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The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, 'I really miss eating dinner with my family.' Which statement from the nurse is the most therapeutic?
- A. What you are feeling is very common.'
- B. Tell me more about your family dinners.'
- C. In a few weeks, you may be allowed to eat.'
- D. You can sit down to dinner even if you do not eat.'
Correct Answer: B
Rationale: The nurse assists the client with expressing feelings and dealing with the aspects of illness and treatment by clarifying and helping the client to focus on and explore concerns. In option 1, the nurse characterizes and classifies the feelings on the basis of an assumption. Option 3 provides false hope and option 4 blocks communication by giving advice.
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When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct Answer: A
Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.
The nurse is teaching a group of women at a community center about risk factors for spousal abuse. Which would the nurse identify as risk factors? Select all that apply.
- A. alcohol or drug use
- B. low income or poverty
- C. being over the age of 40
- D. a higher level of education
- E. having a large circle of friends
- F. pregnancy, especially if it is unplanned
Correct Answer: A,B,F
Rationale: Alcohol/drug use, poverty, and unplanned pregnancy are established risk factors for spousal abuse. Age, education, and social circles are not specific risk factors.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Flush with normal saline and recount the drop rate.
Correct Answer: B
Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.
A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
- A. Pulse characteristics
- B. Open airway
- C. Entrance and exit wounds
- D. Cervical spine injury
Correct Answer: A
Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.
A charge nurse observes an unlicensed assistive personnel (UAP) talking in an unusually loud voice to a client with schizophrenia experiencing delirium. Which priority action should the charge nurse take?
- A. Enter the room and inform the client that everything is all right.
- B. Speak to the UAP immediately while in the client's room to solve the problem.
- C. Ensure the client's safety, calmly ask the UAP to step outside the room, and inform the UAP that her or his voice was unusually loud.
- D. Explain to the UAP that speaking so loudly is tolerated only if the client is talking loudly and the UAP needs to get the client's attention.
Correct Answer: C
Rationale: The nurse must ascertain that the client is safe and then discuss the matter with the UAP in an area away from the hearing of the client. If the client hears the conversation, the client may become more confused or agitated. The remaining options are incorrect actions for this situation.