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A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?'
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response acknowledges the client's feelings and initiates a discussion about the potential impact of retirement on their well-being. It shows empathy and encourages open communication, allowing the nurse to explore the client's concerns and fears about retirement. This approach promotes client-centered care and helps the nurse understand the client's perspective better.
Choices A, B, and D are incorrect because they do not address the client's feelings or concerns directly. Option A assumes the client's main motivation for retirement is to spend time with family, which may not be the case. Option B and D provide suggestions without first understanding the client's thoughts and emotions, potentially dismissing their feelings. It is essential to prioritize the client's autonomy and individual needs in such discussions.
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A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A: Remove the cap and place it sterile-side up on a clean surface. This is essential to maintain the sterility of the solution and prevent contamination. Placing the cap sterile-side up ensures that the inside of the cap, which will come in contact with the solution again, remains sterile. Placing it on a clean surface prevents contamination from the surface. Options B, C, and D do not directly address maintaining the sterility of the solution. Option B is about spill management within the sterile field, which is important but not the primary concern when pouring the solution. Holding the bottle in the center (Option C) or with the label facing away (Option D) does not directly impact the sterility of the solution.
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
- A. I know that I can change my advance directives if needed in the future.
- B. My healthcare proxy will make decisions as soon as I sign the power of attorney.
- C. My family can overrule the decisions made by my healthcare proxy.
- D. Advance directives from one state are valid in any other state.
Correct Answer: A
Rationale: Rationale: Option A is correct because it shows the client understands that advance directives can be modified. This is crucial as preferences may change over time. Option B is incorrect as the healthcare proxy only makes decisions when the client cannot. Option C is incorrect as the healthcare proxy's decisions are legally binding. Option D is incorrect because advance directives must comply with state laws and may not be universally recognized.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle of doing good or promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by actively seeking to alleviate the client's suffering and promoting their emotional well-being.
Rationale for why the other choices are incorrect:
A: Fidelity relates to the nurse's obligation to be faithful and keep promises made to the client, which is not directly demonstrated in this scenario.
B: Veracity is the principle of truthfulness, which is not the primary focus of the nurse's actions in this situation.
C: Autonomy refers to respecting the client's right to make their own decisions, which is not the main principle being demonstrated when the nurse is providing comfort and support.
E, F, G: These choices are not provided, but based on the context of the scenario, they are not relevant to the nurse's actions in providing comfort
For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn’s disease.
- A. Fever
- B. Steatorrhea
- C. Anemia
- D. Weight loss
- E. Diarrhea
Correct Answer: A, B, C, D
Rationale: To determine which assessment findings are consistent with ulcerative colitis, diverticulitis, or Crohn's disease, we need to analyze the characteristics of each condition.
1. Fever : This finding can be seen in all three conditions, but it is more commonly associated with Crohn's disease due to the inflammatory nature of the disease.
2. Steatorrhea (B): This is a common symptom of Crohn's disease due to malabsorption issues, making it a key indicator for this condition.
3. Anemia (C): Anemia is a common complication of inflammatory bowel diseases like ulcerative colitis and Crohn's disease, often related to chronic inflammation and blood loss.
4. Weight loss (D): This is a common feature of all three conditions due to malabsorption, decreased appetite, and chronic inflammation.
Therefore, the correct answer is A, B, C, D as these findings are consistent with all three conditions. Diarrhea (E