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?.

Answer and Explanation

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.

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Correct Answer is C

Explanation

This action would cause the nurse to intervene because it increases the risk of choking and aspiration for a client with dysphagia, which is difficulty swallowing. The nurse would instruct the UAP to feed the client small amounts of food slowly, allowing time for chewing and swallowing.

Choice A is wrong because offering thickened liquids is a safe practice for a client with dysphagia. Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration.

Choice B is wrong because placing the client in an upright position is also a safe practice for a client with dysphagia. This position helps prevent food from entering the airway and facilitates swallowing.

Choice D is wrong because allowing ample time between bites is another safe practice for a client with dysphagia. This helps the client avoid feeling rushed or overwhelmed and reduces the risk of aspiration.

A. Straighten the auditory canal by pulling it down and toward the front. B. Gently pull the auricle up and back before instilling the drops. C. Ask the client to lower the head and take a deep breath during the instillation. D. Don sterile glove and gently insert one finger in the canal to promote the flow of the drops.

Correct Answer is B

Explanation

Gently pull the auricle up and back before instilling the drops. This technique straightens the auditory canal and allows the drops to reach the eardrum.

It also prevents contamination of the ear canal by the finger.

Choice A is wrong because pulling the auditory canal down and toward the front is the proper method for children, not adults.

This technique is used for children because their auditory canal is shorter and more curved than adults.

Choice C is wrong because lowering the head and taking a deep breath during the instillation has no effect on the administration of otic drops.

It may also cause discomfort or dizziness for the client.

Choice D is wrong because wearing sterile gloves and inserting one finger in the canal is unnecessary and potentially harmful.

It may introduce bacteria or damage the ear canal or eardrum.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) is feeding a client with dysphagia. What action would cause the nurse to intervene?

Correct Answer is C

Explanation

Which technique is the proper method to administer otic drops to an adult client?

Correct Answer is B

Explanation

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