When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Provide a box of tissues for the client to use when coughing.

Assist the client in changing into a fresh hospital gown.

Teach the client to cover the mouth with hands when coughing.

Obtain face masks for staff to wear upon entering the room.

Answer and Explanation

The Correct Answer is A

A. Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B. Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C. Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D. Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

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Correct Answer is D

Explanation

A. This can strain the back and increase the risk of injury. It's important to use proper body mechanics, such as bending the knees and keeping the back straight, when reaching for objects.
B. Bending at the waist can strain the back and increase the risk of injury. It's important to lift objects with the legs, not the back.
C. This can strain the back and hips. It's important to use proper body mechanics, such as using the legs and core muscles to push or pull heavy objects.
D. Standing erect with knees bent provides a strong base of support and helps to distribute weight evenly. Bending the knees allows for lifting with the legs, which is less stressful on the back and reduces the risk of injury. Pulling a draw sheet and moving a client in bed requires a combination of strength and proper body mechanics. Standing erect with knees bent helps to prevent strain on the back and muscles

A. Satisfaction vs. Depression. B. Integrity vs. Despair. C. Intimacy vs. Isolation. D. Trust vs. Mistrust.

Correct Answer is B

Explanation

A. This option does not correspond to one of Erik Erikson's stages. Erikson's theory includes eight stages of psychosocial development, and this specific stage is not part of his framework. While depression is a relevant concern in older adults, the correct terminology and stage must be identified based on Erikson’s theory.
B. This is Erikson's eighth and final stage of psychosocial development, typically occurring in late adulthood. In this stage, individuals reflect on their lives and either achieve a sense of integrity and fulfillment or experience despair and regret. The behaviors of withdrawing from friends, crying often, and seeking increased contact with family members are consistent with feelings of despair, as individuals may struggle with reflecting on their lives and their sense of accomplishment.
C. This is Erikson's sixth stage, which occurs during young adulthood (approximately ages 18 to 40). In this stage, individuals focus on forming intimate relationships and avoiding isolation. The behaviors described are more characteristic of older adulthood rather than young adulthood, so this stage is not applicable to the client's situation.
D. This is Erikson's first stage, occurring in infancy (from birth to about 18 months). During this stage, the primary task is developing trust in caregivers and the environment. The client’s behaviors are not related to the issues of trust or mistrust from early childhood but rather reflect challenges faced in older adulthood.

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When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is B

Explanation

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