Author Question: A client is in the early stages of shock and is restless. What comfort measures does the nurse ... (Read 55 times)

saliriagwu · **on:** Jun 25, 2018

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)

a. Bringing the client warm blankets
b. Giving the client hot tea to drink
c. Massaging the client's painful legs
d. Reorienting the client as needed
e. Sitting with the client for reassurance

Question 2

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best?

a. Do you have any concerns about sexuality?
b. I'm glad to hear you are sleeping well now.
c. Sleep near your spouse in case of emergency.
d. Why would you move into the guest room?

Carliemb17 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A, D, E
The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

Answer to Question 2

ANS: A
Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.