Nokea
A nurse is reinforcing teaching with a newly licensed nurse about using the therapeutic technique of confrontation when caring for a client. Which of the following instructions should the nurse include in the teaching?
- A. Offer the client personal opinions.
- B. Change the subject when talking with the client.
- C. Use an aggressive tone of voice with the client.
- D. Establish a trusting relationship with the client.
Correct Answer: D
Rationale: Confrontation should be used in a therapeutic manner, requiring trust and sensitivity to help the client recognize inconsistencies in thoughts or behaviors.
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A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. Cool skin
- B. Bradycardia
- C. Urine output 20 mL/hr
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Urine output 20 mL/hr. In dehydration, the body tries to conserve water, leading to decreased urine output. This finding indicates the body's attempt to retain fluids. A: Cool skin is incorrect as dehydration often presents with warm, dry skin due to decreased sweating. B: Bradycardia is unlikely in dehydration as the body tries to maintain cardiac output by increasing heart rate. D: A normal sodium level of 142 mEq/L does not specifically indicate dehydration.
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?
- A. Put on sterile gloves.
- B. Assist the client to the left Sims' position.
- C. Hang the enema container 61 cm (24 in) above the anus.
- D. Insert the tubing about 15 cm (6 in) into the anus.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the left Sims' position. This position helps to facilitate the flow of the enema solution into the colon by allowing gravity to assist in the process. Placing the client in the left Sims' position helps to ensure proper administration and effectiveness of the enema.
A: Putting on sterile gloves is not necessary for administering a soapsuds enema.
C: Hanging the enema container 61 cm above the anus is not a standard practice for administering a soapsuds enema.
D: Inserting the tubing about 15 cm into the anus is too shallow and may not reach the desired area for the enema to be effective.
A nurse is reinforcing teaching with a client who has a new diagnosis of heart failure. Which of the following tools should the nurse use when speaking with client?
- A. Materials should be culturally diverse.
- B. Information must be accurate and current.
- C. Materials should be written at the eighth-grade level.
- D. Materials should be written in the client's spoken language.
- E. Materials should be distributed to the client in advance.
Correct Answer: A,B,C,D
Rationale: The correct tools for teaching a client with heart failure diagnosis are A, B, C, and D. A: Culturally diverse materials ensure inclusivity and relevance. B: Accurate and current information enhances understanding and compliance. C: Eighth-grade level ensures clarity and simplicity. D: Using the client's spoken language promotes comprehension. These tools cater to different learning needs and facilitate effective communication. Other options like distributing materials in advance (E) may not address immediate questions or concerns.
A nurse is caring for a client who has a respiratory infection. The nurse should have the client sit in a high-Fowler's position to help mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: B
Rationale: High-Fowler's position enhances lung expansion and secretion clearance from the upper lobes.
A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
- A. Pain
- B. Hearing loss
- C. The client's culture
- D. Motor impairment
Correct Answer: A
Rationale: The correct answer is A: Pain. Pain can significantly impair a client's ability to concentrate and retain information during a teaching session. It may cause distress and make it difficult for the client to focus on the instructions provided. Therefore, addressing the pain as a priority before proceeding with teaching is crucial for effective learning.
Hearing loss (B), the client's culture (C), and motor impairment (D) can also present barriers to learning, but these can be accommodated through appropriate communication methods and cultural sensitivity. However, pain directly affects the client's cognitive function and must be managed before effective teaching can take place.