A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Hearing acuity intact

Oriented to person only

Full range of motion bilateral lower extremities

Ability to use call light

Answer and Explanation

The Correct Answer is B

A)   Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B)   Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C)   Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D)   Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.

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Correct Answer is A

Explanation

A) Play music in the client's room. - Music therapy can be a beneficial nonpharmacological intervention for managing pain and promoting relaxation.
B) Keep the client's room well lit. - Bright lighting may exacerbate pain for some clients; dim lighting or allowing the client to control the lighting can be more helpful.
C) Ensure that the client's room is kept at a cool temperature. - Temperature preferences can vary among individuals; the nurse should adjust the room temperature according to the client's comfort.

D) Encourage the client to abstain from distracting activities. - Engaging in distracting activities can help divert the client's attention from pain, so encouraging them may be appropriate.

A. "He is here in the hospital, but I cannot tell you anything else." B. "I cannot confirm or deny that we have a client by that name." C. "The client's condition is stable right now." D. "I will tell him you called."

Correct Answer is A

Explanation

A. "He is here in the hospital, but I cannot tell you anything else."- This response respects the client's confidentiality and does not disclose protected health information to unauthorized individuals.

B. "I cannot confirm or deny that we have a client by that name."- This response is evasive and does not provide any useful information.
C. "The client's condition is stable right now."- Disclosing the client's condition without their consent is a violation of confidentiality.
D. "I will tell him you called."- This response breaches the client's confidentiality by confirming their presence in the hospital.

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A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take

Correct Answer is A

Explanation

A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

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