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A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:
- A. Reinforce the nursing assistant's use of this intervention over the bony prominence.
- B. Explain to the nursing assistant that massage is effective because it improves blood flow to the area.
- C. Inform the nursing assistant that massage is even more effective when combined with the use of lotion.
- D. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massage over a reddened area on a bony prominence is contraindicated as it can further damage tissue and reduce blood flow, increasing the risk of pressure ulcers. The nurse should instruct the assistant to stop massaging the area to prevent harm.
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When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
- A. That there was adequate disclosure of information.
- B. That the client understood the information.
- C. That there was voluntary consent on the client's part.
- D. That the client has full awareness of the potential complications.
- E. That the client's relative, spouse or legal guardian was present.
Correct Answer: A,B,C,D
Rationale: Informed consent requires adequate disclosure, client understanding, voluntary consent, and awareness of complications. A relative's presence is not mandatory unless the client is incapacitated.
The primary distinguishing characteristic of risk management when compared and contrasted to performance improvement is that risk management activities focus on:
- A. Historical data and performance improvement activities focus on current data.
- B. Current data and performance improvement activities focus on historical data.
- C. Decreasing financial liability and performance improvement activities focus on process improvements.
- D. Decreasing falls and performance improvement activities focus on process improvements.
Correct Answer: C
Rationale: Risk management focuses on decreasing financial liability by mitigating risks, while performance improvement focuses on enhancing processes and outcomes.
A nurse is having difficulty establishing a relationship with an aggressive client. What strategy will most likely improve the relationship?
- A. The nurse and the client agree to work to improve their involvement in the therapeutic relationship.
- B. The nurse establishes goals for having only positive interactions with the client.
- C. The nurse agrees to be submissive so the client can dominate the relationship.
- D. The nurse seeks assistance from colleagues to become more aware of the quality of the interactions and more sensitive to the dynamics of communication.
Correct Answer: D
Rationale: Seeking colleague assistance enhances self-awareness and communication skills, improving the therapeutic relationship with an aggressive client.
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
- A. Extremities warm to touch.
- B. Improved respiratory status.
- C. Decreased muscle pain with activity.
- D. Participation in self-care measures.
- E. Lungs clear to auscultation.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
A 9-year-old child is scheduled for an electromyelogram. To prepare the child for this procedure, what should the nurse do?
- A. Wait until just before the test to tell the child what will be done.
- B. Ask the child to draw a picture of the body structures involved.
- C. Show the child the equipment that will be used in the test.
- D. Verbally explain what will be done during the test.
Correct Answer: D
Rationale: A verbal explanation in age-appropriate terms helps a 9-year-old understand the procedure, reducing anxiety and promoting cooperation.