A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

A client who has Guillain-Barré syndrome

A client who has systemic sclerosis

A client who has amyotrophic lateral sclerosis (ALS)

A client who has a lumbosacral spinal tumor

Answer and Explanation

The Correct Answer is D

Choice A reason:

A client who has Guillain-Barré syndrome: Guillain-Barré syndrome (GBS) can cause significant muscle weakness and paralysis, including the muscles involved in swallowing. Clients with GBS are at high risk for aspiration and may require specialized feeding techniques or assistance from a nurse rather than an AP.

Choice B reason:

A client who has systemic sclerosis: Systemic sclerosis, also known as scleroderma, can affect the esophagus and cause difficulty swallowing. These clients may need careful monitoring and assistance with meals to prevent choking and ensure adequate nutrition.

Choice C reason:

A client who has amyotrophic lateral sclerosis (ALS): ALS affects the motor neurons and can lead to progressive muscle weakness, including the muscles involved in swallowing. Clients with ALS often require specialized feeding techniques and close monitoring during meals to prevent aspiration.

Choice D reason:

A client who has a lumbosacral spinal tumor: A lumbosacral spinal tumor primarily affects the lower back and may cause pain or mobility issues, but it does not typically impair swallowing. Therefore, this client is the most appropriate for the AP to assist with meals, as they are less likely to have complications related to eating.

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Correct Answer is B

Explanation

Choice A reason:

Health care provider: While health care providers, such as doctors, have extensive knowledge about medications and their uses, they may not always have the most up-to-date information on specific drug compatibilities. Pharmacists specialize in medications and are more likely to have immediate access to detailed compatibility data.

Choice B reason:

Hospital pharmacist: Pharmacists are the primary resource for information on drug compatibility. They have access to comprehensive databases and resources that provide detailed information on drug interactions and compatibility. Consulting the hospital pharmacist ensures that the nurse receives accurate and current information regarding the safe administration of ampicillin and gentamicin sulfate.

Choice C reason:

Nurse manager: Nurse managers oversee nursing staff and ensure that patient care standards are met. While they have a broad knowledge of clinical practices, they may not have the specific expertise or resources to provide detailed information on drug compatibility.

Choice D reason:

Medication sales representative: Medication sales representatives are knowledgeable about the products they promote, but their primary role is to market medications. They may not have the comprehensive and unbiased information needed to determine drug compatibility. It is always best to consult a pharmacist for this type of information.

A. It clearly articulates the expectations of the client. B. It demonstrates empathy towards the client. C. It sets limits on the client’s manipulative behavior. D. It uses reflection when talking with the client.

Correct Answer is B

Explanation

Choice A reason:

While articulating expectations is important, the nurse’s response is more focused on addressing the client’s feelings and encouraging participation in therapy. Simply stating expectations without addressing the client’s emotions may not be as effective.

Choice B reason:

The nurse’s response demonstrates empathy by acknowledging the client’s feelings and gently guiding them towards participating in group therapy. This approach helps build trust and rapport, which are essential in therapeutic relationships, especially with clients exhibiting delusional behavior.

Choice C reason:

Setting limits on manipulative behavior is important, but in this context, the nurse’s response is more about encouraging participation and showing understanding rather than strictly setting limits.

Choice D reason:

Reflection involves mirroring the client’s feelings or statements to show understanding. While the nurse’s response does show understanding, it is not a direct example of reflection. The primary focus is on empathy and encouragement.

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A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer ampicillin and gentamicin sulfate via IV infusion. Which of the following resources should the nurse consult first regarding medication compatibility?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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