11. The nurse is caring for a child who has just returned from surgery following atonsillectomy and adenoidectomy. Which action by the nurse is appropriate?A) Offer ice cream every 2 hoursB) Place the child in a supine positionC) Allow the child to drink through a straw
D) Observe swallowing patterns
The correct answer is D: Observe swallowing patternsThe nurse should observe for increased swallowing frequency to check for hemorrhage.12. The nurse is caring for a client with acute pancreatitis. After pain management, whichintervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolationC) Provide a diet high in proteinD) Institute seizure precautionsThe correct answer is A: Cough and deep breathe every 2 hoursRespiratory infections are common because of fluid in the retro peritoneum pushing upagainst the diaphragm causing shallow respirations. Encouraging the client to cough anddeep breathe every 2 hours will diminish the occurrence of this complication.13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist theclient with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for mealsC) Provide additional servings of fruits and raw vegetablesD) Encourage the client to eat fish, liver and chickenThe correct answer is A: Offer small meals of high calorie soft foodIf the client is losing weight because of poor appetite due to the pain, assist in selectingfoods that are high in calories and nutrients, to provide more nourishment with lesschewing. Suggest that frequent, small meals be eaten instead of three large ones. Tominimize jaw movements when eating, suggest that foods be pureed.14. A client treated for depression tells the nurse at the mental health clinic that he recentlypurchased a handgun because he is thinking about suicide. The first nursing action shouldbe to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric careC) Respect the client's confidential disclosureD) Phone the family to warn them of the riskThe correct answer is A: Notify the health care provider immediatelyThe health care provider must be contacted immediately as the client is a danger to self andothers. Hospitalization is indicated.15. The initial response by the nurse to a delusional client who refuses to eat because of abelief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"C) "These feelings are a symptom of your illness."D) "You’re safe here. I won’t let anyone poison you."The correct answer is A: "You think that someone wants to poison you?"This response acknowledges perception through a reflective question which presentsopportunity for discussion, clarification of meaning, and expressing doubt.