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After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?
- A. Ask the client to remain quiet so the procedure can be performed safely.
- B. Concentrate on completing the insertion as efficiently as possible.
- C. Calmly reassure the client that the discomfort will be temporary.
- D. Tell the client a joke as a means of distraction from the procedure.
Correct Answer: C
Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.
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Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?
- A. Asking to speak to someone
- B. Asking to be alone
- C. Listening to music
- D. All of the above
Correct Answer: D
Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.
During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?
- A. Reassure the client that many obese individuals have concerns about sex.
- B. Remind the client that sexual relationships can remain unaffected by obesity.
- C. Determine the frequency of sexual intercourse.
- D. Ask the client to talk about specific concerns.
Correct Answer: D
Rationale: Option D is the best response as it allows the client to express her specific concerns, providing the nurse with valuable assessment data. This open-ended question encourages the client to share her worries and feelings, which can guide the nurse in addressing her unique needs. Options A and B make assumptions about the client's concerns based on her weight, potentially invalidating her feelings and inhibiting effective communication. Option C is premature as understanding the client's concerns should precede discussions about the frequency of sexual intercourse, which may not address the core issues the client is facing.
The client with partial-thickness (second-degree) and full-thickness (third-degree) burns is at risk of infection. What intervention has the highest priority in decreasing the client's risk of infection?
- A. Administration of plasma expanders
- B. Use of careful handwashing technique
- C. Application of a topical antibacterial cream
- D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: The correct answer is the use of careful handwashing technique. Proper handwashing is the most effective way to prevent the transmission of infectious organisms. Option A, administration of plasma expanders, addresses hypovolemia in burn patients but does not directly decrease the risk of infection. Option C, application of a topical antibacterial cream, is beneficial but not as effective as proper handwashing in preventing infection. Option D, limiting visitors, may help reduce the risk of exposure to pathogens but is not as critical as ensuring healthcare providers maintain strict hand hygiene, which is the cornerstone of infection control in any healthcare setting.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
- A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
- B. Notify the healthcare provider and request a prescription for a large-volume enema.
- C. Assess the client's medical record to determine the client's normal bowel pattern.
- D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
Correct Answer: C
Rationale: The first step in addressing a client's reported change in bowel habits is to assess the client's normal bowel pattern. This assessment helps the nurse understand the client's typical bowel habits and identify any deviations from the norm. By assessing the medical record first, the nurse gains valuable information that guides further interventions. In this scenario, offering prune juice (Option A) or increasing fluids (Option D) may not be appropriate until the client's normal bowel pattern is known. Notifying the healthcare provider for a large-volume enema (Option B) is premature without understanding the client's baseline. Therefore, assessing the client's medical record is the priority before proceeding with any interventions.
In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the healthcare provider as soon as possible?
- A. Daily black, sticky stool
- B. Daily dark brown stool
- C. Firm brown stool every other day
- D. Soft light brown stool twice a day
Correct Answer: A
Rationale: The correct answer is 'Daily black, sticky stool.' Black sticky stool (melena) is indicative of gastrointestinal bleeding, a serious condition that requires immediate attention from the healthcare provider. Options B and D, 'Daily dark brown stool' and 'Soft light brown stool twice a day,' respectively, represent variations of normal stool characteristics and do not raise immediate concerns about the client's health. Option C, 'Firm brown stool every other day,' suggests constipation, which is of lesser concern and can be managed with interventions.