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Which of the following actions should the nurse Include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Use a face shield with a mask when providing care to the client.
- B. Tell the client.You seem to be very upset.""
- C. Engage the panic alarm:
- D. Initiate seclusion protocol
Correct Answer: B
Rationale: The correct answer is B because acknowledging the client's emotions can help de-escalate the situation. By stating, "You seem to be very upset," the nurse shows empathy and understanding, which can help the client feel heard and validated. Using a face shield, engaging the panic alarm, or initiating seclusion protocol are not appropriate actions in this scenario as they do not address the client's emotional state or help in calming them down. Face shield and panic alarm are more related to safety precautions, while seclusion protocol should only be considered as a last resort for safety reasons. Therefore, choice B is the most appropriate action for interacting with a client who is aggravated, pacing, and speaking loudly.
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Which of the following findings should the nurse expect?
- A. The client is oriented times three
- B. The client opens eyes to sound.
- C. The client is unable to obey commands.
- D. The client withdraws from pain
Correct Answer: A
Rationale: The correct answer is A: The client is oriented times three. This indicates that the client is alert and aware of person, place, and time. This finding is crucial in assessing the client's mental status and cognitive function. Opening eyes to sound (B) is a basic response but does not indicate orientation. Inability to obey commands (C) suggests altered mental status. Withdrawing from pain (D) may indicate a physical reflex rather than cognitive function. Overall, being oriented times three is the most comprehensive assessment of mental alertness and cognitive function.
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Apply suction while rotating the catheter.
- B. Rinse the catheter to remove secretions:
- C. Dan sterile gloves.
- D. Insert the catheter during the client's inspiration.
- E. Turn on the suction and set the pressure
Correct Answer: C,D,E,A,B
Rationale: To perform nasotracheal suctioning correctly, the nurse should follow these steps:
1. Dan sterile gloves (C): Ensures aseptic technique to prevent infection.
2. Insert the catheter during the client's inspiration (D): Reduces the risk of hypoxia and trauma.
3. Turn on the suction and set the pressure (E): Prepares the equipment for suctioning.
4. Apply suction while rotating the catheter (A): Maximizes removal of secretions.
5. Rinse the catheter to remove secretions (B): Ensures cleanliness of the catheter for next use.
Other choices are incorrect:
- F and G are not applicable in this sequence as they do not contribute to the safe and effective performance of nasotracheal suctioning.
Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: The correct answer is B: Advance directives can be signed without legal representation. This is correct because advance directives are legal documents that individuals can complete on their own without the need for a lawyer. They allow individuals to specify their healthcare wishes in advance. Choice A is incorrect as medical care can be initiated regardless of advance directives. Choice C is incorrect as advance directives must be in writing to be legally valid. Choice D is incorrect as social workers typically provide support but do not usually offer legal representation.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings
- D. Discourage the client from coughing during feedings
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This is important for clients with dysphagia as it helps facilitate safe swallowing by promoting proper alignment of the head and neck. Sitting at or below the client's eye level reduces the risk of aspiration and choking during feeding. This position also allows the nurse to closely monitor the client for signs of difficulty swallowing.
Choice A is incorrect because instructing the client to lift her chin when swallowing can actually increase the risk of aspiration in individuals with dysphagia. Choice B is incorrect as talking with the client during feeding may distract them and increase the risk of swallowing difficulties. Choice D is incorrect because coughing is a protective mechanism that helps clear the airway, so discouraging coughing during feedings is not recommended for clients with dysphagia.
Select the 3 statements the nurse should include in the teaching.
- A. Notify your provider if you experience vomiting or diarrhea.
- B. Limit alcohol intake to no more than one drink per day
- C. You should eat foods that are low in fat.
- D. You can drink beverages that contain caffeine.
- E. You should eat foods highs in protein.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A is important as vomiting and diarrhea can lead to dehydration. B is crucial for liver health and overall well-being. C is essential for heart health and maintaining a healthy weight. The other choices are incorrect. D can worsen symptoms and interfere with medication. E may not be suitable for certain health conditions and can lead to weight gain. No information is provided for options F and G.