The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Remind the UAP to continue rubbing the hands together until they are dry.

Instruct the UAP to return to the client's room to perform handwashing.

Supervise the UAP in the next client's room to evaluate hand hygiene.

Advise the UAP to wear gloves when obtaining vital signs for all clients.

Answer and Explanation

The Correct Answer is A

A.   Reminding the UAP to continue rubbing the hands together until they are dry ensures proper use of the hand rub, which is effective when fully dry.
B.   Handwashing with soap and water is necessary after certain activities (e.g., after using the restroom, or when hands are visibly soiled), but using an alcohol-based hand rub is appropriate for routine hand hygiene.
C.   Supervising in the next client's room is less direct and immediate than ensuring proper technique now.
D.   Wearing gloves for all clients is not necessary and does not replace proper hand hygiene.

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

Explanation

A) This is a common symptom as individuals may avoid social interactions and isolate themselves due to ongoing distress.
B) Exaggerated startle response: Individuals may have an increased startle reflex following trauma, which can persist over time.
C) Intrusive thoughts: These are unwanted and distressing thoughts related to the trauma that can continue to affect the individual.
D) Avoidance of places associated with the assault: This behavior is a protective mechanism to prevent re-experiencing the traumatic event.
E) Overeating: Overeating is not a characteristic sequalae of rape trauma.

F) Hallucinations: Hallucinations are not typically associated with long-term symptoms of rape- trauma syndrome. Hallucinations can occur in severe cases, particularly if there are co-occurring mental health disorders such as PTSD.

A. Chew food slowly and thoroughly before attempting to swallow. B. Sip fluids slowly with each meal and between meals. C. Eliminate or reduce intake of fatty and gas forming foods. D. Plan volume-controlled, evenly-spaced meals throughout the day.

Correct Answer is D

Explanation

A. While chewing food well is important to aid digestion and prevent discomfort, meal timing and portion control are the primary concerns in gastric bypass patients.

B. Sipping fluids slowly is important, but fluids should generally be taken between meals rather than with meals to prevent stretching the stomach pouch and to avoid dumping syndrome.
C. Reducing fatty and gas-forming foods can help avoid discomfort, but this is less critical than ensuring proper food breakdown through thorough chewing.
D. After gastric bypass surgery, small, frequent meals help prevent dumping syndrome, a condition in which food moves too quickly from the stomach to the small intestine, causing nausea, dizziness, and diarrhea. Portion control is essential to avoid overstretching the reduced stomach pouch and ensure adequate nutrient absorption.

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The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

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

Explanation

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Correct Answer is D

Explanation

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