In the context of caring for a client diagnosed with psoriasis, which action by the nurse would address the client’s psychosocial need for acceptance?
Allowing the client to express their feelings.
Wearing gloves during the client interview.
Offering a handshake during introductions.
Encouraging the client to join a support group.
The Correct Answer is C
Choice A rationale
Allowing the client to express their feelings is an important part of providing psychosocial support. However, it does not specifically address the client’s need for acceptance.
Choice B rationale
Wearing gloves during the client interview can actually reinforce feelings of stigma and rejection, as it may suggest that the nurse is afraid of touching the client or catching their condition.
Choice C rationale
Offering a handshake during introductions can be a powerful gesture of acceptance, especially for a client with a visible skin condition like psoriasis. It communicates that the nurse is not afraid of physical contact and accepts the client as they are.
Choice D rationale
Encouraging the client to join a support group can provide them with a sense of community and shared experience, but it does not specifically address the client’s need for acceptance in their individual interactions with healthcare providers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.
Choice B rationale
While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.
Choice C rationale
Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.
Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.
Choice D rationale
Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.
Correct Answer is D
Explanation
Choice A rationale
While a case management evaluation of the client’s home environment could potentially identify areas for improvement, it may not directly address the caregiver’s immediate need for relief from their caregiving responsibilities. The caregiver is experiencing sleepless nights and frequent bouts of crying, which could be signs of caregiver burnout or depression. Therefore, immediate respite care may be more beneficial.
Choice B rationale
Employing a private duty nurse for respite could provide temporary relief for the caregiver. However, this option might not be feasible due to potential financial constraints. Additionally, it may not provide the caregiver with the emotional support they may need.
Choice C rationale
Proposing that extended family could relocate to the area to provide support is a potential long-term solution. However, it may not be feasible or practical for extended family members to relocate. This option also does not address the caregiver’s immediate need for relief and support.
Choice D rationale
Advising the caregiver to contact social services to locate a respite care facility for the client could provide the caregiver with the immediate relief they need. Respite care facilities offer temporary relief for caregivers by providing short-term care for the individual they are caring for. This would allow the caregiver to rest and take care of their own needs, which could help alleviate their symptoms of sleepless nights and frequent bouts of crying.
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