A nurse is speaking with the sibling of a client who refuses to see visitors.
Which of the following actions should the nurse take?
Arrange for the sibling to visit the client in the dayroom.
Refer the sibling to the client's provider.
Tell the sibling the client does not want visitors.
Encourage the client to visit with the sibling.
The Correct Answer is C
Choice A rationale
Arranging a visit without the client’s consent disregards their right to refuse visitors, which is important to respect their autonomy.
Choice B rationale
Referring the sibling to the provider does not address the client’s current refusal and bypasses the nurse’s role in facilitating communication.
Choice C rationale
Informing the sibling that the client does not want visitors respects the client’s wishes and maintains their confidentiality.
Choice D rationale
Encouraging the client to visit with the sibling may pressure the client and does not respect their current refusal of visitors. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Drinking alcohol before bed can disrupt sleep patterns and reduce overall sleep quality. While alcohol may initially induce drowsiness, it can lead to fragmented sleep, causing more awakenings during the night.
Choice B rationale
Eating a meal just before bedtime can cause discomfort and interfere with the ability to fall asleep. The body's digestion process can disrupt the onset of sleep and reduce sleep quality.
Choice C rationale
Taking a nap after lunch can interfere with the body's natural sleep-wake cycle, making it more difficult to fall asleep at night. Napping late in the day can reduce the need for sleep at bedtime.
Choice D rationale
Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep. Reducing caffeine consumption, especially in the afternoon and evening, can improve sleep quality.
Correct Answer is B
Explanation
Choice A rationale
Increasing the client's daily caloric intake is not an intervention specifically recommended for clients taking lithium. Lithium therapy requires monitoring of fluid and electrolyte balance, but there is no specific recommendation to increase caloric intake as part of the treatment plan.
Choice B rationale
Administering lithium with meals is recommended to reduce gastrointestinal upset. Lithium can cause stomach irritation, and taking it with food helps minimize this side effect, improving the client's comfort and adherence to the medication regimen.
Choice C rationale
Monitoring for hypoglycemia is not a standard intervention for clients taking lithium. Lithium primarily affects fluid and electrolyte balance, particularly sodium levels, but it is not associated with causing hypoglycemia. Monitoring for lithium toxicity and maintaining appropriate hydration are more critical aspects of care.
Choice D rationale
Decreasing dietary potassium is not required for clients taking lithium. Lithium does not affect potassium levels significantly, and there is no need to modify potassium intake. The focus should be on maintaining adequate hydration and monitoring lithium levels to avoid toxicity.
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