A nurse is assisting with staff education about hand hygiene.
Which of the following instructions should the nurse include in the teaching?

The correct answer is choice A and E.

Choice A rationale:

The nurse should plan to ask the client what they are hearing. This is a therapeutic communication technique known as seeking clarification. It allows the nurse to gain more information and understand the client’s perspective. It can also help the client feel heard and validated, which can build trust and rapport.

Choice B rationale:

Telling the client their hallucinations are not real is not recommended. While it’s true that the hallucinations are not real, from the client’s perspective, they are very real and can be very frightening. Telling them otherwise can come across as dismissive and invalidating, which can damage the therapeutic relationship.

Choice C rationale:

Escorting the client to a group meeting may not be appropriate at this time. Given the client’s current state of agitation and confusion, they may not be able to participate effectively in a group setting. It could also potentially disrupt the group dynamic.

Choice D rationale:

Restraining the client should be a last resort and only used when the client is a danger to themselves or others. In this case, while the client is agitated and confused, they do not appear to be an immediate danger.

Choice E rationale:

Reducing excess stimulation around the client can be beneficial in this situation. Excess stimulation can exacerbate symptoms of psychosis such as hallucinations and agitation. By creating a calm and quiet environment, it can help reduce these symptoms and help the client feel more at ease.

Choice A rationale:

Uncapped sharps being put in a puncture-resistant container (choice A) is a safe and appropriate practice for the disposal of sharp objects, such as needles. This choice demonstrates adherence to infection control principles and minimizes the risk of accidental needlestick injuries.

Choice B rationale:

Soiled linens being placed on the floor (choice B) is not a safe or acceptable practice. Placing soiled linens on the floor can lead to contamination of the environment and pose a risk of spreading infection. Proper linen disposal protocols should be followed, which may include using designated linen hampers or containers.

Choice C rationale:

Waste containers being lined with single bags (choice C) is a standard practice for waste disposal. Using single bags makes it easier to handle and dispose of waste materials safely. It is a recommended infection control measure.

Choice D rationale:

Dampened cloths being used for dusting the area (choice D) is generally a safe practice for cleaning and dusting surfaces. Dampened cloths can help prevent the spread of dust and allergens. However, it's essential to ensure that the cloths are cleaned and disinfected regularly to prevent bacterial growth.