The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Washing for a total of 20 seconds.

Lathering using a circular movement.

Turning the water off using bare hands.

Holding hands below elbows when rinsing.

Answer and Explanation

The Correct Answer is C

Choice A reason: Washing for a total of 20 seconds is correct and meets hand hygiene guidelines.

Choice B reason: Lathering using a circular movement is an appropriate technique for thorough handwashing.

Choice C reason: Turning the water off using bare hands can lead to recontamination of the hands. The UAP should use a paper towel to turn off the faucet.

Choice D reason: Holding hands below elbows when rinsing is correct to allow water to run off the hands and prevent contamination.

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Correct Answer is B

Explanation

Choice A reason: Attempting to comfort the client by agreeing with the delusions is not therapeutic and may reinforce the delusional beliefs.

Choice B reason: Presenting a personal perception of reality in a nonconfrontational manner helps the client recognize reality without creating conflict or distress.

Choice C reason: Disagreeing with the statement and setting clear limits may be perceived as confrontational and could increase the client's distress.

Choice D reason: Informing the healthcare provider is important but should not be the immediate action. Addressing the client's delusions therapeutically is the first priority.

A. Begin with questions that are less sensitive in nature. B. Get the most difficult questions over with first. C. Share personal values to put the client at ease. D. Ask questions in a vague, nonspecific format.

Correct Answer is A

Explanation

Choice A reason: Starting with less sensitive questions helps build rapport and makes the client feel more comfortable before addressing more sensitive topics such as domestic violence.

Choice B reason: Getting the most difficult questions over with first can make the client feel uncomfortable and defensive, potentially hindering the interview process.

Choice C reason: Sharing personal values is not appropriate and can bias the interview, making the client less likely to open up.

Choice D reason: Asking vague, nonspecific questions does not help gather the necessary information effectively and may confuse the client.

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The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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