A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:

Exhibits
Which of the following are the most appropriate interventions for this client? Select all that apply.

Encourage the client to increase physical activity and engage with peers.

Suggest the client remain in bed to avoid unnecessary exertion.

Teach the caregiver how to monitor for signs of infection in pressure injuries.

Assist the client in using the restroom to avoid incontinence.

Answer and Explanation

Correct Answer : A,C,D

The correct answers are Choices A, C, and D.

Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.

Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.

Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.

Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.

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Correct Answer is A

Explanation

Choice A rationale

Donning appropriate personal protective equipment (PPE), including an N95 respirator mask, face shield, gown, gloves, and shoe coverings, is crucial to protect the nurse from potential exposure to the virus during close contact with a symptomatic client.

Choice B rationale

Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.

Choice C rationale

Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.

Choice D rationale

Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.

A. Inform him that the nurse is busy admitting a new client and will talk to him later. B. Put his behavior on extinction (do not acknowledge it) and continue talking with the newly admitted client. C. Introduce him to the newly admitted client and ask him to join in the conversation. D. Encourage him to go to the nurse's station and talk with another nurse.

Correct Answer is A

Explanation

Choice A rationale

Informing the client that the nurse is busy and will talk to him later is a professional and appropriate response. This approach acknowledges the client's need for attention while setting a clear boundary that respects the nurse's current responsibilities. It also provides a time frame for when the client can expect to receive attention, which can help reduce anxiety or agitation. This method promotes orderly and efficient care without compromising the needs of the newly admitted client.

Choice B rationale

Putting the client's behavior on extinction by not acknowledging it might seem effective, but it can lead to feelings of being ignored or dismissed. This approach is not therapeutic in a psychiatric setting, where clients often require validation and structured interactions. Ignoring a client's request can escalate the behavior or contribute to a sense of isolation. Therapeutic communication involves active listening and responding appropriately to all clients.

Choice C rationale

Introducing the client to the newly admitted client and asking him to join the conversation can be disruptive and inappropriate. This action may not address the urgency of the client's concern and can intrude on the privacy and focus needed for the newly admitted client. It is important to maintain a structured and private environment for admissions to ensure that the new client feels supported and understood.

Choice D rationale

Encouraging the client to go to the nurse's station and talk with another nurse may not be practical, especially if the other nurses are also occupied. This response can seem dismissive and may not adequately address the client's immediate concern. It is more effective to provide a clear time frame or alternative solution for when the client will receive attention. Proper delegation requires ensuring that the alternative option is available and can provide the necessary support.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is A

Explanation

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