Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

"I can learn to manage my thoughts better through therapy."

"This diagnosis means that I am crazy."

"Many people have the same response to a stressful situation as I am having right now."

"I can use holistic approaches like meditation to help my symptoms."

"I will probably need to be on medication for the rest of my life."

"I am at high risk for post-traumatic stress disorder because I have acute stress disorder."

Answer and Explanation

Correct Answer : B,E,F

B. This statement suggests a misunderstanding or stigma associated with mental health diagnoses. It's important for the nurse to clarify that experiencing acute stress disorder or any other psychological response to trauma does not equate to being "crazy." This can help reduce stigma and promote understanding that such responses are normal reactions to abnormal situations.
E. This statement indicates a potential misunderstanding about the duration of medication use. Clonazepam, in this case, is prescribed to manage acute symptoms related to anxiety and sleep disturbance. The nurse should explain that medication use for psychological symptoms is typically temporary and part of a broader treatment plan that may include therapy and other interventions aimed at recovery and long-term well-being.
F. While acute stress disorder is a risk factor for developing post-traumatic stress disorder (PTSD), not everyone who experiences acute stress disorder will develop PTSD. It's important for the nurse to provide education about the differences between acute stress disorder and PTSD, their symptoms, and the importance of ongoing monitoring and support to prevent long-term psychological difficulties.

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Correct Answer is A

Explanation

Rationale

A. Pairing the newly hired UAP with the most experienced UAP can provide mentoring and guidance. This allows the experienced UAP to share knowledge, demonstrate best practices, and help the new UAP navigate unfamiliar situations or complex care needs. It promotes skill development and ensures that care is provided effectively and safely.

B. Assigning less complex clients to the newly hired UAP initially can help ease them into their role and build confidence. It allows them to focus on learning routines, policies, and procedures without the added stress of managing highly complex care situations. However, this approach should be temporary and paired with opportunities for training and skill development.

C. Direct observation of the newly hired UAP's care delivery is crucial to assess their competency in various tasks. It provides firsthand insight into their skills, adherence to protocols, and ability to handle

client needs independently. Based on observations, appropriate feedback and additional training can be provided as needed.

D. Reviewing the UAP's skills checklist and discussing their previous experience with the hiring manager or supervisor provides essential background information. This helps in understanding the UAP's strengths, areas for improvement, and any specific training needs. It ensures that appropriate assignments and support are provided based on their skill level.

A. Instruct the nurse to use water with 5% dextrose (DW). B. Send an unlicensed assistive personnel to gather equipment. C. Prompt the nurse to apply povidone to the site. D. Direct the nurse to attach the luer-lock tip to the irrigation port.

Correct Answer is D

Explanation

Rationale

A. Using water with 5% dextrose (DW) is appropriate for irrigating certain types of catheters, especially those that require a non-saline solution to maintain patency. However, the choice of irrigation solution should be based on the specific type of catheter and the facility's policies. It does not directly address the immediate issue of the luer-lock syringe.

B. Sending someone else to gather equipment may be necessary in some situations but does not address the current issue of the nurse preparing to irrigate with a luer-lock tipped syringe. This option delays addressing the immediate concern.

C. Applying povidone (such as povidone-iodine solution) to the site is a step in the preparation for aseptic technique but does not address the specific issue of the syringe type or the irrigation process itself.

D. Luer-lock syringes are commonly used for irrigation purposes because they securely attach to irrigation ports, preventing accidental disconnection during the procedure. Directing the nurse to attach the luer-lock syringe ensures that the irrigation can be performed safely and effectively.

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Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPS. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Correct Answer is A

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock tipped syringe. Which action should the charge nurse take?

Correct Answer is D

Explanation

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Exhibits

Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.