A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?
"I will call the doctor and get a prescription."
"I will cover the catheter so he cannot see it."
"I will provide more stimulation in his environment."
"Let's wait until tonight to see if he continues this behavior."
The Correct Answer is B
Choice A reason : While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.
Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.
Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.
Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.
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Related Questions
Correct Answer is D
Explanation
Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.
Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.
Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.
Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.
Correct Answer is D
Explanation
Choice A reason : Tarry stools, also known as melena, can be a sign of gastrointestinal bleeding, which may occur in cirrhosis due to the development of esophageal varices. However, it is not a direct symptom of cirrhosis itself but rather a complication that can arise from the condition¹.
Choice B reason : Blood in the urine is not a typical finding associated with cirrhosis. While cirrhosis can lead to problems with kidney function, hematuria is not a direct symptom of liver disease and may indicate other urological conditions¹.
Choice C reason : Moist skin is not commonly associated with cirrhosis. Patients with cirrhosis often experience skin changes, but these typically include jaundice, bruising, and spider angiomas, not increased moisture of the skin¹.
Choice D reason : Spider angiomas are a common finding in cirrhosis. They are small, spider-like capillaries visible under the skin and are caused by the increased estrogen levels that occur due to the liver's inability to metabolize hormones properly. They are most often found on the face, neck, upper chest, and arms¹².
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