A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

"This unit has a policy against staff harassment."

"It is important to dress the right arm first."

"Dressing must be a frustrating experience for you."

"We will give you a class on dressing tomorrow."

Monitor the client's white blood cell count.

Answer and Explanation

The Correct Answer is C

A. "This unit has a policy against staff harassment."

This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.

B. "It is important to dress the right arm first."

This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.

C. "Dressing must be a frustrating experience for you."

This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.

D. "We will give you a class on dressing tomorrow."

This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.

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Correct Answer is C

Explanation

A. Warn the colleague that copying health information is unlawful:

While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.

B. Send an email to facility administrators reporting the action:

Reporting the colleague's actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.

C. Communicate the colleague's activities to the unit charge nurse:

This is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

D. Dispose the copies and continue with client care assignments:

While disposing of the copies may prevent further unauthorized access to patient information, it does not address the issue of the colleague's inappropriate handling of the records. It's essential to report the incident to the appropriate authority for further investigation and follow-up.

A. Risk for infection. B. Impaired physical mobility. C. Risk for impaired skin integrity. D. Self care deficit.

Correct Answer is C

Explanation

A. Risk for infection:

Neuropathy can compromise the ability to detect injuries or wounds on the feet. Consequently, there's a risk of wounds going unnoticed, becoming infected, and leading to serious complications. While preventing infection is important, the primary concern in this scenario is preventing the occurrence of wounds or skin breakdown in the first place.

B. Impaired physical mobility:

Impaired physical mobility may be a concern for clients with neuropathy, especially if it affects their ability to walk or perform activities of daily living. However, in this scenario, the client is reporting increasing numbness and tingling in the lower extremities, indicating a sensory issue rather than a motor one. Therefore, while physical mobility is important, it may not be the immediate priority for promoting foot care in this case.

C. Risk for impaired skin integrity:

This option addresses the potential risk of skin breakdown or damage due to decreased sensation in the lower extremities, which is characteristic of neuropathy. With increasing numbness and tingling, there's a higher risk that the client may not be able to perceive injuries or pressure points, leading to skin damage or ulceration. Preventing skin integrity issues is crucial to avoid complications such as infections or wounds.

D. Self-care deficit:

Neuropathy can indeed impact a person's ability to perform self-care activities, including foot care. However, the priority in this scenario is to prevent complications related to neuropathy, such as skin integrity issues, rather than addressing deficits in self-care abilities. While self-care education and support may be necessary in the long term, immediate intervention to prevent skin breakdown takes precedence.

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A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

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Naxlex Comprehensive Predictor Exams

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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