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A nurse is caring for an alert and oriented client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family on behalf of the client?

The client's sense of loss can be lessened through retaining dignity and control of certain areas of their life such as ADLs.

Allowing the client to function independently will strengthen their muscles and promote healing from the illness.

The client's decision in regards to their care should not influence their family's decision to assist with ADLs.

The ADLs can only be performed by a member of the healthcare team.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. The rationale for self-care that the nurse should communicate to the client's family is that the client's sense of loss can be lessened through retaining dignity and control of certain areas of their life such as ADLs. Allowing the client to perform self-care activities independently, to the extent possible, promotes the client's autonomy and helps to preserve their selfesteem and sense of control over their life. As the client nears the end of life, it is important to respect their wishes and promote their comfort and well-being in every way possible.

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Correct Answer is B

Explanation

A. Use only written communication whenever possible to minimize the client's frustration.Written communication can be helpful in some situations, but it should not be the primary mode of communication for clients with moderate hearing loss unless necessary.

B. Minimize background noises such as the television and ensure that lighting is adequate to see the nurse's face.Reducing background noise and ensuring proper lighting are critical strategies for effective communication with individuals with hearing loss. These steps make it easier for the resident to hear and understand, and they also allow the resident to use visual cues, such as lip-reading, to enhance communication.

C. Use vocabulary and concepts that are as simple as possible.
While simplifying vocabulary may help some individuals, it is not necessary or beneficial for all residents with hearing loss. This could come across as condescending unless it aligns with the client’s cognitive ability.

D. Repeat each direction or question multiple times, even if the client states he heard and understands the directions: Repeating unnecessarily can be frustrating and counterproductive for the client. It is more effective to ensure the initial communication is clear and check for understanding without excessive repetition unless the resident indicates they need clarification.

A. Cleanse the catheter from the meatus outward using mild soap and warm water. B. Use the same cleansing cloth for cleaning of the perineal area and the catheter tubing. C. Use chlorhexidine gluconate (CHG) to cleanse the perineal area

Correct Answer is A

Explanation

The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.

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A nurse is caring for an alert and oriented client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family on behalf of the client?

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Naxlex Comprehensive Predictor Exams

A resident of a long-term care facility has moderate hearing loss and is hard of hearing. When communicating with this resident, which of the following would be the best initial technique?

Correct Answer is B

Explanation

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Correct Answer is A

Explanation

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