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Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
- A. My mother has the same thing.
- B. I'll sit with you for a while.
- C. I think you should try having surgery.
- D. Don't cry, everything is going to be okay.
- E. Do you have any questions for me right now?
Correct Answer: A,C,D
Rationale: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client’s feelings. Offering presence and open-ended questions are therapeutic.
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The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their
- A. Dairy intake.
- B. Fiber intake.
- C. Fat intake.
- D. Calcium intake.
Correct Answer: B
Rationale: Fiber regulates bowel function in IBS. Dairy and fat may worsen symptoms, and calcium is unrelated to IBS management.
The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client
- A. Trendelenburg's position.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Right lateral with the head of the bed lowered.
Correct Answer: C
Rationale: The left lateral position allows the enema solution to flow into the sigmoid colon via gravity. Other positions are less effective or impractical.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
- A. Diabetes insipidus
- B. Cushing's syndrome
- C. Hemophilia
- D. Inflammatory bowel disease
Correct Answer: B
Rationale: Cushing’s syndrome involves elevated cortisol levels, which impair wound healing by suppressing immune responses and collagen synthesis. Diabetes insipidus primarily affects fluid balance, hemophilia affects clotting but not healing directly, and inflammatory bowel disease is less directly related to wound healing compared to Cushing’s syndrome.
The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply.
- A. Promote client autonomy
- B. Maintain family dynamics and support
- C. Maintains privacy and confidentiality
- D. Prevent potential intimidation or coercion
- E. Minimize the risk of retaliation
Correct Answer: A,C,D,E
Rationale: Excluding family promotes autonomy, privacy, and prevents intimidation or retaliation. Maintaining family dynamics is not a priority in this context.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.