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","E"]

Explanation

A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.

B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.

C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.

D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.

E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.

A. Jugular vein distention B. Skin turgor, tenting at clavicular area C. Elevated hematocrit D. Oral mucous membranes dry and sticky

Correct Answer is ["B","C","D"]

Explanation

A. Jugular vein distention: Jugular vein distention is not typically associated with deficient fluid volume (dehydration). Instead, it is often seen in conditions of fluid overload, such as heart failure or volume overload. Therefore, this finding is not accurate for deficient fluid volume.

B. Skin turgor, tenting at clavicular area: Skin turgor refers to the skin's ability to return to its normal position after being pinched or pulled. In cases of deficient fluid volume (dehydration), skin turgor is decreased, leading to delayed return of the skin to its normal state. Tenting at the clavicular area is a specific sign of decreased skin turgor and is indicative of dehydration.

C. Elevated hematocrit: Deficient fluid volume (dehydration) leads to hemoconcentration, where there is a relative increase in the proportion of red blood cells to plasma volume. As a result, the hematocrit level, which represents the percentage of red blood cells in the total blood volume, increases. An elevated hematocrit is a laboratory finding commonly associated with deficient fluid volume.

D. Oral mucous membranes dry and sticky: Dehydration can lead to decreased saliva production and dryness of the oral mucous membranes. Dry and sticky oral mucous membranes are common clinical signs of deficient fluid volume (dehydration) and indicate inadequate fluid intake or loss.

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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

The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

Correct Answer is ["B","E"]

Explanation

The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

The client tells the nurse. "The need to urinate comes on me all of a sudden, and it feels as though I have to go immediately-that I can't wait." The nurse charts that the client is experiencing:

The nurse understands that how a client feels on the inside about being male, female, both or neither is known as:

The client asks the nurse "Why is it necessary to secure the indwelling urinary catheter to my thigh?" The nurse's best response would be. "It is Important to prevent:

A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

When assessing a client's sexuality, the nurse is aware that one's own personal values and attitudes:

A client who has a terminal illness asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

When working with clients of any age, the nurse keeps in mind that the key to mutually-satisfying, healthy sexual relationships between partners is most often:

The nurse is caring for a client with a fluid volume deficit and hypovolemia. What actions can the nurse take without a physician's order?