Nokea
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?
- A. Nonverbal communication conveys less truth than what the client states verbally.
- B. The client's sociocultural background influences nonverbal communication.
- C. Nonverbal communication is a poor reflection of what the client feels.
- D. The client enacts nonverbal communication consciously.
Correct Answer: B
Rationale: The correct answer is B: The client's sociocultural background influences nonverbal communication. Nonverbal communication is greatly impacted by an individual's cultural norms, values, and beliefs. This influences gestures, facial expressions, posture, and personal space preferences. Understanding the client's sociocultural background helps the nurse interpret nonverbal cues accurately.
Choice A is incorrect because nonverbal communication can often convey more truth than verbal statements as it can be more spontaneous and genuine. Choice C is incorrect because nonverbal behavior can provide valuable insights into a client's true feelings and emotions. Choice D is incorrect because nonverbal communication is often unconscious and can be influenced by subconscious factors.
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A nurse is reinforcing teaching with a newly licensed nurse about respecting a client's personal space. The nurse should include in the teaching that which of the following actions require client consent? (Select all that apply.)
- A. Removing the client's dentures
- B. Checking capillary refill of the client's finger
- C. Palpating for pedal edema
- D. Taking a radial pulse
- E. Observing a mole on the client's shoulder
Correct Answer: A, C
Rationale: Actions that involve physical touch or intrusion into personal space, such as removing dentures or palpating edema, require consent.
A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)
- A. Remove every other staple.
- B. Wipe cleansing solution directly over the surgical incision.
- C. Remove remaining staples.
- D. Remove the wound dressing.
- E. Clean the skin along the sides of the incision.
Correct Answer: D, E, A, C, B
Rationale: First, remove the wound dressing to expose the incision. Then, clean the skin along the sides to reduce infection risk. Next, remove every other staple to maintain stability before removing the remaining ones. Finally, wipe cleansing solution to keep the site clean.
A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. A client who has NPO status since midnight for an endoscopy
- B. A client who has heart failure and is receiving diuretic therapy
- C. A client who has end-stage kidney disease who will undergo dialysis
- D. A client who has gastroenteritis and is receiving oral fluids
Correct Answer: B
Rationale: The correct answer is B: A client who has heart failure and is receiving diuretic therapy. In heart failure, the heart's ability to pump blood effectively is compromised, leading to fluid retention. Diuretics are prescribed to reduce fluid overload by increasing urine output. This process can potentially lead to fluid volume deficit if excessive fluid is removed. Clients with heart failure on diuretics are at risk for electrolyte imbalances and dehydration.
A: NPO status for an endoscopy does not necessarily indicate fluid volume deficit.
C: Clients with end-stage kidney disease undergoing dialysis are at risk for fluid volume overload due to the accumulation of waste products and fluid in the body.
D: Clients with gastroenteritis receiving oral fluids are typically at risk for fluid volume deficit, but the scenario does not provide enough information to confirm this as the correct choice.
In summary, choice B is correct because clients with heart failure on diuretics are at risk for fluid volume deficit due to the medication
A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Grape juice
- B. Lemon sherbet
- C. Skim milk
- D. Carrot juice
Correct Answer: A
Rationale: The correct answer is A: Grape juice. A clear liquid diet includes transparent liquids like water, broth, tea, and clear juices without pulp. Grape juice fits this criteria as it is a clear liquid that is easily digestible. Lemon sherbet (B) contains dairy and solid components, not suitable for a clear liquid diet. Skim milk (C) is a dairy product and not transparent. Carrot juice (D) has pulp and is not considered a clear liquid.
A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.