The nurse is discussing discharge plans with a client. the client states im worried about going home

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use?

Exploring

Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.

While a nurse is providing food to a client in traction, the client reports feeling uncomfortable from being in the same position. Which nursing intervention is priority in this situation?

Repositioning the client

The nurse should first reposition the client so that he or she is in a more comfortable position, and then the nurse should offer basic hygienic measures. The nurse should assist the client with the meal after repositioning. Health education should be provided after repositioning.

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus?

Evaluating whether the necessary lifestyle changes are understood

Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler?

Preoperational

The second stage of Piaget's theory of cognitive development is the preoperational stage. It is observed from 2 to 7 years. During this stage, the child may learn to think with the use of symbols and mental images. The first stage is the sensorimotor stage, observed form birth to 2 years. During this stage, the child learns about himself and his environment through motor and reflex actions. The fourth stage is formal operations, characterized by a prevalence of egocentric thought. The concrete operations stage is stage 3, which signifies that the child is able to perform mental operations.

The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output? Record your answer using a whole number.

495 mL

Intake: Gastric tube: 250 x 3 = 750 mL; IV: 900 - 550 = 350 mL; Intake total: 1100 mL. Output: Urinary output: 150 + 220 + 235 = 605 mL. I & O difference: 1100 - 605 = 495 mL

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent?

Whether the client is allowed to give consent

A person is legally unable to sign a consent until the age of 18 or 19 years (depending upon individual state or provincial laws) unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.

The parents of an adolescent child are worried about their daughter's use of laxatives. Which other behavior in the child does the nurse associate with bulimia nervosa?

The child indulges in binge eating

Bulimia nervosa is an eating disorder characterized by binge eating and the use of laxatives and self-induced vomiting to prevent weight gain. Anorexia nervosa is a clinical syndrome with both physical and psychosocial components. Clients with anorexia nervosa refuse to maintain body weight at the minimal normal weight for their age and height. An individual with anorexia nervosa has an intense fear of gaining weight. This individual often starves to lose weight.

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what?

Urinary Output

As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

Which professional standard does the nurse feel is most important for critical thinking?

Evaluation Criterion

An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Which definition is involved in the caring process called knowing according to Swanson's theory of caring?

Striving to understand an event as it has meaning in the life of another

In Swanson's theory of caring process, knowing involves striving to understand an event as it has meaning in the life of another. The definition of being emotionally present for the other is related to the caring process called being with. The definition of sustaining faith in the other's capacity to get through an event or transition is related to the caring process called maintaining belief. The definition of facilitating the other's passage through life transitions and unfamiliar events is related to the caring process called enabling.

The registered nurse is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a healthcare setting. Which statement made by the nursing student indicates a need for further education?

"I should avoid asking about OTC medications"

During medication reconciliation the nurse should ask about all over-the counter medications the client may be taking. The nurse should compare new medication orders with the current list to ensure accuracy. Comprehensive and current lists of the client's medications should be obtained to make sure that there is not a risk for negative drug interactions. The nurse should eliminate distractions and go slowly when reconciling the client's medications to avoid errors.

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?

Making eye contact with the client

The nurse should make eye contact with the client to show interest in starting a conversation with a client with hearing loss. Smiling while seeing the client would help to build a positive relationship. Nodding in front of the client helps to regulate the conversation. Leaning forward towards the client shows attention and awareness.

What interventions should the nurse follow when giving health education to an elderly client?

Assess the client for pain before teaching

Ensure the client is not preoccupied or anxious

Teach one concept at a time according to the client's interest

The nurse must assess the client for pain and ensure that the client is physically well enough to learn. The nurse must begin teaching after determining that the client is not preoccupied or too anxious to comprehend the material. The nurse must postpone teaching if the client appears disinterested. The nurse should sit facing the client so that the client is able to view the nurse's expressions and lip movement. The nurse should refrain from taking down notes during the teaching because this action conveys a lack of interest. Because older adults process information more slowly than young people, the nurse should allow the client to take some time to respond to the nurse's queries.

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites?

Diminished plasma protein level

The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the liver's ability to manufacture albumin that maintains the colloid oncotic pressure. Potassium is not produced by the body, nor is its major function the maintenance of fluid balance.

A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness?

The children do not have physical shelter and may sleep outdoors or in vehicles

Public health organizations use the term absolute homelessness to describe people who have no physical shelter. These children sleep outdoors, in vehicles, abandoned buildings, or other places not intended for human habitation. Relative homelessness describes those who have a physical shelter but one that does not meet the standards of health and safety. Children from both sections of the community tend to be under-immunized and are at risk for childhood illnesses. Both types of homeless children are unable to meet residency requirements for public schools and are more likely to drop out of school and be rendered unemployable. A lack of finances leads both types of homeless children to seek healthcare only in emergency conditions.

Which feature is most likely related to entry-level nurse competencies

Working as a team member and collaborating with other team members

The entry level nurse competency involves the nurse working as a team member and collaborating with other team members. A nurse leader motivates others, set the objectives, guides the staff, and shows a participatory approach in the decision-making process.

On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client?

Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage?

Generativity vs. Stagnation

The generativity versus stagnation stage precedes integrity versus despair; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. Identity versus role confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus?

Teach the client how to exercise the legs

The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function, but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do?

Set priorities and outcomes using the client's and family's input

Outcomes should be set with the client and family, if feasible, just as priorities of interventions are considered with the client and family when possible. Physical needs should be met before psychosocial needs. Outcomes may be developed using two methods: writing specific outcome statements or choosing outcomes from the NOC.

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of what?

Integrity vs. despair

According to Erikson, poor self-concept and feelings of despair are conflicts manifested in those who are older than 65 years of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generativity versus stagnation conflict is manifested during middle adulthood, 45 to 65 years of age.

What could be the reason for cataracts in a 36-year-old client?

Prolonged exposure to heat

Prolonged exposure to metal powders

Glass workers are exposed to heat and metal powders for prolonged periods, which may increase their risk of developing cataracts. A prolonged exposure to pesticides may cause pesticide poisoning. Prolonged exposure to cement dust may cause bronchitis. Prolonged exposure to anesthetic gases may have reproductive effects.

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death?

Revising the client's will and planning a visit to a friend

Revising the will and planning a visit to a friend are realistic, productive, and constructive ways of using this time. Crying and talking openly about death are signs of depression. Going from healthcare provider to healthcare provider demonstrates disbelief, denial, or desperation. Refusing to follow treatments and stating that the client is going to die anyway indicates anger and hopelessness, not acceptance.

Which description relates to Gesell's theory of development?

Growth in humans is both cephalocaudal and proximodistal

Growth is maximized only if environmental conditions are adequate

The pattern of maturation follows a fixed developmental sequence in humans

According to Gesell's development theory, human growth is both cephalocaudal and proximodistal. It also states that maximum growth is achieved only if adequate environmental conditions are present. It explains that the maturation pattern follows a fixed developmental sequence in humans. The theory states that each child's growth pattern is unique. It also postulates that not only genetic factors but also environmental factors are essential for directing the developmental sequence

Which physiologic changes may occur during the first trimester of pregnancy?

Fatigue

Morning sickness

Breast Enlargement

Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. Increased libido is observed during the second trimester of pregnancy. Braxton Hicks contractions are observed during the third trimester of pregnancy.

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit?

Detachment

When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic, but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

The registered nurse tells a nursing student, "In the nursing model, the registered nurse is responsible for all aspects of care for one or more clients during a shift of care and the care can be delegated." Which disadvantage would be most likely related to this nursing model?

The continuity of care is a problem

When the registered nurse is responsible for the care aspects of one or more clients during a shift of care, the nursing model of total client care may come into practice. The lack of continuity of care is a disadvantage of this model. The registered nurse may not spend the time with the client as a team leader in the 'team nursing' model. Another disadvantage associated with this model is that the team leader may also require taking extra time to delegate work to the team. The primary nursing model does not involve the associate nurse changing the care plan without a discussion with the primary nurse.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain?

Prayer

Hypnosis

Aromatherapy

Guided Imagery

Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

A registered nurse is teaching a nursing student about caring for a client before leaving the healthcare facility. Which statement made by the nursing student indicates the need for further education?

"I should give limited information about the client to the healthcare provider who received the referral."

The nurse should provide as much client information as possible to the healthcare provider who received the referral because this action helps to avoid the provider asking duplicate questions and helps to avoid the omission of important information. The nurse should instruct the client about any potential food-drug interactions. The nurse should involve the client and his or her family in the referral process. The nurse should teach the client about the safe and effective use of medications and medical equipment.

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation?

Move the neighboring client to a room at the end of the hall

Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms, because they need to be monitored. The use of a sedative should not be the initial intervention.

The nurse is preparing to perform endotracheal suctioning of a client with respiratory difficulties. Before beginning the procedure, what should the nurse do?

Administer 100% oxygen to the client

Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs. The client who has an endotracheal tube may not be able to follow commands to take deep breaths or cough, or have the strength to do either, which is why manual bagging is preferred. A new sterile suction catheter should be used each time the client is suctioned, but the suction tubing and equipment need not be changed.

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for what?

Blood Clotting

Calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Calcium is responsible for a number of body functions, such as bone health, blood clotting, and muscle contraction and nerve impulses; however, it is not directly related to bile and blood production or digestion of fats.

An older adult in an acute care setting is having urinary incontinence. Which interventions would help the client?

Provide voiding opportunities

Avoid indwelling catheterization

Promote measures to prevent skin breakdown

An older adult should be provided voiding opportunities to minimize urinary incontinence. Indwelling catheterization should be avoided because this action increases the risk of infection and may cause discomfort. Measures to prevent skin breakdown should be taken because the client may develop skin problems due to incontinence. Nutritional support and frequent beverages and snacks should be provided to a client with malnutrition.

A client has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response?

"You were in a work-related accident this morning"

The correct response is truthful and provides basic information that may prompt recollection of what occurred; it is a starting point. Asking the client to tell the nurse what happened ignores the client's question; avoidance may increase anxiety. Saying "you will remember more as you get better" ignores the client's question; the frustration of trying to remember will increase anxiety. Saying "it was necessary to amputate your leg after the accident" is too blunt for the initial response to the client's question; the client may not be ready to hear this at this time.

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's hierarchy of needs does this nursing action address?

Safety

A call bell system enables the client to communicate with the staff and supports safety and security, which is a second-level need. Self-esteem involves intrapersonal needs, the fourth level of basic needs. Physiological needs include air, food, and water and represent the first level of needs. Interpersonal needs involve love and belonging, which are third-level needs.

Which nursing interventions indicate client care that supports physical functioning? .

Interventions to maintain client's nutritional status

Interventions to maintain client's regular bowel patterns

Providing interventions to maintain the client's nutritional status and providing interventions to maintain the client's regular bowel patterns indicates interventions that support physical functioning [1] [2]. Providing interventions to facilitate a client's learning and providing interventions to alter the client's undesirable behavior indicates interventions to support psychosocial functioning and facilitates lifestyle changes. Providing interventions to prevent complications related to electrolyte imbalance indicates the nursing care that supports homeostatic regulation.

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past 2 weeks. The client states, "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client?

"You are worried about paying your bills?"

Reflection can help the client to elaborate. The statement "Don't worry; your bills will get paid eventually" offers false assurance; the statement "When was the last time you were admitted for hyperglycemia?" uses professional jargon; and the statement "You really shouldn't be drinking alcohol because of your diagnosis of diabetes" is offering advice, all of which can all restrict the client's response.

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed healthcare worker tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse?

"The client's frightened and taking it out on the staff. Let's think of approaches we can take."

The correct response interprets the client's behavior without belittling the unlicensed healthcare worker's feelings; it encourages the unlicensed healthcare worker to get involved with plans for future care. Telling the unlicensed healthcare worker to be patient recognizes the client's feelings, but it does not address the unlicensed healthcare worker's feelings or help the unlicensed healthcare worker cope with the client's behavior. The nurse should not assume the unlicensed healthcare worker has nothing to contribute and that only the nurse can deal with the problem. Saying "Just ignore it" does not help the unlicensed healthcare worker understand the client's behavior, nor does it demonstrate an understanding of the client's feelings.Â

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care?

Identify personal feelings towards this client

Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament?

Negative reaction to new stimuli

A slow-to-warm up child may react negatively with mild intensity to any new stimuli or a change. A difficult child is highly active as well as irritable and irregular in habits. An easy child usually has a positive mild-to-moderately intense mood.

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first?

Assess the patency of the airway

The nurse should assess the airway status first because surgery and anesthesia may impair the patency of the airway. Once the patency of the airway is established, the nurse may assess the client's comfort and level of consciousness. Reviewing the order for intravenous fluids is not as important as assessing the airway.

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?

Sequence of steps used to meet the client's needs

The nursing process is a step-by-step method that scientifically provides for a client's nursing needs. Procedures used to implement client care, activities employed to identify a client's problem, and mechanisms applied to determine nursing goals for the client are only steps in the nursing process.

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through?

Launching children and moving on

The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation?

Implementation

The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client's physical, psychological, social culture.

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the student nurse indicates the need for further education?

"I should advise the certified medical assistant to administer intravenous medication"

Certified medical assistants are eligible to administer PO (by mouth) medications in long-term care settings in some areas. The nurse should set up and prepare medications in distraction-free areas. The nurse should be vigilant during the entire process of medication administration. The nurse should identify each client using at least two identifiers before administering medications.

While caring for a client dealing with pain, the nurse assesses the health status and prioritizes his or her needs. Which phase of the helping relationship is observed?

Orientation Phase

During the orientation phase, the nurse assesses the health status of the client and prioritizes his or her needs. During the working phase, the nurse encourages and helps the client to set treatment goals. In the termination phase, the nurse evaluates the achievement of treatment goals with the client. In the preinteraction phase, the nurse reviews the client's medical and nursing history and talks to the caregivers.

The nurse is caring for an older client with arthritis. The client has difficulty standing from and lowering into a chair because of pain. The nurse uses wooden blockers to elevate the chair legs, which helps the client sit and stand with little discomfort. Which critical thinking attitude is involved in this situation?

Creativity

Creativity is the critical thinking attitude involved in this situation. Creativity involves finding solutions outside of the standard routines of care while maintaining standards of practice. Humility involves admitting any limitations in knowledge and skills. Curiosity involves learning a great deal of information about a client in any critical situation. Integrity involves building trust from your coworkers.

What is a characteristic of the primary nursing model?

Care is provided by the registered nurse to the client during a stay in a facility

The primary nursing model includes one primary registered nurse who provides care to the same client during their stay in a facility. According to the total patient care model, the care can be delegated. Total patient care also involves the registered nurse being responsible for all the aspects of care for one or more clients during a shift of care. The team nursing model requires the registered nurse to lead a team of other registered nurses, practical nurses, and unlicensed assistive personnel.

Which intrinsic factors may contribute to falls in older adults?

Deconditioning

Impaired vision

Falls in older clients may be due to intrinsic factors and extrinsic factors. Deconditioning and impaired vision are intrinsic factors that can lead to falls. Inappropriate foot wear, improper use of assistive devices like walkers, and a lack of familiarity with the hospital room are extrinsic factors.

What does the nurse recognize as the reason the faucet handles on the sinks in a client's room are considered contaminated?

They are touched by dirty hands when turning the water on

Unwashed hands are considered contaminated and are used to turn on sink faucets. Recontamination of washed hands may be prevented by using foot pedals or a paper towel barrier when closing the faucets. They are not considered contaminated because they are not in sterile areas; areas cannot be sterile. It is unrelated to the number of people, but rather to being touched by contaminated hands. Although bacterial growth is facilitated in moist environments, this is not why sink faucets are considered contaminated.

An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation?

Let the client continue to think his or her own way

Mistaking the date and time are possible signs of dementia. In this situation, the client would benefit from validation therapy, which involves the adult continuing to think in his or her own way. Minimizing environmental stress can help to reduce confusion, but this is not the appropriate action for the given client's situation. Recognizing the inner needs and feelings of the client is more important than reinforcing the confused older adult's misperceptions. Reminiscence is a therapeutic approach that involves recalling the past to resolve present conflicts.

Which nursing interventions require a nurse to wear gloves?

Cleaning a newborn immediately after delivery

Emptying a portable wound drainage system

Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub; there is no indication that the nurse is in contact with bodily secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come into contact with the client's body fluids. PPE is not necessary when obtaining the blood pressure of a client, even if the client is HIV positive.

A nurse finds that his or her surgical mask has become moist before going to a surgery. What should the nurse do?

Dispose of the mask

The nurse should dispose of a mask if it gets moist or wet because the mask might have been contaminated. The nurse should not wait till the mask gets dry; instead, the mask should be changed. Coughing or sneezing should be avoided when the nurse is in a sterile area. The nurse should talk less after wearing a dry or sterile mask to minimize respiratory airflow.

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may do what?

Cause the device to pull away from the skin

If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching?

Wash hands with soap and water

Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile

What is the most important skill of the nurse leader?

Clinical care coordination

The most important leadership skill for a nursing student is clinical care coordination. Priority setting, time management, and clinical decision-making are secondary components included in clinical care coordination

The nurse is assessing a client with impaired hearing. Which action of the nurse is most important for establishing a good communication with the client?

Getting the clients attention before speaking

The first step that the nurse should take for starting a communication with a client with impaired hearing is getting client's attention before speaking. The nurse should never shout and should always speak in a normal volume. The nurse should reduce the environmental noise before starting a conversation to avoid disturbances. The nurse should always rephrase the sentences rather than repeating if misunderstood because it can cause confusion.

Which findings in the older client are associated with a urinary tract infection (UTI)?

Confusion
Incontinence
Slight rise in temperature

An older client with a urinary tract infection (UTI) is likely to appear confused. An older client may experience incontinence while a younger client may experience urgency. The older client may develop a slight rise in temperature. The classic symptoms of a UTI in a younger client are fever, dysuria, and urgency.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching?

Replace the drainage bad at least once a week

It is recommended to change the bag at least once a week. Once a day, the client should wash the first inches of the catheter, starting at the insertion site and moving outward. The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried. The drainage bag, not the insertion site, should be cleaned with the vinegar and water solution

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an N95 respirator mask before entering the room.

A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect?

Demonstrating a personal bias

When nurses make judgmental remarks and client needs are not placed first, the standards of care are violated and quality of care is compromised. Assessments should be objective, not subjective and biased. There is no information about the client's acuity to come to this conclusion regarding priorities. The statement does not reflect information about complexity of care

Which information would the nurse share with a client who refuses to follow the prescribed treatment regimen and plans to leave the hospital against medical advice?

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients quizlet?

What should the nurse do when a hospitalized client is observed to have a ritualistic pattern of behavior?

Which professional standard does the nurse feel is most important for critical thinking?