Nokea
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: The correct answer is D because it offers the patient autonomy by providing a choice between brushing their teeth independently or having assistance. This empowers the patient to make decisions regarding their personal hygiene, promoting independence and self-esteem. Choice A does not offer a choice or empower the patient. Choice B focuses solely on the location of the toothbrush and does not address the patient's needs. Choice C does not provide the patient with a sense of control over their hygiene routine. By contrast, choice D acknowledges the patient's needs, offers a choice, and encourages independence.
You may also like to solve these questions
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: C
Rationale: The correct answer is C - Observing closely for signs of respiratory distress. In encephalitis, there is a risk of respiratory compromise due to brain inflammation affecting the respiratory center. Monitoring for signs of respiratory distress is critical to intervene promptly if breathing becomes compromised.
A - Measuring fluid intake and output is important but not as critical as monitoring respiratory distress in encephalitis.
B - Evaluating ventilation capacity and lung sounds is important, but close observation for respiratory distress takes precedence for immediate intervention.
D - Administering an indwelling urethral catheter is not directly related to the client's immediate critical needs in encephalitis.
A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic’s standard STD teaching. Which statement by the student indicates the need for additional instruction?
- A. “There is no guarantee that I won’t contract an STD if I choose to be sexually active.”
- B. “Abstinence is the only sure way to avoid an STD.”
- C. “If I use a condom with spermicide, I will be safer than if I don’t use one.”
- D. “If I question my partner about past sexual encounters, I can avoid STDs.”
Correct Answer: D
Rationale: The correct answer is D. This statement indicates a need for additional instruction because questioning a partner about past sexual encounters may not be a reliable method to avoid STDs. Here's the rationale:
1. A: Correct - Acknowledges the reality that engaging in sexual activity carries risks, even with precautions.
2. B: Correct - Emphasizes that abstinence is the most effective way to prevent STD transmission.
3. C: Correct - Using a condom with spermicide can reduce the risk of STD transmission, although it's not foolproof.
4. D: Incorrect - Relying solely on partner questioning is not a comprehensive or foolproof method to prevent STDs. It overlooks the potential for misinformation or lack of disclosure from the partner.
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment?
- A. Carrying out a physician’s order to intubate a client
- B. Educating a novice nurse on the principles of triage
- C. Using the nursing process to diagnose a blocked airway
- D. Interviewing privately a client suspected of being a victim of abuse
Correct Answer: D
Rationale: The correct answer is D because interviewing a client suspected of being a victim of abuse involves critical thinking in assessment by gathering relevant information, analyzing the situation, and making informed decisions. This activity helps identify potential risks and ensures the client's safety. On the other hand, options A and C involve implementing orders and diagnosing conditions, respectively, which are more related to clinical decision-making rather than assessment. Option B focuses on education, which is not directly linked to assessment activities.
Which nursing intervention is most appropriate for a client with multiple myeloma?
- A. Monitoring respiratory status
- B. Balancing rest and activity
- C. Restricting fluid intake
- D. Preventing bone injury
Correct Answer: D
Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.
After the surgical incision has been clised and the anesthesia has wear-off, the patient is extubated and transferred to the postanesthesia care unit (PACU). Who is responsible for transferring the patient?
- A. Circulating nurse
- B. scrub nurse
- C. surgeon
- D. anesthesiologist
Correct Answer: D
Rationale: The correct answer is D: anesthesiologist. The anesthesiologist is responsible for transferring the patient to the PACU as they are in charge of the patient's anesthesia management throughout the surgery. They are trained to assess the patient's condition post-surgery, manage any immediate postoperative complications, and ensure a smooth transition to the PACU staff for continued care. The circulating nurse (A) is responsible for managing the operating room environment, the scrub nurse (B) assists the surgeon during the surgery by passing instruments, and the surgeon (C) performs the surgical procedure but does not typically transfer the patient to the PACU.