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A nurse is caring for a client who has been admitted to the hospital.

Exhibits

Select the 5 actions the nurse should take.

Provide frequent rest periods for the client.

Instruct the client to avoid blowing their nose forcefully.

Assess the client s level of orientation.

Place the client on a low-carbohydrate diet.

Restrict the client's sodium intake.

Advise the client to avoid the use of soap and alcohol-based lotions.

Place the client under contact isolation.

Answer and Explanation

Correct Answer : A,B,C,E,F

A: Provide frequent rest periods for the client. This is correct because the client has anaemia (low haemoglobin and hematocrit), which can cause weakness and fatigue. Rest periods can help conserve energy and prevent complications.
B: Instruct the client to avoid blowing their nose forcefully. This is correct because the client has thrombocytopenia (low platelet count), which can increase the risk of bleeding. Blowing the nose forcefully can cause nasal bleeding or rupture of blood vessels.
C: Assess the client’s level of orientation. This is correct because the client has hepatic encephalopathy (brain dysfunction due to liver failure), which can cause confusion, mood changes, and disorientation. Assessing the client’s level of orientation can help monitor the severity of hepatic encephalopathy and guide appropriate interventions.
D: Place the client on a low-carbohydrate diet. This is incorrect because a low-carbohydrate diet can worsen hepatic encephalopathy by increasing ammonia production in the gut. The client should be on a high-protein, high-calorie diet to provide adequate nutrition and prevent muscle wasting.
E: Restrict the client’s sodium intake. This is correct because the client has ascites (fluid accumulation in the abdomen) due to portal hypertension (high blood pressure in the portal vein). Restricting sodium intake can help reduce fluid retention and prevent further complications.
F Advise the client to avoid the use of soap and alcohol-based lotions. This is correct because the client has pruritus (itching) due to high bilirubin levels in the blood. Soap and alcohol-based lotions can dry out the skin and worsen pruritus. The client should use mild cleansers and moisturizers to soothe the skin.
G: Place the client under contact isolation. This is incorrect because there is no indication that the client has an infectious disease that requires contact isolation. Contact isolation is used for clients who have diseases that can be transmitted by direct or indirect contact with the client or their environment, such as Clostridioides difficile infection or methicillin-resistant Staphylococcus aureus infection.

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Correct Answer is A

Explanation

Explanation:

"I will use a cool-mist vaporizer in my baby's room." This statement demonstrates an understanding of the teaching. Using a cool-mist vaporizer can help maintain moisture in the air and alleviate nasal congestion in infants.

Incorrect:

B- "I will leave my baby's bib on while he is sleeping." This statement indicates a lack of understanding. It is not safe to leave a bib on an infant while they are sleeping as it can pose a suffocation risk.

C- "I will leave the plastic covering on the crib mattress." This statement indicates a lack of understanding. The plastic covering on the crib mattress should be removed as it can pose a suffocation hazard.

D- "I will lay my baby's head on a pillow while he is in the crib." This statement indicates a lack of understanding. Pillows should not be used in the crib for infants as they can increase the risk of suffocation and SIDS (Sudden Infant Death Syndrome).

A. "It's understandable to feel nervous before this treatment. Most people feel better after, but you have the right to change your mind at any time." B. "I know this is a difficult decision, but the doctor believes ECT is the best option for you. Are you sure you want to cancel?" C. "That's completely fine! We can reschedule for another time when you're feeling more ready." D. "You signed the consent form, so you need to go through with the treatment. It's important to follow through on your commitments."

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

Acknowledges the client's feelings:It's important for the nurse to validate the client's concerns and let them know that it's understandable to feel nervous or uncertain about ECT.
Provides information about the treatment:The nurse can offer information about the potential benefits of ECT,but it's important not to pressure the client or make them feel like they have to go through with it.
Reassures the client of their right to change their mind:This is a crucial aspect of informed consent.The client has the right to withdraw their consent at any time,even after signing the consent form.

Choice B rationale:

Places undue pressure on the client:This response implies that the doctor knows what's best for the client and that the client should go through with the treatment even if they have doubts.This can undermine the client's autonomy and decision-making ability.

Choice C rationale:

May minimize the client's concerns:While rescheduling the treatment is an option,it's important to explore the client's concerns more thoroughly before suggesting this.It's possible that the client has valid reasons for not wanting to go through with ECT,and these reasons should be addressed.

Choice D rationale:

Is disrespectful of the client's autonomy:This response suggests that the client is obligated to go through with the treatment simply because they signed a consent form.This ignores the fact that people can change their minds and that consent is an ongoing process.

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A nurse is caring for a client who has been admitted to the hospital. Exhibits Select the 5 actions the nurse should take.

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A nurse is caring for a client who has been admitted to the hospital.

Exhibits

Select the 5 actions the nurse should take.