A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

"I will have the nursing staff check on you frequently during the night."

"You are right to be afraid. This is a new place for you."

"I will give you your prescribed sleeping medication to help you fall asleep."

"Describe your concerns about sleeping to me.”

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. "Describe your concerns about sleeping to me.".

Choice A rationale:

While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.

Choice B rationale:

Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.

Choice C rationale:

Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.

Choice D rationale:

Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears. This allows the nurse to understand the client’s perspective and provide appropriate emotional support.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B: Empty the drainage bag when it is three-fourths full.

Choice A rationale:

Cleaning the perineal area at least once a day is important for maintaining hygiene, but it is not the most relevant action in this scenario. The focus here is on managing the urinary catheter and its drainage bag.

Choice B rationale:

Emptying the drainage bag when it is three-fourths full is the correct action. An indwelling urinary catheter requires regular drainage to prevent the risk of infection and blockages. Allowing the bag to become too full could lead to backflow and increase the likelihood of urinary tract infections.

Choice C rationale:

Flushing the catheter with sterile water daily is not typically part of routine catheter care. Catheter flushing might be done for specific medical reasons, but it is not a general guideline for indwelling catheters.

Choice D rationale:

Disconnecting the drainage bag when emptying and measuring urine is incorrect. Maintaining a closed system is crucial to prevent introducing bacteria into the urinary tract. Disconnecting the bag could increase the risk of infection.

A. Clean hands with an alcohol-based hand rub immediately after removing gloves. B. Remove the cover gown in the client's room after providing care. C. Place the client in a room with negative-pressure airflow. D. Wear a mask when administering oral medications to the client.

Correct Answer is B

Explanation

The correct answer is choice B. Remove the cover gown in the client’s room after providing care. This is because Clostridium difficile spores are not effectively killed by alcohol-based hand rubs and can survive on surfaces for a long time. Removing the gown in the client’s room helps to contain any spores that may have settled on the gown, preventing them from being spread to other areas.

Choice A rationale:

Cleaning hands with an alcohol-based hand rub immediately after removing gloves is wrong because C. difficile spores are resistant to alcohol-based hand rubs. The recommended practice is thorough handwashing with soap and water to physically remove the spores from the hands.

Choice C rationale:

Placing the client in a room with negative-pressure airflow is wrong because this measure is used for airborne infections, such as tuberculosis. C. difficile is spread via the fecal-oral route, primarily through contact with contaminated surfaces or hands, not through the air.

Choice D rationale:

Wearing a mask when administering oral medications to the client is wrong because C. difficile is not spread through respiratory droplets. Masks are not necessary unless there is a risk of splash or spray of contaminated material.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use?

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?