A nurse is teaching a class about client advocacy. The nurse should include which of the following as an example of client advocacy?
A nurse communicates a client's wishes to their provider.
A nurse keeps a promise to return to a client's room.
A nurse accepts responsibility for their own actions.
A nurse protects a client's personal health information.
The Correct Answer is A
Choice A rationale
Advocacy is defined as the act of speaking on behalf of the client to ensure their preferences and needs are met. When a nurse communicates a client's specific wishes to a provider, they are acting as a bridge between the client and the medical hierarchy. This ensures the client's autonomy is respected and that the plan of care aligns with the client's values, especially when the client may feel intimidated or unable to speak for themselves.
Choice B rationale
Keeping a promise to return to a client's room is an example of the ethical principle of fidelity. Fidelity involves being faithful to commitments and following through on promises made to others. While this builds trust and is essential for a therapeutic relationship, it is distinct from advocacy. Advocacy specifically involves representing the client's interests to others, whereas fidelity is about the direct reliability and integrity of the nurse-client relationship itself.
Choice C rationale
Accepting responsibility for one's own actions is the definition of accountability. This principle ensures that the nurse is answerable for the quality of care they provide and for any errors that may occur. Accountability is a professional obligation to the self, the profession, and the public. While it is a core value in nursing, it does not involve the act of representing or protecting the rights and wishes of the client to external parties.
Choice D rationale
Protecting a client's personal health information is an application of the principle of confidentiality and is legally mandated by regulations such as HIPAA. While keeping information private is a way of caring for the client, advocacy is more proactive and involves intervening to support the client's rights or choices. Confidentiality is a baseline legal and ethical requirement for all healthcare interactions rather than a specific act of speaking up or representing a client's voice.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Acute pain triggers the sympathetic nervous system, leading to a "fight or flight" response which commonly results in elevated blood pressure. This physiological reaction is a measurable manifestation of stress and discomfort in nonverbal clients. Normal blood pressure is typically considered to be less than 120/80 mmHg. Monitoring vital signs is a critical component of pain assessment when the patient cannot provide a self-report. Sustained elevations in blood pressure often indicate that the body is reacting to noxious stimuli.
Choice B rationale
In the presence of acute pain, pupils generally dilate rather than constrict due to the activation of the sympathetic nervous system. Mydriasis, or pupil dilation, is a common autonomic response to pain and high-stress levels. Constricted pupils, or miosis, are more frequently associated with the use of opioid medications or specific neurological conditions. Therefore, observing constricted pupils would typically lead a nurse to investigate causes other than acute pain, such as drug effects or specific brainstem injuries.
Choice C rationale
The physiological response to acute pain typically causes an increase in heart rate, known as tachycardia, rather than a decrease. A normal adult resting heart rate ranges from 60 to 100 beats per minute. When a client experiences pain, the release of catecholamines like adrenaline increases cardiac output and heart rate. A decreased heart rate, or bradycardia, is generally not a manifestation of acute pain and might indicate other issues like vagal stimulation, heart block, or the effect of certain medications.
Choice D rationale
Acute pain usually causes an increase in the respiratory rate and may lead to shallow breathing as the patient attempts to guard the painful area. A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A reduced respiratory rate, or bradypnea, is often a sign of respiratory depression, which can be caused by high doses of analgesics like opioids, rather than the pain itself. Identifying rapid, labored, or irregular breathing is more common in patients experiencing acute distress.
Correct Answer is A
Explanation
Choice A rationale
Methicillin-resistant Staphylococcus aureus is a multi-drug resistant organism that is primarily transmitted through direct physical contact with the patient or indirect contact with contaminated surfaces. Contact precautions require the use of gloves and a gown when entering the room to prevent the spread of the pathogen via the hands or clothing of healthcare workers. These measures are essential for infection control to protect other patients in the healthcare environment from colonization.
Choice B rationale
Protective precautions, also known as reverse isolation, are used to protect immunocompromised clients, such as those with severe neutropenia, from environmental pathogens. The goal is to keep the patient safe from others, whereas MRSA requires precautions to keep others safe from the patient's bacteria. Protective environments typically involve positive pressure rooms and HEPA filtration, which are not the standard or necessary protocols for managing a localized or systemic MRSA infection.
Choice C rationale
Airborne precautions are indicated for pathogens that remain suspended in the air for long periods and travel over long distances, such as tuberculosis, rubeola, or varicella. MRSA does not spread through the air via small droplet nuclei. Implementing airborne precautions would involve using N95 respirators and negative pressure rooms, which are unnecessary and consume excessive resources since MRSA is not a respiratory pathogen that stays airborne in a way requiring such high-level filtration.
Choice D rationale
Droplet precautions are intended for pathogens transmitted by large-particle droplets expelled during coughing, sneezing, or talking, which generally travel only 3 to 6 feet. Examples include influenza and pertussis. While MRSA can sometimes be found in sputum, its primary mode of transmission in the healthcare setting is through contact with the skin or environment. Therefore, contact precautions are the standard evidence-based intervention rather than droplet precautions for a diagnosis of MRSA.
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