A client makes minimal eye contact with others and remains alone in their room during the day. Which question is an important consideration when planning the client’s care?
Has the client had negative interactions with other clients in the past?.
Does the client have hostile thoughts about others?.
Is the client fearful of others on the unit?.
What are the client’s cultural norms?.
The Correct Answer is D
What are the client’s cultural norms? This question is important because it helps to assess whether the client’s behavior is influenced by their cultural background and values, which may differ from those of the staff and other clients.
For example, some cultures may value privacy, modesty, or respect for elders more than others, and may avoid eye contact or social interaction as a sign of politeness or deference.
Understanding the client’s cultural norms can help to provide culturally sensitive and appropriate care.
Choice A is wrong because it assumes that the client’s behavior is caused by negative interactions with other clients, which may not be the case.
Choice B is wrong because it assumes that the client’s behavior is caused by hostile thoughts about others, which may not be the case.
Choice C is wrong because it assumes that the client’s behavior is caused by fear of others in the unit, which may not be the case.
These choices are not relevant to planning the client’s care and may reflect bias or stereotyping on the part of the staff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Interview the client privately and ask if anyone is harming her.
This is because the nurse has a duty to assess the client for possible elder abuse and report any suspicions to the appropriate authorities.
The nurse should not assume that the son is the abuser or that the client will disclose the abuse without being asked directly.
The nurse should also respect the client’s autonomy and privacy and not confront the son or provide an elder abuse brochure without the client’s consent.
Choice A is wrong because it may imply that the client is responsible for preventing the abuse or that the nurse has already made a judgment about the situation.
It may also be ineffective if the client is unable or unwilling to read the brochure or seek help. Choice C is wrong because it may delay the assessment and intervention for the client.
It may also be biased and unfair to observe the son without interviewing him or the client first.
Choice D is wrong because it may violate the client’s rights and preferences.
It may also be premature to report the abuse without confirming it with the client or obtaining more evidence.
Correct Answer is C
Explanation
Motrin is a brand name for ibuprofen, which is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause renal toxicity, especially in older adults and patients with renal disease.
Therefore, the nurse should be most concerned about this medication and its potential adverse effects on the patient’s kidney function.
Choice A is wrong because digoxin is a cardiac glycoside that is used to treat heart failure and atrial fibrillation. Digoxin has a narrow therapeutic index and can cause toxicity if the dose is too high or if the patient has hypokalemia. However, digoxin does not directly affect the kidneys and can be safely used in patients with renal disease if the dose is adjusted according to the patient’s creatinine clearance.
Choice B is wrong because levothyroxine is a synthetic thyroid hormone that is used to treat hypothyroidism. Levothyroxine does not have any major interactions with the kidneys and can be used in patients with renal disease without dose adjustment.
Choice D is wrong because Tylenol is a brand name for acetaminophen, which is an analgesic and antipyretic drug. Acetaminophen does not have any anti-inflammatory effects and does not affect the kidneys at therapeutic doses. However, acetaminophen can cause hepatotoxicity if the dose exceeds 4 g per day or if the patient has liver disease or alcohol abuse.
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