indicate compromised circulation.

Indications for Dialysis

Volume overload is a critical reason for initiating dialysis treatment.
Presence of hyperkalemia, particularly potassium levels above 5.2 mEq/L, requires intervention.
Metabolic acidosis and elevated BUN or creatinine levels signal the need for dialysis.

Effectiveness of Hemodialysis

Successful dialysis is indicated by a decrease in serum potassium and creatinine levels.
A reduction in BUN levels reflects effective waste clearance from the bloodstream.

Pain During Peritoneal Dialysis

Pain may arise from rapid instillation of dialysate or accumulation of fluid under the diaphragm.
Warming the dialysate before instillation can help mitigate discomfort.
Rapid outflow of dialysate typically does not cause pain.

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Description

This quiz focuses on appropriate nursing interventions when dealing with clients exhibiting suspicious behaviors. You'll need to select the best strategies that encourage communication and understanding during an assessment interview. Test your knowledge on effective nursing practices in mental health assessments.