Nokea
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
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A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, 'If you don't eat, I'll put restraints on your wrists and feed you.' The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault is the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client and force-feeding them constitutes a threat of harm, which is considered assault. This is inappropriate behavior and violates the client's autonomy. Battery (choice A) involves actual harmful or offensive contact, which is not present in this situation. Negligence (choice C) refers to a failure to exercise reasonable care, which is not applicable here. Malpractice (choice D) involves professional negligence or misconduct, which is also not relevant in this context.
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
- A. Provide frequent rest periods for the client
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions.
- D. Place the client on a low-carbohydrate diet
- E. Instruct the client to avoid blowing their nose forcefully
- F. Assess the client's level of orientation.
Correct Answer: A,B,C,E,F
Rationale: The correct actions for the nurse to take are A, B, C, E, and F. Providing rest periods (A) promotes healing and recovery. Restricting sodium intake (B) is important for certain conditions like hypertension. Advising the client to avoid soap and alcohol-based lotions (C) can prevent skin irritation. Instructing the client to avoid blowing their nose forcefully (E) prevents potential harm to nasal passages. Assessing the client's level of orientation (F) is crucial for monitoring mental status and detecting any changes. These actions prioritize the client's well-being, safety, and overall health.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place a container for soiled linens inside the client's room. This intervention is important to prevent the spread of infection. Placing a container for soiled linens inside the client's room ensures that contaminated linens are contained and not mixed with other linens, reducing the risk of transmitting the infection to others.
Rationale for why other choices are incorrect:
A: Wearing an N95 mask is not necessary unless the client has airborne precautions, such as tuberculosis.
C: Placing the client in a negative airflow room is typically reserved for clients with airborne infections to prevent the spread of droplet nuclei in the air.
D: Removing the mask after exiting the client's room is incorrect as the mask should be removed before exiting to prevent contamination outside the room.
In summary, choice B is correct as it directly addresses infection control measures related to soiled linens, while the other choices are not relevant to isolation precautions or are incorrect based on standard
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. This is the correct action as it validates the client's feelings and provides reassurance that anger is a common emotion when dealing with a cancer diagnosis. By acknowledging the client's emotions, the nurse can build trust and support the client through the grieving process.
A: Discussing risk factors is not the priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage.
C: Providing written information about loss and grief phases may not address the client's current emotional state.
In summary, option D is the best choice as it acknowledges the client's feelings and offers support during a difficult time.
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
- A. Examine personal values about the issue.
- B. Tell the parents that this is a necessary procedure.
- C. Inform the parents that the staff does not require their consent.
- D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A
Rationale: The correct answer is A: Examine personal values about the issue. The nurse should reflect on their own beliefs and values to ensure they can provide unbiased care. This step is essential to maintain professionalism and respect for the parents' autonomy. It allows the nurse to approach the situation with empathy and understanding.
B: Telling the parents that the procedure is necessary may come off as dismissive of their beliefs and could create conflict.
C: Informing the parents that staff does not require their consent is unethical and goes against the child's and parents' rights. It disregards their autonomy.
D: Contacting a spiritual support person may be helpful, but it should not be the first step. The nurse should first address their own values and then involve spiritual support if needed.
In summary, option A is the best course of action as it promotes respectful and patient-centered care.