A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?

Tolerates physical discomforts

Performs self-care independently

Begins reconnecting with their partner

Is eager to review the birth experience

Answer and Explanation

The Correct Answer is D

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Correct Answer is C

Explanation

Choice A Reason:

Confronting the client regarding inappropriate behavior is not appropriate. Individuals with memory loss may exhibit behaviors that result from their cognitive impairment, and confrontation can lead to distress.

Choice B Reason:

Offering several meal options at lunchtime can be overwhelming for clients with memory loss. Simplifying choices and providing clear options are more effective strategies.

Choice C Reason:

Maintain low-level lights in common areas. Maintaining low-level lights in common areas is a helpful strategy for clients with confusion and memory loss, as it creates a more comfortable and less disorienting environment. Bright or fluctuating lighting can be confusing and distressing for individuals with cognitive impairments.

Choice D Reason:

Using symbols in communal room signage may not be sufficient for individuals with advanced memory loss. Clear, written signage with words and pictures may be more helpful in guiding them to the correct locations and providing information.

A. Select the central tip of a finger. B. Wear sterile gloves. C. Keep the finger in a dependent position. D. Milk or massage the finger site.

Correct Answer is C

Explanation

Choice A Reason:

Select the central tip of a finger is incorrect. The nurse should select a puncture site on the side of the finger, slightly off-center from the central tip, as it tends to be less painful. The side of the finger has an adequate blood supply and can provide an accurate blood sample without causing excessive discomfort.

Choice B Reason:

Wearing sterile gloves is incorrect. Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. However, clean hands and proper hand hygiene are essential. The nurse should perform hand hygiene before the procedure.

Choice C Reason:

Keeping the finger in a dependent position is correct. Keeping the finger in a dependent position (hanging down) can promote blood flow and make it easier to obtain a blood sample. This is a recommended technique to facilitate the puncture and collection of blood.

Choice D Reason:

Milking may hemolyze specimen and introduce excess tissue fluid.

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A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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