Nokea
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
- A. Biofeedback
- B. Deep breathing
- C. Distraction
- D. Imagery
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
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The UAP is caring for the client who has been placed in bilateral wrist restraints. Which direction should the nurse give to the UAP?
- A. "The wrist restraint must remain on at all times but can be loosened if needed."
- B. "The client attempted to harm staff; only enter the room with another person."
- C. "Ask the client about the need for toileting and offer liquids every two hours."
- D. "Assess the client's skin condition and provide hand exercises every two hours."
Correct Answer: C
Rationale: The UAP should check toileting and hydration needs every two hours, as the restrained client cannot manage these independently. Skin assessment (D) is beyond UAP scope.
The nurse is preparing a presentation on workplace incivility. Which incivility behaviors should the nurse plan to include in the presentation? Select all that apply.
- A. Verbal intimidation of nurses and invasion of personal space by HCPs.
- B. Personal insults, then ignoring a person as if that person is not present.
- C. Discussion between the nurse and HCPs about the client's condition.
- D. Teasing that occurs between nurses, HCPs, or other employees.
- E. Reporting the behaviors using the facility's incivility report form.
Correct Answer: A,B,D
Rationale: A: Verbal intimidation and space invasion are uncivil. B: Insults and ignoring are uncivil behaviors. D: Teasing can be disrespectful and uncivil. C and E are not behaviors but actions.
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
- A. I must document and report any information.
- B. I can't make such a promise.
- C. That depends on what you tell me.
- D. I must report everything to the treatment team.
Correct Answer: B
Rationale: Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
Which of these instructions should the nurse include when preparing a client for a radioactive iodine (I-131) uptake test and treatment for hyperthyroidism?
- A. Avoid taking aspirin for 3 days prior to the test.'
- B. You may eat a light breakfast on the morning of the test.'
- C. Expect to stay in the hospital for 24 hours after treatment.'
- D. In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation.'
Correct Answer: A
Rationale: In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation. The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours.
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?
- A. I am sorry. Referral information can only be provided by the client's providers
- B. I can never give any information out by telephone. How do I know who you are?
- C. Since this is a referral, I can give you this information
- D. I need to get the client's written consent before I release any information to you
Correct Answer: D
Rationale: In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared.