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When performing a return demonstration of using a gait belt for a female patient with right-sided weakness, which observation indicates that the caregiver has learned the correct procedure?
- A. Standing on the female patient's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
- B. Standing on the female patient's weak side, the caregiver provides security by holding the gait belt from the back.
- C. Standing behind the female patient, the caregiver provides balance by holding both sides of the gait belt.
- D. Standing slightly in front and to the right of the female patient, the caregiver guides her forward by gently pulling on the gait belt.
Correct Answer: B
Rationale: When assisting a patient with right-sided weakness using a gait belt, the caregiver must stand on the weak side of the patient to provide optimal support and security. By standing on the weak side and holding the gait belt from the back, the caregiver can effectively prevent falls and guide the patient's movements. This position allows for better control over the patient's balance. Standing on the strong side (option A) does not offer the necessary support if the patient leans towards the weak side. Standing behind the patient and holding both sides of the gait belt (option C) does not provide focused support to the weak side. Standing slightly in front and to the right (option D) may not offer adequate assistance to prevent falls on the weak side, making it an incorrect choice.
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The client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
- A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
- B. Sit quietly in the client's room until the client leaves the bathroom.
- C. Allow the client to cry alone and leave the client in the bathroom.
- D. Talk to the client and attempt to find out why the client is crying.
Correct Answer: D
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.
Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?
- A. Maintain standard precautions.
- B. Initiate contact isolation measures.
- C. Insert an indwelling urinary catheter.
- D. Instruct the client in the use of adult diapers.
Correct Answer: A
Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.
The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a 'tearing' sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the nurse make?
- A. Try not to worry, you and your baby are in good hands.'
- B. I understand your concerns. I'll let your health care provider know you need to talk.'
- C. I don't have time to answer questions now but I'll plan for us to have time to talk later.'
- D. I can understand that you are fearful. We are doing everything possible for your baby.'
Correct Answer: D
Rationale: Clients have a concern for the safety of their baby during labor and delivery, especially when a problem arises. Empathy and a calm attitude with realistic reassurances are important aspects of client care. Dismissing or ignoring the client's concerns can lead to increased fear and a lack of cooperation. Option 1 uses a cliché and provides false reassurance. Options 2 and 3 place the client's feelings on hold.
The home health nurse visits a client with cancer undergoing anti-cancer treatment. The nurse asks how the client is coping, and the client cries and with an angry voice says, 'Nobody understands. I am hanging on, trying to take one day at a time, but it is all I can do to get up in the morning.' How does the nurse best respond?
- A. What kind of support do you think would be most helpful to you at this time?
- B. I would be upset too if the people around me didn't act like they cared.
- C. Dealing with family is a challenge, even for people who are feeling healthy.
- D. Why don't you attend a support group for women who are going through the same thing?
Correct Answer: A
Rationale: Asking about desired support empowers the client to express needs, addressing their feelings of being misunderstood. Empathizing without guidance, focusing on family, or suggesting a support group without client input is less client-centered.
A client has an initial positive result of an enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The client begins to cry and asks the nurse what this means. Which knowledge should the nurse use to provide support to the client?
- A. The client is HIV positive, but the client's CD4 cell count is high.
- B. The client is HIV positive, but the disease has been detected early.
- C. There are occasional false-positive readings with this test; results can be verified by repeating it one more time.
- D. False-positive results can occur, and more testing is needed before diagnosing the client as being HIV positive.
Correct Answer: D
Rationale: If the client tests positive for HIV with the ELISA test, the test is repeated because of the potential for a false-positive result (e.g., from a recent influenza or hepatitis B vaccine) or a false-negative result if drawn too early after infection. If the test is positive a second time, the Western blot (a more specific test) is done to confirm the finding. The client is not diagnosed as HIV positive unless the Western blot is positive. Some laboratories also run the Western blot a second time with a new specimen before making a final determination.