When demonstrating an empathic presence to a client, which of the following actions should the nurse take?
- A. Use an open posture
- B. Write down what the client says for accurate documentation
- C. Establish and maintain eye contact
- D. Nod in agreement with the client throughout the conversation
Correct Answer: A
Rationale: Using an open posture is crucial when demonstrating empathy to a client. This body language conveys openness, understanding, and a willingness to listen, creating a safe space for the client to express themselves. Establishing and maintaining eye contact is also important as it fosters a sense of connection and validation for the client. Writing down what the client says is essential for accurate documentation and memory but does not directly contribute to demonstrating empathic presence. Nodding in agreement with the client throughout the conversation may show attentiveness, but it does not necessarily reflect empathy or active listening as it could be misinterpreted as simply agreeing with what is being said.
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A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?
- A. Decrease in heart rate
- B. Fluid volume deficit causes tachycardia
- C. Decrease in blood pressure
- D. Increase in respiratory rate
Correct Answer: A
Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.
During a peripheral vascular assessment, a healthcare professional places the bell of the stethoscope on a client's neck and hears an audible vascular sound associated with turbulent blood flow. This sound indicates which of the following?
- A. Narrowed arterial lumen
- B. Distended jugular veins
- C. Impaired ventricular contraction
- D. Asynchronous closure of the aortic and pulmonic valve
Correct Answer: A
Rationale: The correct answer is A: Narrowed arterial lumen. Arterial bruits are abnormal sounds caused by turbulent blood flow through narrowed or occluded arteries. This turbulent flow creates a blowing sound, which is heard as an arterial bruit. Distended jugular veins (choice B) are typically associated with venous issues, not arterial abnormalities. Impaired ventricular contraction (choice C) and asynchronous closure of the aortic and pulmonic valve (choice D) are not directly related to the audible vascular sound described in the scenario.
A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?
- A. Decreased calcium
- B. Elevated potassium
- C. Increased sodium
- D. Low hemoglobin
Correct Answer: A
Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.
When providing a bath, in which order will the nurse clean the body, beginning with the first area?
- A. Face
- B. Eyes
- C. Perineum
- D. Back and buttocks
Correct Answer: B
Rationale: The correct sequence for giving a bath starts with cleaning the eyes, followed by the face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and finally the buttocks/anus. Therefore, the first area to be cleaned during a bath is the eyes. Choices A, C, and D are incorrect as per the standard procedure for providing a bath.
While auscultating the anterior chest of a client newly admitted to a medical-surgical unit, a nurse listens to the audio clip of breath sounds through her stethoscope. What type of breath sounds does the nurse hear?
- A. Crackles
- B. Rhonchi
- C. Friction rub
- D. Normal breath sounds
Correct Answer: D
Rationale: The correct answer is D: Normal breath sounds. In the scenario described, the nurse hears normal bronchovesicular breath sounds, which are moderate in intensity and resemble blowing as air moves through the larger airways during inspiration and expiration. Crackles (choice A) are typically heard in conditions like heart failure or pneumonia and are not present in this case. Rhonchi (choice B) are low-pitched, continuous sounds often associated with conditions like chronic bronchitis or bronchiectasis. Friction rub (choice C) is a grating sound usually heard in conditions like pleurisy or pericarditis, which is not the case here where normal breath sounds are heard.