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A nurse manager is discussing the responsibility of nurses caring for clients who have Clostridium difficile. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system
- B. Use alcohol-based hand sanitizer when leaving the client's room
- C. Clean contaminated surfaces in the client's room with a phenol solution
- D. Have family members wear a gown and gloves when visiting
Correct Answer: D
Rationale: The correct answer is D because having family members wear a gown and gloves when visiting a client with Clostridium difficile is essential to prevent the spread of infection. Options A, B, and C are incorrect. Negative air-flow systems are not necessary for preventing the spread of C. difficile. While alcohol-based hand sanitizers are effective for routine hand hygiene, they may not be sufficient for C. difficile. Cleaning contaminated surfaces with a phenol solution is not the most effective method for preventing the spread of C. difficile, as spores can be resistant to many disinfectants.
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A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
- A. Increase in frequency of swallowing.
- B. Moderate sanguineous drainage on the drip pad.
- C. Bruising to the face.
- D. Absent gag reflex.
Correct Answer: A
Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.
A nurse is teaching a client who has Parkinson's disease about dietary modifications. Which of the following instructions should the nurse include?
- A. Eat high-protein, high-calorie meals
- B. Drink milk with every meal
- C. Avoid foods high in carbohydrates
- D. Drink carbonated beverages with meals
Correct Answer: A
Rationale: The correct answer is A: 'Eat high-protein, high-calorie meals.' Individuals with Parkinson's disease benefit from consuming high-protein, high-calorie meals to help maintain muscle mass and energy levels. This dietary modification is important in managing the symptoms of Parkinson's disease. Choice B is incorrect because there is no specific requirement for drinking milk with every meal for individuals with Parkinson's disease. Choice C is incorrect as carbohydrates are also essential for a balanced diet and should not be completely avoided. Choice D is incorrect as carbonated beverages may interfere with the absorption of nutrients from food and are not recommended for individuals with Parkinson's disease.
A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?
- A. Prepare a new dose of insulin injection
- B. Administer the insulin as it is
- C. Wipe the needle with an alcohol swab
- D. Ask the provider for guidance
Correct Answer: A
Rationale: The correct action for the nurse to take is to prepare a new dose of insulin injection. Accidentally brushing the needle on a contaminated surface can lead to infection risk. Administering the insulin as it is or just wiping the needle with an alcohol swab would not be sufficient to eliminate the risk of infection. Asking the provider for guidance is not necessary in this situation as the nurse can independently take the appropriate action to ensure patient safety.
A nurse is working in an acute care mental health facility and is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?
- A. All-or-nothing thinking.
- B. Euphoric mood.
- C. Disorganized speech.
- D. Hypochondriasis.
Correct Answer: C
Rationale: The correct answer is C: Disorganized speech. Disorganized speech is a hallmark symptom of schizophrenia, characterized by impaired thought processes that lead to incoherent, disjointed communication. All-or-nothing thinking (Choice A) is more commonly associated with cognitive distortions seen in conditions like anxiety disorders. Euphoric mood (Choice B) is not a typical finding in schizophrenia, as individuals with this disorder often display a flat or blunted affect. Hypochondriasis (Choice D) involves a preoccupation with having a serious illness and is not a primary symptom of schizophrenia.
What is the proper technique for measuring blood pressure manually?
- A. Use a stethoscope to listen for the Korotkoff sounds
- B. Ensure the patient is seated with the arm supported
- C. Use a manual sphygmomanometer
- D. Deflate the cuff slowly while listening to the heartbeat
Correct Answer: A
Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.