Nokea
A nurse is planning care for a new client. Which of the following actions should the nurse plan to take in order to use the technique of presence to establish the nurse-client relationship?
- A. Telephones the client at his home prior to admission to make an introduction.
- B. Dominate the conversation to reduce the client's anxiety.
- C. Share stories about personal experiences with the client.
- D. Use active listening when with the client.
Correct Answer: D
Rationale: Using active listening helps establish presence by showing genuine interest and attention to the client.
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A nurse is reviewing the plan of care for a client who has a respiratory infection. The nurse should plan to have the client lie on his stomach with pillows elevating his chest and stomach to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: C
Rationale: Prone positioning with elevation allows mucus drainage from posterior lung segments.
A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
- A. Move body parts rapidly through the movements.
- B. Support extremities above and below joints.
- C. Stretch the body part just beyond the existing range of motion.
- D. Continue moving body parts if muscle spasticity occurs.
Correct Answer: B
Rationale: The correct answer is B: Support extremities above and below joints. This is because supporting the extremities above and below the joints helps to maintain proper alignment and stability during passive range of motion exercises, preventing injury and ensuring effective movement. Moving body parts rapidly (choice A) can cause muscle strain or injury. Stretching the body part beyond existing range (choice C) can lead to muscle or ligament damage. Continuing movement if spasticity occurs (choice D) can exacerbate muscle tightness. This is why choice B is the most appropriate action to take during passive range of motion exercises.
A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?
- A. Non-palpable spleen
- B. Slightly moist skin
- C. Presence of surface papillae on tongue
- D. Depigmented hair
Correct Answer: D
Rationale: The correct answer is D: Depigmented hair. Malnutrition can lead to changes in hair color and texture, resulting in depigmented or thinning hair. This is due to the body lacking essential nutrients needed for healthy hair growth. Non-palpable spleen (A) is not typically associated with malnutrition. Slightly moist skin (B) is more likely to be seen in a well-nourished individual. Presence of surface papillae on the tongue (C) is not a common manifestation of malnutrition. Therefore, depigmented hair (D) is the most likely manifestation of malnutrition in this scenario.
While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?
- A. A systolic murmur
- B. A third heart sound (S3)
- C. An expected heart sound
- D. A fourth heart sound (S4)
Correct Answer: A
Rationale: The correct answer is A: A systolic murmur. Turbulence between S1 and S2 indicates a heart sound occurring during systole. Systolic murmurs are abnormal heart sounds heard between S1 and S2, often indicating a problem with the heart valves. S3 and S4 heart sounds occur after S2 and are associated with ventricular filling abnormalities. An expected heart sound would not exhibit turbulence. Therefore, the correct choice is A.
A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
- A. Chlorhexidine washes
- B. Urinary catheterization
- C. Malnutrition
- D. Multiple caregivers
Correct Answer: B
Rationale: The correct answer is B: Urinary catheterization. This is a common cause of HAIs due to the introduction of bacteria into the urinary tract. Catheters provide a direct pathway for bacteria to enter the body, leading to infections such as urinary tract infections. The other choices are incorrect because:
A: Chlorhexidine washes are actually used to prevent infections by killing bacteria on the skin.
C: Malnutrition can weaken the immune system and make individuals more susceptible to infections, but it is not a direct cause of HAIs.
D: Multiple caregivers can increase the risk of infections if proper hygiene practices are not followed, but it is not a specific cause of HAIs like urinary catheterization.