A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.
Which of the following clients should the nurse instruct the AP to report to the nurse?

A client who has a prescription for compression stockings and did not receive them.

A client who consumes all the food from their meal tray.

A client who requests to sit in the bedside chair while watching TV.

A client who requests assistance to use the bedside commode.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should instruct the assistive personnel (AP) to report the client who has a prescription for compression stockings but did not receive them. This situation involves a missed intervention that is crucial for the client's health and safety. Reporting this to the nurse allows timely intervention and ensures that the client receives the necessary care.

Choice B rationale:

Consuming all the food from the meal tray is not a cause for concern and does not require immediate reporting to the nurse. It is a normal behavior and does not indicate any potential issues with the client's health or safety.

Choice C rationale:

The client's request to sit in the bedside chair while watching TV is a common and appropriate request. It does not pose any risk to the client's health or safety and does not require immediate reporting to the nurse.

Choice D rationale:

A client requesting assistance to use the bedside commode indicates a need for assistance with a basic activity of daily living. The AP should assist the client with this request as appropriate and does not need to report it to the nurse unless complications or concerns arise during the process.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should prioritize the client's concerns and engage in therapeutic communication. By asking the client about their concerns, the nurse demonstrates empathy and encourages the client to express their feelings, which can help address any fears or anxieties related to using a bedpan. This approach promotes trust and allows the nurse to provide appropriate support and education to the client.

Choice B rationale:

This option does not address the client's concerns about using a bedpan. Instructing the client to use nearby furniture does not address the client's emotional needs or provide appropriate assistance for the current situation.

Choice C rationale:

This response is authoritarian and does not respect the client's autonomy or emotional state. It may cause the client to feel powerless and anxious, which can negatively impact the nurse-client relationship.

Choice D rationale:

Involving the physical therapist in this situation is unnecessary and does not address the client's immediate concern. It also does not promote open communication between the nurse and the client about the client's feelings regarding using a bedpan.

A. Tolerates physical discomforts B. Is eager to review the birth experience C. Begins reconnecting with their partner D. Performs self-care independently

Correct Answer is B

Explanation

The correct answer is B. The taking-in phase of maternal adjustment is characterized by the passive and dependent behavior of the mother, who focuses on her own needs and relies on others for assistance. The mother is eager to review the birth experience and share her feelings with others, which helps her process and integrate what happened. The other options are incorrect because they describe manifestations of other phases of maternal adjustment: tolerating physical discomforts and performing self-care independently are typical of the taking-hold phase while beginning reconnecting with their partner is typical of the letting-go phase.

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A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.Which of the following clients should the nurse instruct the AP to report to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is near the end of life and is on complete bed rest.The client states that he needs to have a bowel movement and the nurse offers a bedpan.The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

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A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.
Which of the following clients should the nurse instruct the AP to report to the nurse?