A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?

Instruct the client to avoid eating raw vegetables.

Initiate a referral for the client to a home health agency.

Remind the client of the importance of medication adherence.

Tell the client to avoid places where there are large crowds of people.

Answer and Explanation

The Correct Answer is B

Choice A reason: Instructing the client to avoid eating raw vegetables may be a precautionary measure due to potential immunosuppression from AIDS, but it does not directly demonstrate advocacy. Advocacy would involve actions that support the client's rights, choices, and interests, and while dietary advice is important, it is not an advocacy action in itself.

Choice B reason: Initiating a referral for the client to a home health agency is a clear demonstration of client advocacy. This action shows that the nurse is taking steps to ensure the client receives the necessary support to manage their condition at home, respecting their wish to maintain independence and quality of life.

Choice C reason: Reminding the client of the importance of medication adherence is part of the nurse's educational role but does not necessarily reflect advocacy. Advocacy would involve more proactive measures to support the client's treatment and care decisions.

Choice D reason: Telling the client to avoid places where there are large crowds of people is good advice to reduce the risk of infections, but it is not an advocacy action. Advocacy involves representing the client's interests and facilitating their choices and access to care.

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Correct Answer is D

Explanation

Choice A reason: While it is generally advised to avoid taking blood pressure readings from an arm with a PICC line to prevent complications, if the right arm cannot be used, as may be the case with the other clients listed, the nurse may have to use the left arm with extreme caution, ensuring not to disrupt the PICC line.

Choice B reason: Bell's palsy affects facial nerves and does not typically impact the measurement of blood pressure. Therefore, there is no contraindication to using the left arm for a blood pressure reading in a client with left-sided Bell's palsy.

Choice C reason: A client with right-sided weakness due to Parkinson's disease can have their blood pressure taken on the left side if the right side is too weak to provide an accurate reading or if using the right side would cause discomfort to the client.

Choice D reason: For a client with a right upper extremity arteriovenous fistula, typically created for dialysis access, blood pressure measurements should not be taken on that arm to avoid damaging the fistula. Therefore, the left arm should be used for blood pressure readings in this case.

A. Press down on the orbital area of the eye. B. Press down on the trapezius muscle. C. Use a 25-gauge needle. D. Elicit a reflex with a reflex hammer.

Correct Answer is B

Explanation

Choice A reason : Pressing down on the orbital area of the eye is not a recommended method for eliciting a response from a painful stimulus in an unresponsive patient due to the potential for injury to the eye.

Choice B reason : Pressing down on the trapezius muscle is an acceptable method for eliciting a response from a painful stimulus in an unresponsive patient. This technique is less invasive and can be performed safely to assess the patient's level of consciousness or response to pain without causing harm⁸.

Choice C reason : Using a 25-gauge needle is not an appropriate method for eliciting a response from a painful stimulus in an unresponsive patient. This could cause unnecessary harm and is not a standard practice in clinical settings.

Choice D reason : Eliciting a reflex with a reflex hammer is a method used to assess reflexes, not to elicit a response from a painful stimulus in an unresponsive patient. This tool is used to test neurological function and reflex integrity, not to assess pain response.

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A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?

Correct Answer is D

Explanation

A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

Correct Answer is B

Explanation

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A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hours. Which of the following actions should the nurse take in managing the client's PICC line?

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