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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Correct. Lightheadedness upon standing, also known as orthostatic hypotension, can be a common side effect of ACE inhibitors. Advising the client to sit down when experiencing lightheadedness will help prevent falls.
B. Incorrect. Discontinuing the medication without consulting a healthcare provider is not appropriate. Lightheadedness can be managed with strategies like changing positions slowly.
C. Incorrect. Restricting fluid intake is not necessary unless advised by a healthcare provider.
Adequate hydration is important, especially with the use of certain medications.
D. Incorrect. While potassium supplements might be prescribed in some cases with ACE inhibitors, the primary concern in this situation is addressing orthostatic hypotension.

A. Ask the client if they would like to watch television. B. Use short, simple sentences when speaking with the client. C. Allow the client to have 1 hr of time alone in their room. D. Move the client to a table where other clients are playing cards.

Correct Answer is B

Explanation

A. Incorrect. Offering to watch television may not address the client's agitation and anxiety effectively.
B. Correct. The client's behaviors suggest anxiety or agitation. Using short, simple sentences when speaking with the client can help reduce their stress and facilitate communication.
C. Incorrect. While some clients may benefit from alone time, it's important to assess the client's preferences and needs. Isolating the client in their room might not be the best approach if they are seeking engagement.
D. Incorrect. Moving the client to a group setting may increase their discomfort or agitation. It's important to consider the client's current emotional state and tailor interventions accordingly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is making a follow-up call to a client who has a new prescription for an ACE Inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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