A client makes minimal eye contact with others and remains alone in their room during the day. Which question is an important consideration when planning the client’s care?
Has the client had negative interactions with other clients in the past?.
Does the client have hostile thoughts about others?.
Is the client fearful of others on the unit?.
What are the client’s cultural norms?.
The Correct Answer is D
What are the client’s cultural norms? This question is important because it helps to assess whether the client’s behavior is influenced by their cultural background and values, which may differ from those of the staff and other clients.
For example, some cultures may value privacy, modesty, or respect for elders more than others, and may avoid eye contact or social interaction as a sign of politeness or deference.
Understanding the client’s cultural norms can help to provide culturally sensitive and appropriate care.
Choice A is wrong because it assumes that the client’s behavior is caused by negative interactions with other clients, which may not be the case.
Choice B is wrong because it assumes that the client’s behavior is caused by hostile thoughts about others, which may not be the case.
Choice C is wrong because it assumes that the client’s behavior is caused by fear of others in the unit, which may not be the case.
These choices are not relevant to planning the client’s care and may reflect bias or stereotyping on the part of the staff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“Tell me what your pain feels like.” This question allows the nurse to assess the quality of pain, which is one of the characteristics of pain that can help determine its cause and treatment. Quality of pain refers to how the client describes the pain, such as sharp, dull, burning, throbbing, etc.
Choice A is wrong because it assesses the intensity of pain, not the quality. Intensity of pain is how much the pain hurts on a scale of 0 to 10 or using other methods.
Choice C is wrong because it assesses the precipitating factors of pain, not the quality. Precipitating factors are events or activities that trigger or worsen the pain.
Choice D is wrong because it assumes a specific quality of pain without asking the client. The nurse should not suggest words to describe the pain, but rather let the client use their own words.
Correct Answer is A
Explanation
Two 4x4 gauze cloths saturated with purulent drainage. This statement provides the best documentation of the amount of wound drainage because it specifies the size and number of gauze cloths, the type and amount of exudate, and the presence of infection
Choice B is wrong because it does not indicate the size or number of dressings, the type or amount of exudate, or the presence of infection.
Choice C is wrong because it does not indicate the size or number of dressings, the type of exudate, or the presence of infection.
Choice D is wrong because it does not indicate the size or number of dressings, the type of exudate, or the presence of infection.
Normal ranges for wound drainage are categorized as scant, minimal, moderate, or large/copious The type of wound drainage can be described as serous, sanguineous, serosanguineous, or purulent
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