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 A
Explanation
This is because coughing can indicate aspiration of the feeding into the lungs, which can lead to pneumonia and other serious complications. Aspiration is reported in up to 89% of patients receiving nasogastric tube feeding.
Therefore, the nurse should prioritize assessing the client for signs of aspiration and ensuring proper tube placement.
Choice B is wrong because mild abdominal cramps are a common side effect of nasogastric tube feeding and do not require immediate intervention unless they are severe or persistent.
Choice C is wrong because high-pitched bowel sounds are normal and indicate peristalsis and digestion.
They do not indicate a problem with the tube feeding.
Choice D is wrong because one to two soft bowel movements per day are desirable and indicate adequate nutrition and hydration.
They do not indicate a problem with the tube feeding.
Normal ranges for gastric residual volume are less than 200 mL for adults and less than 100 mL for children. Normal ranges for pH of gastric aspirate are 1 to 5.
Correct Answer is B
Explanation
I should always have my breakfast ready to eat before injecting my morning insulin. This statement confirms that the client understands the importance of matching insulin administration with food intake to prevent hypoglycemia.
Choice A is wrong because hemoglobin A1C should be checked every 3 months, not monthly, to monitor long-term glycemic control.
Choice C is wrong because eating early and taking extra insulin later can cause fluctuations in blood glucose levels and increase the risk of complications.
Choice D is wrong because on sick days, the client should check blood sugar more
often and eat small amounts of carbohydrates to prevent hyperglycemia and ketoacidosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.