A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?
Countertransference
Boundary crossing
Promoting trust
Veracity
The Correct Answer is C
A. Incorrect. Countertransference refers to the nurse's emotional reaction to the client based on the nurse's personal feelings or past experiences.
B. Incorrect. Boundary crossing refers to the nurse's actions that blur the professional boundaries of the nurse-client relationship, and this action does not necessarily represent boundary-crossing.
C. Correct. The nurse's action of interrupting the bath to obtain a healthy meal for the client demonstrates an immediate response to the client's need and promotes trust and rapport between the nurse and the client.
D. Incorrect. Veracity refers to truthfulness and honesty, but it does not directly apply to the nurse obtaining a meal for the client who is hungry.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Phenytoin is known to be a teratogenic medication, meaning it can cause birth defects. It is important for females of childbearing age to use effective contraception while taking phenytoin and to discuss pregnancy plans with their healthcare provider.
B. Incorrect. Skipping a dose of phenytoin can lead to changes in blood levels of the medication and may result in decreased seizure control. Nausea should be managed with the guidance of the healthcare provider.
C. Incorrect. Phenytoin can require regular monitoring of blood levels, but the frequency of blood work may vary based on the client's individual needs. Blood work is usually done more frequently than every 6 months, especially when starting or adjusting the medication.
D. Correct. Phenytoin can cause gingival hyperplasia, which leads to swollen and overgrown gums. This is a common side effect that clients should be informed about.
Correct Answer is B
Explanation
The occiput refers to the back of the head. Placing a small pillow or padding under the occiput can help relieve pressure and provide support to the client's head and neck when they are placed in the supine position.
Breasts: When in the prone position, breasts may be compressed or flattened. To relieve pressure, it may be necessary to use positioning techniques that distribute weight evenly and avoid direct pressure on the breasts, such as using cushions or foam pads to support the chest and torso.
Heels: The heels are prone to pressure ulcers when a client is lying in the supine position for extended periods. To relieve pressure, it is important to use proper heel offloading techniques, such as placing heel protectors or pillows under the lower legs to elevate the heels off the bed surface and prevent direct pressure.
Coccyx: The coccyx is the tailbone region at the base of the spine. When in the supine position, pressure on the coccyx can be relieved by using a cushion or padding under the pelvic area, specifically under the bony prominence of the coccyx, to reduce direct pressure and provide comfort.
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