Comfort Practice Questions

NCLEX-RN: Physiological Integrity: Basic Care & Comfort Practice Questions

• As the registered nurse in the emergency department, you are taking care of an adolescent

client who had just fractured their femur during gymnasium class at their high school. After casting, you will be discharging the client with crutches. Which of the following client goals that is paired with its learning domain should be included in the patient teaching plan for this client and the parents?

• Psychomotor domain: The client will slightly bend their elbows when holding the hand grips.

• Psychomotor domain: The client will rest their weight on the padded areas on the top of

the crutches.

• Cognitive domain: The client will slightly bend their elbows when holding the hand grips.

• Cognitive domain: The nurse will tell the client how often the tips on the crutches must

be replaced.

Correct Response: A

The client goal that is paired with its learning domain that should be included in the patient teaching plan for this client and the parents is “The client will slightly bend their elbows when holding the hand grips” which is part of the psychomotor domain and not the cognitive domain. Lastly, the “nurse will” is an intervention and not a client goal or expected outcome which should be learner, not nurse, oriented.

• Which basic activity of daily living assistive device can be useful for the client who is a

ected with poor ne motor coordination?

• An aphasia aid

• A button hook

• Honey thickened liquids

• A word board

Correct Response: B

The basic activity of daily living assistive device can be useful for the client who is a ected with poor ne motor coordination is a button hook that would be used for the dressing activity of daily living.

An aphasia aid and a word board are assistive devices to facilitate communication when the client is aVected with a communication deVcit such as aphasia; and, lastly honey thickened liquids are indicated for clients with a swallowing disorder and they are not indicated for clients with poor ne motor coordination.

• As the nurse in an ambulatory care area, you see a new client enter with a cane that appears

too short for the client. What should you do?

• Place the client in a wheelchair to protect their safety in the clinic.

• Remove the cane from the client to protect their safety.

• Teach the client about the proper length of a cane.

• Have the client use a wheelchair rather than the cane.

Correct Response: C

You should teach the client about the proper length of a cane. The proper length of the cane should be the length that only permits the client’s elbow to be slightly Vexed. Some canes like a wooden cane are not adjustable to the client’s height and others can be adjusted to meet the height needs of the client.

You would not place the client in a wheelchair or ask the client to use a wheelchair and you would also not take the cane, which is their personal property, away from them. You would use this observation as a learning need assessment and, as such, you should teach the client about the proper length of a cane and help them to adjust the height of the cane if the client’s cane is a height adjustable one.

• You are caring for a post-operative client who is complaining of abdominal distention

and atus. Which intervention would you most likely do for this client?

• A cleansing enema

• A retention enema

• A return-Vow enema

• A laxative

Correct Response: C

The most likely intervention for this client, after getting a doctor’s order, is a return ow enema. Return- ow enemas, similar to a carminative enema, are used to relieve atus and stimulate peristalsis which is frequently a problem after a client has received anesthesia.

Cleansing enemas are used to relieve constipation; and a retention enema is used to administer a medication, to soften stool and to lubricate the rectum so that it is easier and more comfortable for the client to defecate.

Finally, the data in this question does not indicate that the client is constipated and in need of

a laxative.

• Which of the following is a commonality that is shared in terms of both restraints

and urinary catheters?

• Both can lead to infection.

• Both are invasive procedures.

• Both are considered sentinel.

• Both are the last resort.

Correct Response: D

The commonality that is shared in terms of both restraints and urinary catheters is that both

are the last, not the rst, treatment of choice. Both indwelling urinary catheters and restraints pose risks and complication; therefore, both of these interventions must be prevented with the use of preventive measures.

Indwelling urinary catheters are invasive but restraints are not invasive; indwelling urinary catheters can lead to infection but restraints do not. Lastly, neither are sentinel. A sentinel event is an event or occurrence, incident or accident that has led to or may have possibly