Choice A rationale

Guided imagery involves the use of mental visualization to relieve stress and manage pain. By thinking about a peaceful setting, such as the client’s grandfather's farm, they can divert attention from the pain and enter a state of relaxation. This technique helps reduce pain perception by engaging the mind in positive, soothing imagery, which can lead to decreased stress and muscle tension.

Choice B rationale

Listening to music is a distraction technique rather than guided imagery. While it can help take the mind off pain, it does not involve the mental visualization process that is central to guided imagery. Music can help by shifting attention away from pain and providing a calming effect through auditory stimulation.

Choice C rationale

Focused breathing is a relaxation technique that can help manage pain through controlled breathing patterns. It helps reduce anxiety and physical tension by focusing on slow, deep breaths. However, it does not involve the imaginative visualization that characterizes guided imagery.

Choice D rationale

Noticing the sensation of muscle tension is part of body awareness techniques, which involve paying attention to and understanding bodily sensations. While this can help in managing pain by addressing muscle tension, it is different from the mental visualization process of guided imagery.

Choice A rationale

Health information should not be disclosed to an employer for pre-employment screening without the client's consent, as it violates privacy regulations and the client's right to confidentiality. Such disclosures could lead to discrimination or bias in employment decisions.

Choice B rationale

Disclosing health information to a family member without the client's consent is a breach of confidentiality. The client must provide explicit permission, unless the situation involves an immediate risk to the client's or others' safety, which is not indicated here.

Choice C rationale

Sharing health information with a medical interpreter service on behalf of a client is permissible, as it facilitates communication between the client and healthcare providers. This action supports the client's care and ensures accurate understanding of medical information, making it an exception to the confidentiality rule.

Choice D rationale

Disclosing health information to an insurance agency regarding a life insurance policy requires the client's consent. It involves sharing sensitive information that could affect policy terms and premiums. Without consent, this disclosure would breach confidentiality laws.

Choice A rationale

Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.

Choice B rationale

Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.

Choice C rationale

Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.

Choice D rationale

While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.

Step 1: Convert all liquid intake to mL: 8 oz of milk = 8 oz × 30 mL/oz = 240 mL 10 oz of water = 10 oz × 30 mL/oz = 300 mL 4 oz of gelatin = 4 oz × 30 mL/oz = 120 mL

Step 2: Sum the liquid intake: Total intake = 240 mL + 300 mL + 120 mL = 660 mL

The nurse should record 660 mL on the I&O.

Choice A rationale

Reviewing the client's photograph in the medical record is an effective method to ensure accurate identification. This practice aligns with patient safety protocols and minimizes the risk of medication errors by confirming the patient's identity through a visual match with a documented image.

Choice B rationale

Requesting an assistive personnel to identify the client might be unreliable if the personnel is unfamiliar with the client or makes an error. This approach does not provide a secure verification method and could lead to mistakes.

Choice C rationale

Asking the client to state their room number is not reliable since a client with advanced dementia may not remember their room number accurately. This method does not ensure proper identification and can lead to errors.

Choice D rationale

Having the client state their phone number is inappropriate for clients with advanced dementia, who may struggle to recall such information. This method is not a secure or accurate way to verify identity.

Choice A rationale

A repressed grief response, where an individual avoids expressing their grief, is considered delayed grief, not exaggerated grief. This can manifest as physical symptoms or psychological issues later on.

Choice B rationale

Grief that begins following a terminal diagnosis is anticipatory grief, which is a normal response as individuals begin to process the impending loss. It prepares them emotionally for the eventual death.

Choice C rationale

Exaggerated grief involves intense, prolonged, and often harmful reactions such as self-destructive behaviors. This type of grief can significantly impair a person's ability to function and may require professional intervention.

Choice D rationale

A grief response triggered by a secondary loss (e.g., loss of job or home) is known as cumulative grief. While it complicates the grieving process, it does not inherently lead to the exaggerated, self-destructive behaviors seen in exaggerated grief.

Choice A rationale

Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.

Choice B rationale

Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.

Choice C rationale

Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.

Choice D rationale

Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.

Choice A rationale

Using disinfectant to clean the blood pressure cuff after use is an appropriate infection control measure. It reduces the risk of cross-contamination between clients by ensuring medical equipment is sanitized.

Choice B rationale

Double-bagging a client's linens each day is not necessary unless the linens are heavily soiled or contaminated with pathogens. Routine double-bagging is not an effective infection control practice and is resource-intensive.

Choice C rationale

Wearing sterile gloves when bathing a client who is incontinent is unnecessary. Non-sterile gloves are sufficient for this task, and sterile gloves should be reserved for surgical or invasive procedures to maintain sterility.

Choice D rationale

Rinsing contaminants from a bedpan with hot water can create aerosols that spread pathogens. Proper protocol involves cleaning and disinfecting the bedpan with appropriate solutions to ensure infection control. .

Choice A rationale

Unlocking and removing the inner cannula is the first step. It allows access to the inner cannula for cleaning and ensures that the tracheostomy tube remains patent.

Choice B rationale

Pouring 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin provides the necessary solution for cleansing the inner cannula and stoma site, helping to maintain sterility and prevent infection.

Choice C rationale

Scrubbing the inside and outside of the inner cannula with a small brush ensures that any mucus or debris is removed, reducing the risk of infection and maintaining clear airways.

Choice D rationale

Wiping the inside of the inner cannula with a folded pipe cleaner helps to remove any remaining debris or solution, ensuring that the inner cannula is thoroughly cleaned.

Choice E rationale

Cleansing the stoma site with 0.9% sodium chloride solution helps to remove any mucus or debris from the site, maintaining hygiene and reducing the risk of infection.

Choice A rationale

Avoid placing toilet tissue in the bedpan after defecation to prevent contamination of the stool specimen. Toilet tissue can introduce foreign substances that may interfere with lab results.

Choice B rationale

Urinate after the specimen collection is incorrect because urine can contaminate the stool sample. The client should urinate before collecting the stool specimen to avoid mixing the two.

Choice C rationale

Placing 1.3 cm (0.5 in) of formed stool into a culture tube is insufficient for a proper stool sample. Typically, a larger sample is needed to ensure enough material is available for testing.

Choice D rationale

Keeping the specimen in a warm area is incorrect because stool samples should be kept in a cool environment to preserve the integrity of the specimen until it can be analyzed.