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The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?
- A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.
- B. Challenge members of the healthcare team whose opinions differ from the wishes of the client.
- C. Educate the client about current nursing literature findings related to the client's ethical dilemma.
- D. Listen to the ethics committee discussions and then inform the client what actions should be taken.
Correct Answer: A
Rationale: Self-awareness prevents bias in advocacy.
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The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. Foreskin should not be retracted.
- C. An erection may occur while providing care.
- D. Pubic area should be kept shaved.
Correct Answer: B
Rationale: Non-retractable foreskin should not be forced to prevent discomfort.
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.
A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?
- A. Include caregiver in discussion of pain relief strategies.
- B. Encourage the client to talk about her fear related to pain.
- C. Explain that analgesics will be given whenever needed.
- D. Provide therapeutic touch along with comfort and support.
Correct Answer: B
Rationale: Discussing fears allows personalized reassurance.
The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?
- A. Remove the coffee from the tray, advising the client that it is not included in the diet.
- B. Determine which member of the nursing staff brought the cup of coffee to the client.
- C. Remind the client that no milk or creamer can be added to the coffee.
- D. Consult with the dietician to learn if the client is allowed to drink coffee.
Correct Answer: C
Rationale: Black coffee is allowed without additives.
The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?
- A. Avoids adjusting the height of the hand grips.
- B. Holds the crutch 6 inches (15 cm) to the side.
- C. Fits the crutch 2 finger widths from axilla.
- D. Walks with the arms fully extended.
Correct Answer: C
Rationale: Proper crutch fit prevents nerve damage.