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A client is very anxious about receiving chest physiotherapy (CPT) for the first time at home. When planning for the client's care, which concept about CPT should the home care nurse use to reassure the client?
- A. CPT will help the client cough more often.
- B. There are no risks associated with this procedure.
- C. CPT will resolve all of the client's respiratory symptoms.
- D. CPT will assist with mobilizing secretions to enhance more effective breathing.
Correct Answer: D
Rationale: CPT is an intervention to assist with mobilizing and clearing secretions to enhance more effective breathing. CPT will assist the client with coughing if the secretions have been mobilized and the cough stimulus is present. There are risks associated with CPT, including cardiac, gastrointestinal, neurological, and pulmonary effects. It will not resolve all of the client's respiratory symptoms.
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When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct Answer: A
Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.
A mother brings her previously continent 6-year-old son to the pediatric clinic because he has resumed bedwetting. The nurse assesses the home environment and discovers that there is a new baby at home. Which explanation by the nurse best describes for the mother the defense mechanism the son is using?
- A. Regression
- B. Repression
- C. Identification
- D. Rationalization
Correct Answer: A
Rationale: The defense mechanism of regression is characterized by returning to an earlier form of expressing an impulse. Option 2 is characterized by blocking a wish or desire from conscious expression. Option 3 occurs when a person models behavior after someone else. Option 4 occurs when a person unconsciously falsifies an experience by giving a 'rational' explanation.
An older client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse develops a plan of care and should identify which psychosocial outcome as having the greatest impact on improving the client's cognitive abilities?
- A. Improved sleep patterns
- B. Reduced family fears and anxiety
- C. Meeting self-care needs independently
- D. Increased ability to concentrate and participate in care
Correct Answer: D
Rationale: The client needs to be able to concentrate and participate in her or his care. When the client is able to do that, the nurse can work with the client to achieve the other outcomes. Options 1 and 3 address physiological needs rather than psychosocial outcomes. Option 2 is a secondary need and does not address the client.
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
- A. administers medications as ordered
- B. uses gentle touch to reassure the client
- C. tells the client that others see or hear what he does
- D. distracts the client by placing him in the dayroom with others
- E. asks the client if he hears voices telling him to harm himself or others
- F. goes along with what the client says to decrease the risk of increasing the client's anxiety
Correct Answer: A,D,E
Rationale: Medications help manage hallucinations, distraction can reduce focus on hallucinations, and assessing for command hallucinations ensures safety. Touch may increase anxiety, reinforcing hallucinations is nontherapeutic, and going along with delusions can worsen confusion.
While obtaining a lie-sit-stand blood pressure reading on a client, what action is most important for the nurse to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct Answer: A
Rationale: The most crucial action for the nurse to implement when obtaining a lie-sit-stand blood pressure reading is to stay with the client while the client is standing. This is essential to monitor the client's immediate response to position changes and ensure their safety. Recording the findings on the graphic sheet is important for documentation but is not as critical as staying with the client. Keeping the blood pressure cuff on the same arm helps maintain consistency in readings but is not as vital as ensuring client safety. Recording changes in the client's pulse rate is important for a comprehensive assessment but does not take precedence over monitoring the client during position changes.