Nokea
When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?
- A. Investigating the client's insurance coverage for home IV antibiotic therapy
- B. Determining if there are adequate hand washing facilities in the home
- C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
- D. Selecting the appropriate venous access device
Correct Answer: C
Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.
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When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, the next action by the nurse should be to
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contacts with the client to avoid reinforcement of manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct Answer: A
Rationale: When a nurse experiences reluctance to interact with a manipulative client, it is essential to address these feelings constructively. Discussing the feeling of reluctance with an objective peer or supervisor allows the nurse to gain perspective, reflect on the situation, and develop appropriate strategies for patient care. This action promotes self-awareness, professional growth, and ensures that patient care is not compromised. Option B is incorrect because avoiding the client may not address the underlying issues and can impact the therapeutic relationship. Option C is inappropriate as confronting the client may escalate the situation and hinder effective communication. Option D is not the immediate action needed in this scenario, as it focuses on behavior modification rather than addressing the nurse's feelings of reluctance.
The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
- A. Patients who appear unkempt may require guidance on hygiene practices.
- B. Personal preferences can be influenced by health conditions.
- C. The patient's illness may require teaching of new hygiene practices.
- D. Cultural perspectives on cleanliness can vary based on health status.
Correct Answer: C
Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.
A healthcare professional working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during their shift. Which of the following signatures may the healthcare professional legally witness?
- A. A 16-year-old client who is married
- B. A 27-year-old who has schizophrenia
- C. An adoptive parent who brings in their 8-year-old child
- D. A 17-year-old mother who brings in her toddler
Correct Answer: A
Rationale: The correct answer is A. A 16-year-old who is married can legally sign an informed consent form. In this case, being married at 16 may indicate legal emancipation or the ability to consent to medical treatment. Choice B is incorrect because having schizophrenia doesn't automatically imply incapacity to provide informed consent. Choice C is incorrect as an adoptive parent does not have the legal authority to provide consent for medical treatment on behalf of a child without proper documentation. Choice D is incorrect as a 17-year-old mother would generally not have the legal capacity to give consent for her toddler, as parental consent is usually required for minors.
A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?
- A. "I will first dissolve the tablet in water."
- B. "I will insert the tablet between my cheek and teeth."
- C. "I will place the tablet under my tongue."
- D. "I will chew the tablet."
Correct Answer: B
Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.
A healthcare professional is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the healthcare professional include?
- A. When lifting an object, spread your feet apart to provide a wide base of support.
- B. Always lift objects with your back straight and not your legs.
- C. Avoid using any assistive devices.
- D. Bend at the waist to reach objects.
Correct Answer: A
Rationale: The correct instruction to prevent back injuries while lifting is to spread your feet apart to provide a wide base of support. This helps in maintaining stability and reduces the risk of back injury. Choice B is incorrect as lifting objects with your back straight and using your legs is the recommended technique. Choice C is incorrect because assistive devices can actually help prevent back injuries by providing support. Choice D is incorrect as bending at the waist to reach objects can strain the back muscles and increase the risk of injury.