What is the priority intervention for the nurse to enhance meeting the psychosocial needs of a client on transmissionbased precautions?
Allow the client to sleep to build up stamina
Maintain a sixfoot distance from the client
Provide a timeframe for the isolation
Provide the client with diversional activities
The Correct Answer is D
Choice A reason: Allowing the client to sleep to build up stamina is not the priority intervention, because it does not address the psychosocial needs of the client. Sleeping is a physiological need, not a psychosocial need. Sleeping may help the client recover physically, but it does not help the client cope emotionally or socially with the isolation.
Choice B reason: Maintaining a sixfoot distance from the client is not the priority intervention, because it does not enhance the psychosocial needs of the client. Maintaining a sixfoot distance from the client is a safety measure, not a psychosocial intervention. Maintaining a sixfoot distance from the client may help prevent the transmission of infection, but it does not help the client feel less lonely or isolated.
Choice C reason: Providing a timeframe for the isolation is not the priority intervention, because it does not enhance the psychosocial needs of the client. Providing a timeframe for the isolation is an informational intervention, not a psychosocial intervention. Providing a timeframe for the isolation may help the client understand the rationale and duration of the precautions, but it does not help the client feel more engaged or supported.
Choice D reason: Providing the client with diversional activities is the priority intervention, because it enhances the psychosocial needs of the client. Providing the client with diversional activities is a psychosocial intervention, not a physiological, safety, or informational intervention. Providing the client with diversional activities may help the client feel more entertained, stimulated, and connected with others, which can reduce the negative effects of isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Nociceptive pain is not the type of pain that the client is experiencing. Nociceptive pain is caused by the stimulation of nociceptors, which are sensory receptors that detect tissue damage or potential harm. Nociceptive pain is usually localized, sharp, throbbing, or aching. It is associated with injuries such as cuts, burns, sprains, or fractures. The client's pain is not caused by any tissue damage or harm in the distal part of the amputated limb, as there is no tissue left there.
Choice B reason: Neuropathic pain is the type of pain that the client is experiencing. Neuropathic pain is caused by the damage or dysfunction of the nervous system, such as the peripheral nerves, the spinal cord, or the brain. Neuropathic pain is usually chronic, burning, shooting, or tingling. It is associated with conditions such as diabetes, shingles, stroke, or amputation. The client's pain is caused by the disruption of the nerve signals from the amputated limb, which creates a phantom sensation of pain in the missing part.
Choice C reason: Cutaneous pain is not the type of pain that the client is experiencing. Cutaneous pain is caused by the stimulation of the cutaneous receptors, which are sensory receptors that detect touch, temperature, or pressure on the skin. Cutaneous pain is usually superficial, brief, or pricking. It is associated with stimuli such as pinching, scratching, or cold. The client's pain is not caused by any touch, temperature, or pressure on the skin of the distal part of the amputated limb, as there is no skin left there.
Choice D reason: Visceral pain is not the type of pain that the client is experiencing. Visceral pain is caused by the stimulation of the visceral receptors, which are sensory receptors that detect stretch, inflammation, or ischemia in the internal organs. Visceral pain is usually deep, dull, or cramping. It is associated with conditions such as appendicitis, pancreatitis, or bowel obstruction. The client's pain is not caused by any stretch, inflammation, or ischemia in the internal organs of the distal part of the amputated limb, as there are no organs left there.
Correct Answer is C
Explanation
Choice A reason: Popping bursae from standing is not the cause of the grating sound. Bursae are fluidfilled sacs that cushion the joints and reduce friction. Popping bursae may produce a snapping or clicking sound, but not a grating sound.
Choice B reason: A herniated disk in the diseased joint is not the cause of the grating sound. A herniated disk is a condition where the soft inner part of the intervertebral disk bulges out through a tear in the outer layer. A herniated disk may cause pain, numbness, or weakness, but not a grating sound.
Choice C reason: Pieces of bone and cartilage floating is the cause of the grating sound. Osteoarthritis is a degenerative joint disease that causes the breakdown of the cartilage and bone in the joints. Pieces of bone and cartilage may detach and float in the joint space, causing a grating sound when the joint moves.
Choice D reason: Years of an autoimmune process is not the cause of the grating sound. An autoimmune process is a condition where the immune system attacks the body's own tissues. An autoimmune process may cause inflammation, swelling, or damage to the joints, but not a grating sound.
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