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The physician has ordered a culture specimen from a client with a suspected urinary tract infection. The nurse is aware that the specimen should be obtained:
- A. From the first morning voiding
- B. Using a sterile cotton ball placed in the client's vaginal area
- C. From the client's indwelling catheter port
- D. During the client's midstream voiding
Correct Answer: D
Rationale: Midstream voiding provides a clean-catch urine specimen for UTI culture, minimizing contamination first voiding risks sediment, vaginal cotton is irrelevant, and catheter ports are for indwelling cases. Nurses instruct this technique, ensuring accurate pathogen identification, critical for effective treatment.
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Which of the following activities on the part of the nurse most demonstrates individualization of the nursing-care plan for a client?
- A. Include client's preferred times of care and methods used.
- B. Write the care plan instead of taking it off the computer.
- C. Use a care plan from a book but add some things to it.
- D. Select nursing diagnoses that match the client's problems
Correct Answer: A
Rationale: Individualizing a care plan is best shown by including the client's preferred times and methods, tailoring care to their unique needs and lifestyle. For instance, scheduling baths when a client feels most rested respects their routine, enhancing comfort and compliance. Writing plans manually or adapting generic ones lacks this personal touch, while matching diagnoses is standard, not individualized. This approach reflects client-centered care, ensuring interventions like wound care timing fit the individual, boosting effectiveness and satisfaction.
The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
- A. Changing the position of the mask every 2 hours
- B. Applying a protective barrier cream to the client's face
- C. Padding the pressure points on the client's face with soft material
- D. Encouraging the client to remove the mask intermittently for facial skin care
Correct Answer: C
Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.
Mr. Gary died yesterday, His wife is not talking to anyone and prefers to be alone staring blankly at her husband's picture. This is an example of?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: D
Rationale: Not talking, staring blankly post-death is depression (D), per Kubler-Ross withdrawal, sadness dominate. Denial (A) disputes, anger (B) lashes, bargaining (C) negotiates all absent. Depression fits her isolation, making it correct.
What can you expect from Marianne, who is currently at the ONSET stage of fever?
- A. Hot, flushed skin
- B. Increase thirst
- C. Convulsion
- D. Pale,cold skin
Correct Answer: D
Rationale: Fever's onset (chill phase) features vasoconstriction e.g., pale, cold skin as the body raises its setpoint. Hot, flushed skin (flush phase), thirst (later), or convulsions (hyperpyrexia) follow. Nurses expect this initial response e.g., shivering in Marianne, guiding warming measures, per fever physiology.
When providing holistic care to a client, the nurse recognizes that which behaviors are necessary?
- A. Understand and respect each person's definition of health
- B. Understand and respect each person's responses to illness
- C. Focus on a standard definition of health and beliefs
- D. Instruct the client that health is an inactive process
Correct Answer: A
Rationale: Holistic care in nursing embraces the whole person mind, body, spirit requiring tailored approaches. Understanding and respecting each person's definition of health acknowledges their unique values, like viewing wellness as independence or spiritual peace, shaping care plans. Respecting responses to illness honors individual coping like stoicism or seeking support fostering trust. A standard health definition ignores this diversity, risking alienation, while calling health inactive contradicts its dynamic nature people actively pursue it. Holistic nursing uses models like the wellness wheel to integrate dimensions, ensuring care fits the client, not a mold. This flexibility enhances engagement, as when a nurse adapts teaching for a client valuing herbal remedies, strengthening outcomes by aligning with personal beliefs and experiences.