A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?

If you continue to refuse to eat, I will have to insert an NG tube

Why aren't you willing to eat?

"Your nutrition is more important than your beliefs.

Let's discuss some menu options you would be interested in."

Answer and Explanation

The Correct Answer is D

A) If you continue to refuse to eat, I will have to insert an NG tube: This response is coercive and may not be respectful of the client’s autonomy. It can create a sense of fear and mistrust, which can make the client feel pressured or cornered. It is important to respect the client’s beliefs and preferences while also promoting nutrition, so alternative options should be explored in a more collaborative manner.

B) Why aren't you willing to eat?: While it’s important to understand the client’s reasons for refusing to eat, this response could come across as confrontational. It may place the client on the defensive and fail to acknowledge their beliefs and autonomy. A more open-ended and supportive approach is needed to create a dialogue that is respectful and patient-centered.

C) "Your nutrition is more important than your beliefs.": This response disregards the client's personal beliefs and could be perceived as disrespectful. While nutrition is critical, it is important to work within the framework of the client’s values and beliefs. The nurse should strive for a compassionate conversation that balances nutritional needs with cultural or personal beliefs.

D) Let's discuss some menu options you would be interested in.: This response is respectful of the client’s beliefs and autonomy while still addressing the issue of malnutrition. By offering options and engaging the client in the decision-making process, the nurse fosters a collaborative approach. This can help increase the likelihood of the client agreeing to eat while respecting their preferences and beliefs.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

Airborne precautions (Anticipated): Tuberculosis is an airborne disease, requiring negative pressure isolation, N95 respirators, and airborne precautions to prevent transmission.

Rifampin (Anticipated): A key first-line TB medication that inhibits bacterial RNA synthesis. It is part of the standard RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) regimen.

Contact precautions (Contraindicated): TB does not spread via direct contact, so contact precautions (gloves, gowns) are unnecessary unless the client has open wounds with drainage.

Isoniazid (Anticipated): A primary anti-TB drug that inhibits mycolic acid synthesis, crucial for treating active and latent TB infections.

Monthly TB skin test for 1 year (Contraindicated): Once TB is diagnosed, routine Mantoux tests are unnecessary, as they will likely remain positive due to prior exposure.

Pyrazinamide (Anticipated): A bactericidal TB medication used in the intensive phase of treatment to shorten therapy duration.

Ethambutol (Anticipated): Used to prevent drug resistance in TB treatment. Regular eye exams are needed due to the risk of optic neuritis.

A. Document the infiltration. B. Elevate the arm. C. Apply a warm compress. D. Stop the infusion.

Correct Answer is D

Explanation

A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.

B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.

C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.

D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.

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A nurse is assisting in the care of a client who is malnourished and states, ‘’I refuse to eat right now. It goes against my beliefs.’’ Which of the following responses should nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client:

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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