Nokea
Which of the following interventions is most appropriate when working with the family of a client who is being treated for substance abuse?
- A. Advocate for the client before the family
- B. Provide referrals for community resources and support groups
- C. Take the side of the family before the client
- D. Both B and C
Correct Answer: B
Rationale: When working with the family of a client undergoing substance abuse treatment, it is crucial to support not only the client but also their family. Providing referrals for community resources and support groups is an effective intervention as it helps the family access additional support and information to cope with the challenges related to the client's substance abuse. This empowers the family to enhance their understanding of the situation and develop effective coping strategies. Advocating for the client before the family (choice A) may lead to conflicts and hinder the therapeutic process, while taking the side of the family before the client (choice C) can jeopardize the client's progress and trust. Therefore, the most appropriate intervention in this scenario is to provide referrals for community resources and support groups to ensure holistic care for both the client and their family.
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When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she 'can't handle' the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent?
- A. The family cannot provide the consent required in this situation as the older adult is capable of making decisions.
- B. The son cannot waive informed consent for the client since there is no evidence of mental incompetence.
- C. The court will not allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
- D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.
Correct Answer: D
Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so the family cannot provide consent without her involvement, making option A incorrect. There is no evidence of mental incompetence in the client, so the son cannot waive informed consent, making option B incorrect. While therapeutic privilege may have been accepted in the past, it is unlikely to be upheld by today's courts, making option C incorrect. It is crucial for health care providers to obtain informed consent from clients before proceeding with any treatment to avoid legal consequences and uphold ethical standards.
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
- A. Perform cough and deep breathing exercises hourly.
- B. Turn from side to side in bed at least every 2 hours.
- C. Dorsiflex and plantarflex the feet 10 times each hour
- D. Drink approximately 4 ounces of water every hour
Correct Answer: C
Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.
Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?
- A. Make the client comfortable and allow the client to sleep.
- B. Assess the client's neurologic status.
- C. Notify the surgeon about the comment.
- D. Ask the client's family to co-sign the operative permit.
Correct Answer: B
Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.
What nonverbal action should the nurse implement to demonstrate active listening?
- A. Sit facing the client.
- B. Cross arms and legs.
- C. Avoid eye contact.
- D. Lean back in the chair.
Correct Answer: A
Rationale: Active listening is effectively demonstrated through attentive verbal and nonverbal communication strategies. To convey active listening and show the client that the nurse is engaged and attentive, it is essential for the nurse to sit facing the client. This posture communicates openness and willingness to listen. Option B, crossing arms and legs, creates a barrier and can signal defensiveness or disinterest, making it an incorrect choice. Option C, avoiding eye contact, hinders the establishment of a connection and can convey disengagement. Option D, leaning back in the chair, may give the impression of disinterest or lack of engagement. Therefore, maintaining eye contact and sitting facing the client are crucial nonverbal actions to exhibit active listening and promote effective therapeutic communication.
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
- A. Remind the child to clean his genital area.
- B. Defer perineal care because of the child's age.
- C. Retract the foreskin gently to cleanse the penis
- D. Ask the parents why the child is not circumcised
Correct Answer: C
Rationale: When bathing an uncircumcised boy older than 3 years, it is essential to gently retract the foreskin to cleanse the penis. This helps in preventing the buildup of bacteria and maintaining good hygiene. Reminding the child to clean his genital area (Option A) may not be effective due to the child's cognitive development level. Perineal care should not be deferred (Option B) as it is necessary for maintaining hygiene at any age. Asking the parents why the child is not circumcised (Option D) is not relevant to the immediate care required during bathing.