A female nurse is beginning to avoid going into the room of a male client who makes frequent sexual comments about nurses. The nurse's initial response should be to:

call the supervisor.

limit the amount of time spent in the client's room.

have a male nursing assistant provide care.

address the behavior and ask that it stop.

Answer and Explanation

The Correct Answer is D

A. Call the supervisor: While it's important to involve the supervisor if the situation escalates or if additional support is needed, calling the supervisor should not be the nurse's initial response. The nurse should first attempt to address the behavior directly with the client.

B. Limit the amount of time spent in the client's room: Limiting the time spent in the client's room may seem like a temporary solution to avoid the uncomfortable situation, but it does not address the underlying issue of inappropriate behavior. The nurse should address the behavior directly to attempt to resolve it rather than avoiding the client's room altogether.

C. Have a male nursing assistant provide care: Assigning care based on gender may not be feasible or appropriate in all situations. It also does not address the underlying behavior of the client making inappropriate sexual comments. Additionally, it may not be fair to the male nursing assistant to assign care based on the client's behavior.

D. Address the behavior and ask that it stop: This is the most appropriate initial response. The nurse should directly address the client's behavior by setting clear boundaries and expressing that the sexual comments are inappropriate and unacceptable. The nurse can assertively communicate that such behavior will not be tolerated and ask the client to stop. This approach empowers the nurse to assert professional boundaries and encourages respect for both the nurse and other healthcare providers.

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Correct Answer is B

Explanation

When a client experiences increased production of antidiuretic hormone (ADH) and aldosterone due to extreme stress, the body's response is aimed at retaining fluid to maintain blood pressure and hydration. As a result, urinary output decreases because the kidneys retain more water, leading to concentrated urine production. This decrease in urinary output helps conserve fluids and contributes to maintaining blood pressure and hydration levels in response to stress.

A. Serum osmolarity: With increased ADH production, serum osmolarity tends to remain stable or may even increase slightly due to the retention of water. ADH acts on the kidneys to increase water reabsorption, which can concentrate the blood and elevate serum osmolarity.

B. Urinary output: Increased production of ADH and aldosterone leads to decreased urinary output as the kidneys retain more water. This response helps conserve fluid volume and maintain hydration during times of stress.

C. Insensible fluid loss: Insensible fluid loss, which includes water lost through respiration and skin evaporation, is not directly affected by ADH and aldosterone. These hormones primarily influence renal water retention rather than insensible fluid loss.

D. Blood pressure: Although aldosterone can indirectly affect blood pressure by increasing sodium retention and therefore influencing fluid balance, its primary role is to regulate sodium and potassium levels. Blood pressure may be influenced by various factors, including stress, hydration status, and cardiovascular health, but it is not directly decreased as a result of increased ADH and aldosterone production.

A. Multiple lesions on dorsal aspect of feet probably due to elder abuse B. Four burned areas noted on plantar area of each foot C. Several partially healed lesions on bottom of left foot, looks like cigarette burns D. Four round, 2 cm in diameter lesions on plantar aspect of right foot

Correct Answer is D

Explanation

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

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A female nurse is beginning to avoid going into the room of a male client who makes frequent sexual comments about nurses. The nurse's initial response should be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is under extreme stress will have an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse should expect a decrease in which clinical finding?

Correct Answer is B

Explanation

What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Correct Answer is D

Explanation

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A female nurse is beginning to avoid going into the room of a male client who makes frequent sexual comments about nurses. The nurse's initial response should be to: