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A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?
- A. Role ambiguity
- B. Sick role
- C. Role overload
- D. Role conflict
Correct Answer: C
Rationale: The correct answer is C: Role overload. Role overload occurs when an individual feels overwhelmed by the demands of multiple roles, leading to stress and difficulty in managing responsibilities. In this scenario, the partner is struggling to balance caring for their partner with dementia and managing household responsibilities, indicating an excessive workload.
A: Role ambiguity refers to uncertainty about expectations and responsibilities in a role, which is not evident in the scenario.
B: Sick role pertains to the behavior and expectations of individuals who are ill, which is not the focus of the partner's stress.
D: Role conflict involves conflicting demands from different roles, which is not the primary issue in this situation.
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A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
- A. I can place an extension cord across my living room to plug in my television.
- B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
- C. I will place my alarm clock on my bedroom dresser across the room.
- D. I will replace the old throw rug in my kitchen with a new one.
Correct Answer: B
Rationale: Correct Answer: B - "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
Rationale: This statement demonstrates understanding as it shows awareness of potential hazards (low-hanging tree) that could obstruct safe walker use. By hiring someone to trim the tree, the client is proactively ensuring a safe environment for mobility with the walker.
Summary of Incorrect Choices:
A: Placing an extension cord across the living room poses a tripping hazard, which is unsafe for walker use.
C: Placing the alarm clock on the bedroom dresser is unrelated to walker safety.
D: Replacing the throw rug in the kitchen is beneficial but not directly related to walker safety.
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
- A. Advocacy ensures clients' safety health and rights
- B. Advocacy ensures that nurses are able to explain their own actions.
- C. Advocacy ensures that nurses follow through on their promises to clients.
- D. Advocacy ensures fairness in client care delivery and use of resources.
Correct Answer: A
Rationale: The correct answer is A because advocacy in nursing involves actively supporting and promoting clients' safety, health, and rights. Advocacy ensures that nurses prioritize the well-being and best interests of their clients, advocating for their needs and empowering them to make informed decisions about their care. The other choices are incorrect because B focuses on self-explanation rather than client-centered advocacy, C is more about accountability than advocacy, and D touches on fairness but does not directly address the core concept of advocacy for clients' safety, health, and rights.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.