The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Middle-aged man experiencing the acute phase of myocardial infarction (MI)

Older adult with a history of dementia admitted for dehydration

Young adult in the rehabilitative phase after arthroscopic surgery

Middle-aged woman just diagnosed with terminal lung cancer

Answer and Explanation

The Correct Answer is A

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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Correct Answer is ["A","C","D","E"]

Explanation

A. The hot water heater is set at 54°C (130° F): This temperature poses a risk of burns, especially for a client who may have impaired mobility or sensation due to a stroke. Water temperatures above 49°C (120°F) can cause burns, and 54°C (130°F) increases that risk significantly, making it a safety hazard.

B. Grab bars are installed in the bathroom: This is a safety feature rather than a hazard. Grab bars can help prevent falls and provide support for clients with mobility issues, making them an important aspect of home safety, particularly for someone who has experienced a stroke.

C. Area rugs are placed in the living room: Area rugs can create tripping hazards, especially for clients who may have difficulty with balance or mobility after a stroke. If not secured properly, they can lead to falls, making this a safety hazard.

D. Medications are stored in a clear bag: While storing medications in a clear bag may provide visibility, it does not ensure safety. If the bag is not clearly labeled or is accessible to children or pets, it can pose a risk of accidental ingestion or misuse, thus representing a safety hazard.

E. Dim lighting installed throughout the house: Dim lighting can increase the risk of falls, especially for clients with visual impairments or those who may not be able to navigate their environment safely after a stroke. Proper lighting is essential for ensuring safety and preventing accidents, making this a safety hazard.

A. A 60 year old patient who is on a mechanical ventilator B. A 65 year old patient who is vegetarian and obese C. A 45 year old patient who smokes a pack of cigarettes a day D. A 70 year old patient who has a normal WBC count

Correct Answer is A

Explanation

A. A 60 year old patient who is on a mechanical ventilator: This patient is at the highest risk for healthcare-acquired infections (HAIs) due to the use of mechanical ventilation. Ventilated patients are susceptible to ventilator-associated pneumonia and other respiratory infections, making them more vulnerable to HAIs.

B. A 65 year old patient who is vegetarian and obese: While obesity can increase the risk for certain complications, being vegetarian does not inherently increase the risk for HAIs. This patient may have some risk factors, but they are not as significant as those associated with mechanical ventilation.

C. A 45 year old patient who smokes a pack of cigarettes a day: Smoking is a risk factor for various health issues, including respiratory infections, but it does not specifically correlate with a higher risk of HAIs in a hospitalized setting compared to a patient on a mechanical ventilator.

D. A 70 year old patient who has a normal WBC count: Although older age can increase the risk for infections, a normal white blood cell count indicates a functioning immune response. Without additional risk factors, this patient would not be considered the most at risk for developing HAIs compared to a ventilated patient.

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The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client? (Select All that Apply.)

Correct Answer is ["A","C","D","E"]

Explanation

The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

Correct Answer is A

Explanation

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