The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a male clientwith fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the PN implement?
Include "Noncompliance”. as a priority problem in the client's plan of care.
Advise the UAP to re-attempt the daily weight after the client eats breakfast.
Consult with the client about the reasons for his refusal to be weighed
Calculate the client's weight based on the 24-hour fluid intake and output.
The Correct Answer is C
The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.
Choice A rationale:
Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.
Choice B rationale:
Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.
Choice C rationale:
Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.
Choice D rationale:
Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the group of children that the PN should screen for scoliosis because they are at the highest risk of developing this condition. Scoliosis is a lateral curvature of the spine that usually occurs during the growth spurt before puberty. Girls are more likely than boys to have scoliosis, and the condition tends to worsen during adolescence.
A. High school boys are not at high risk of scoliosis and do not need to be screened unless they have signs or symptoms of the condition.
B. High school girls are at lower risk of scoliosis than middle school girls because they have completed most of their growth spurt and their condition is less likely to progress.
C. Middle school boys are at lower risk of scoliosis than middle school girls because they have a slower growth rate and a later onset of puberty.
Correct Answer is A
Explanation
The correct answer is choice A: "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.”.
Choice A rationale:
This response shows empathy and understanding, acknowledging the client's feelings and respecting her decision not to look at or discuss the incision. It allows the client to take control of her own emotions and healing process, while also reassuring her that the nurse will be available whenever she feels ready to talk or see the incision.
Choice B rationale:
Telling the client that she will feel better when she sees the incision minimizes her feelings and may be seen as dismissive. It does not address her emotions or concerns and can be counterproductive to building trust and rapport.
Choice C rationale:
Suggesting to call another nurse to be present while showing the wound might make the client feel uncomfortable or pressured. It is essential to establish a therapeutic nurse-client relationship, and forcing the issue could increase the client's distress.
Choice D rationale:
Telling the client that part of recovery is accepting her new body image and needing to look at her incision is insensitive and inappropriate. It is not the nurse's role to dictate how the client should feel about her body or her healing process. Such a response could potentially harm the nurse-client relationship and hinder the client's emotional healing.
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