The nurse recognizes that the Rationale(s) for giving a client a bath is (are) to: (SELECT ALL THAT APPLY)

develop a nurse-client relationship.

enhance well-being.

assess skin integrity.

stimulate circulation.

moisturize the skin.

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Bathing can indeed foster a nurse-client relationship. It provides an opportunity for interaction and communication between the nurse and the client, promoting trust and rapport.

B Bathing can contribute to the client's overall sense of well-being. It promotes comfort, relaxation, and a feeling of cleanliness, which are important aspects of holistic care.

C. Bathing allows the nurse to visually assess the client's skin integrity. During the process, the nurse can identify any changes in skin color, presence of lesions, wounds, or other abnormalities that may require further assessment or intervention.

D. Bathing, particularly when accompanied by gentle massage or movement of limbs, can stimulate circulation. This helps improve blood flow to tissues, aiding in wound healing and reducing the risk of complications such as pressure ulcers.

E. Depending on the type of bath products used (e.g., moisturizing soap or bath oils), bathing can help moisturize the skin. This is especially beneficial for clients with dry skin or conditions that predispose them to skin dryness.

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Correct Answer is C

Explanation

C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.

A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.

B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.

D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.

A. Only punitive measures work B. Physician's order required C. All less restrictive approaches have been tried D. Inadequate staffing E. Remove restraints every 8 hours

Correct Answer is ["B","C","E"]

Explanation

B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.

C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.

E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.

A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.

D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.

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The nurse recognizes that the Rationale(s) for giving a client a bath is (are) to: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:

Correct Answer is C

Explanation

Medicare and The Joint Commission have identified which criteria that nurses must consider when using patient restraints? (SELECT ALL THAT PPLY)

Correct Answer is ["B","C","E"]

Explanation

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