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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.
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In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next?
- A. Witness the client's signature on the permit.
- B. Answer the client's questions about the surgery.
- C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
- D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to inform the surgeon that the operative permit is not signed and that the client has questions about the surgery. It is the responsibility of the surgeon to explain the procedure to the client and obtain the client's signature on the permit. While the nurse can witness the client's signature on the permit, the procedure must first be explained by the healthcare provider or surgeon, including addressing the client's questions. Therefore, informing the surgeon is the priority to ensure proper communication and consent before the surgery. Answering the client's questions about the surgery (Choice B) may not provide accurate information and could lead to misunderstanding. Reassuring the client (Choice D) is important, but obtaining proper consent and addressing concerns should come first. Witnessing the client's signature (Choice A) is not sufficient if the client has unanswered questions and the permit is not signed.
The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands which to be correct regarding group therapy?
- A. The termination stage begins with the initial group meeting.
- B. Members' feelings about their accomplishments are explored in the working stage.
- C. During the working stage, members may be unclear about the purpose of the group.
- D. Group roles and responsibilities are established in the working stage of group therapy.
Correct Answer: D
Rationale: In group therapy, roles and responsibilities are established during the working stage, as members actively engage. Termination (A) occurs at the end, feelings about accomplishments (B) are explored in termination, and unclarity about purpose (C) occurs in the forming stage.
The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
- A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
- B. Sit quietly in the client's room until the client leaves the bathroom.
- C. Allow the client to cry alone and leave the client in the bathroom.
- D. Talk to the client and attempt to find out why the client is crying.
Correct Answer: D
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.
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.
When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?
- A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
- B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
- C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
- D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.
Correct Answer: B
Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.