Answer to Question 1
B
Feedback:
The nurse should monitor the level of consciousness of the client. The nurse should avoid touching the client, because the client may react violently to physical contact. The nurse should monitor for a decrease in respiratory rate instead of an increase in respiration. The nurse should turn off the television and provide a calm environment to the client instead of encouraging the client to watch television.
Answer to Question 2
C
Feedback:
With urticaria (hives), reddened areas (erythema), itching (pruritus), and burning around swollen patches on the skin may appear. They appear suddenly and may disappear after a few hours or may last for a period of days or weeks. Hives can result from a variety of causes, including foods; additives; medications; viral, bacterial, or parasitic infections; or stress factors (e.g., heat, sun, cold, emotional stress). Asthma is an example of a respiratory response, and latex sensitivity is an example of an allergy with a multisystem response. A food allergy may cause a gastrointestinal response.
The surgical nurse assists the client into the correct position
Application of an ostomy bag or pouch: B, An ostomy nurse applying an ostomy bag to a stoma;
Using small, circular strokes, exfoliate the client’s neck and back.
Positioning the client
Testing client’s ability to identify sharp sensations
The client is positioned for the examination