A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
- A. Requesting a referral for the client to attend reminiscent therapy sessions
- B. Reorienting the client several times throughout the day
- C. Providing assistance for the client when ambulating down the hall
- D. Performing an updated cognitive assessment on the client
Correct Answer: A
Rationale: Requesting reminiscent therapy promotes the client's cognitive function and dignity, aligning with advocacy by prioritizing their best interests.
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A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
- A. It's not too late to cancel the surgery if you want to.
- B. This won't take long and it will be over before you know it.
- C. Why did you make the decision to have this procedure?
- D. You shouldn't be worried because the procedure is very safe.
Correct Answer: A
Rationale: Correct Answer: A. "It's not too late to cancel the surgery if you want to."
Rationale: This response acknowledges the client's emotions and empowers her to make a decision based on her feelings. It shows empathy and respect for her autonomy in making choices about her own body.
Summary of Other Choices:
B: This response dismisses the client's emotions and may come off as insensitive.
C: Asking why the client made the decision can be perceived as judgmental and may increase anxiety.
D: This response invalidates the client's feelings and may not provide reassurance effectively.
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
- A. I'm having difficulty climbing the stairs at my house.
- B. I am tired of having pain in my joints all the time.
- C. I will need assistance with bathing.
- D. I need some help planning my meals to maintain my weight.
Correct Answer: C
Rationale: Difficulty with bathing, an activity of daily living, indicates a need for occupational therapy to address functional limitations.
A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance. Which of the following actions should the nurse take?
- A. Request that the coworker complete an incident report.
- B. File an anonymous report of the incident to the nurse manager.
- C. Identify all witnesses to the incident.
- D. Document a factual account of the incident.
- E. Submit an incident report to the risk manager.
Correct Answer: B,C,D,E
Rationale: Filing an anonymous report, identifying witnesses, documenting the incident, and submitting a report ensure accountability and prevent recurrence without workplace tension.
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
- A. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.
- B. I will have a client who is on airborne precautions wear a mask when out of her room.
- C. I will wear an N95 respirator mask when caring for a client who is on droplet precautions.
- D. I will place a client who has compromised immunity in a negative-pressure airflow room.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of airborne precautions. Airborne precautions require clients to wear a mask when leaving their room to prevent the spread of infectious agents through the air. This statement aligns with the principle of protecting others from exposure.
Explanation for other choices:
A - Incorrect: Visitors, not clients, should wear masks on contact precautions to prevent the spread of infection to the client.
C - Incorrect: N95 respirator masks are used for airborne precautions, not droplet precautions.
D - Incorrect: Negative-pressure airflow rooms are used for clients on airborne precautions, not those with compromised immunity.
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