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 D

Explanation

A) I participate in physical activities 3 times per week: Engaging in physical activity is a positive behavior and is not considered high-risk. Regular physical activity is important for maintaining overall health and preventing obesity, cardiovascular disease, and other health issues.

B) I use sunscreen with an SPF of 10: While using sunscreen is a protective behavior, an SPF of 10 is lower than the recommended SPF of at least 30 for effective protection against harmful UV radiation. This is not the most significant high-risk behavior compared to others, but it still indicates some risk of sun damage.

C) I limit playing video games to 3 hours per day: Limiting screen time to 3 hours per day can be considered a balanced approach to video gaming. While excessive screen time can be problematic, 3 hours per day is not necessarily a high-risk behavior for an adolescent, as long as it doesn't interfere with other important aspects of life, like physical activity, sleep, and socialization.

D) I have had sexual relations, but did not get the HPV vaccine: Engaging in sexual activity without receiving the HPV vaccine is a high-risk behavior. The HPV vaccine helps prevent certain strains of the human papillomavirus, which can cause cervical cancer and other cancers. Lack of vaccination increases the risk of contracting HPV and developing related complications.

A. "For a client who has Clostridium difficile. I will cleanse my hands with an alcohol based rub. B. ‘’Droplet precautions require that I wear a gown and gloves when providing client care." C. ‘’Following a blood spill, I should use a bleach solution with a ratio of 1 to 20. D. "Soiled dressings should be placed in a biohazard trash receptacle."

Correct Answer is D

Explanation

A) "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub.":
This statement is incorrect. When caring for a client with Clostridium difficile (C. diff), hand hygiene must be performed using soap and water, not an alcohol-based rub. Alcohol does not effectively kill C. diff spores. Handwashing with soap and water is essential to reduce the spread of this infection, as alcohol-based hand sanitizers are ineffective against C. diff spores.

B) "Droplet precautions require that I wear a gown and gloves when providing client care.":
This statement is incorrect. Droplet precautions require wearing a surgical mask to protect against large respiratory droplets that may be expelled during coughing or sneezing. Gowns and gloves are not routinely necessary unless there is a risk of contact with body fluids or secretions. Contact precautions, not droplet precautions, would require a gown and gloves.

C) "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20.":
This statement is partially correct but not fully optimal. For blood spills, the correct bleach solution ratio for disinfection is typically 1 part bleach to 9 parts water (a 1:10 ratio) rather than 1:20. The bleach solution must be strong enough to effectively kill pathogens and viruses, so a 1:9 dilution is preferred.

D) "Soiled dressings should be placed in a biohazard trash receptacle.":
This statement is correct. Soiled dressings, particularly those that are contaminated with blood, bodily fluids, or pathogens, should always be disposed of in a biohazard trash receptacle. This ensures the safe and appropriate handling of potentially infectious materials and helps prevent the spread of infection.

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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

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