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When a client's skin is dry, which of the following nursing interventions would be most helpful?
- A. Limit bathing to once or twice a week.
- B. Bathing is daily, but no soap is used.
- C. Bathing daily with mineral oil added to the water.
- D. Bathing with lotion instead of water.
Correct Answer: A
Rationale: Limiting bathing to once or twice weekly prevents further drying of already dry skin, preserving natural oils. Daily bathing, even without soap or with oil, risks exacerbation, and lotion isn't a bath substitute. Nurses apply this to maintain skin integrity.
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A nurse working in a community health center is focusing on illness prevention for a group of young adults. Which action reflects primary prevention?
- A. Screening for sexually transmitted infections
- B. Educating about the risks of smoking
- C. Referring clients with depression to a counselor
- D. Planning care for clients with asthma
Correct Answer: B
Rationale: Primary prevention targets illness before it strikes, ideal for young adults shaping lifelong habits. Educating about smoking risks cancer, lung damage aims to deter uptake or prompt quitting, a modifiable behavior with huge impact, as smoking's a top preventable death cause. Screening for STIs is secondary, catching disease early, not stopping it. Referring depression cases or planning asthma care is tertiary, managing conditions, not preventing onset. Smoking education fits primary prevention's proactive core studies show early awareness cuts initiation rates perfect for a community setting where young adults face peer pressures. Nursing uses this to shift trajectories, reducing chronic illness odds through informed choice, a powerful, scalable action for this age group's health future.
The nurse checked if Mr. Gary's pain improved after medication. This is an example of?
- A. Evaluation
- B. Implementation
- C. Assessment
- D. Planning
Correct Answer: A
Rationale: Checking pain improvement is evaluation (A) assessing outcomes, per process. Implementation (B) delivers, assessment (C) gathers, planning (D) sets not outcome-specific. A fits goal review, making it correct.
Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is a human being. What major ingredient of a therapeutic communication is Nurse Aida using?
- A. Empathy
- B. Positive regard
- C. Comfortable sense of self
- D. Self awareness
Correct Answer: B
Rationale: Nurse Aida uses positive regard (B), valuing Roger as a human despite his behavior, a key therapeutic communication ingredient per Rogers. Empathy (A) involves feeling with the client, not just valuing them. Comfortable sense of self (C) is the nurse's confidence, and self-awareness (D) is understanding one's reactions. Positive regard fosters acceptance, crucial for trust and healing, aligning with Aida's stance, making B correct.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Correct Answer: B
Rationale: Lifting by the buttocks prevents fractures in osteogenesis imperfecta, a brittle bone disorder calcium doesn't strengthen defective collagen, it's lifelong, and other systems (e.g., hearing) may be affected. Nurses teach gentle handling, ensuring safety in this genetic condition.
When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
- A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
- B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
- C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
- D. Clients need to be assessed and the care documented at least once every hour during the shift.
Correct Answer: C
Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.