A nurse notices a client is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds.
Based on these nonverbal cues, which condition should the nurse assess for?
Choking.
Anxiety.
Depression.
Pain.
The Correct Answer is D
Choice A rationale
Choking typically presents with a universal distress signal, such as clutching the throat, and an inability to speak or breathe effectively. While gasping may occur in partial obstructions, a stooped gait and facial grimacing are more indicative of physical discomfort or musculoskeletal strain rather than an acute upper airway obstruction. The nurse should prioritize assessing for airway patency if choking is suspected, but the collective cues point elsewhere.
Choice B rationale
Anxiety often manifests through physiological signs like tachycardia, tachypnea, diaphoresis, or restless movements. While gasping can occur during a panic attack or hyperventilation, a stooped gait and facial grimacing are more classic indicators of physical pain. Anxiety is a psychological state that can influence physical presentation, but the nurse must first rule out a physical cause for the client's distorted posture and strained facial expressions during ambulation.
Choice C rationale
Depression is frequently associated with psychomotor retardation, slumped posture, and a flat affect or saddened facial expression. However, acute gasping and grimacing are less common unless the depression is accompanied by physical symptoms or somatic pain. While a stooped gait can reflect the heavy emotional toll of depression, the combination of all three nonverbal cues suggests a more immediate, acute physical stimulus requiring an assessment of pain levels.
Choice D rationale
Nonverbal cues are critical for identifying pain, especially when a client is moving. A stooped gait suggests the client is guarding a specific area, likely the abdomen or back, to minimize movement-related discomfort. Grimacing is a universal facial expression of distress, and gasping can occur as a reflexive response to sharp, sudden pain. The nurse should use a standardized pain scale to quantify the intensity and determine the location of the discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Autocratic leadership is characterized by individual control over all decisions with little input from group members. In this style, the leader dictates the tasks, roles, and procedures that the staff must follow. By ensuring that all nurses perform specific, pre-determined activities, the leader maintains strict control and hierarchy. This approach is often efficient in emergency situations where quick, decisive action is required without the time for group consensus or lengthy discussions among the nursing staff.
Choice B rationale
Encouraging pride and recognition for following policies is more aligned with transformational or transactional leadership styles. A transformational leader inspires staff to achieve excellence through a shared vision, while a transactional leader uses rewards to motivate compliance. While an autocratic leader expects policy adherence, the focus on building pride and internal motivation suggests a more nuanced approach to leadership that values the emotional buy-in of the nurses rather than just the execution of orders.
Choice C rationale
Ensuring that nurses are satisfied and motivated is a hallmark of democratic or servant leadership. These styles prioritize the well-being of the team and involve staff in decision-making processes to increase job satisfaction and morale. Autocratic leaders are typically less concerned with the individual satisfaction or motivation of the employees and are more focused on the completion of tasks and the maintenance of organizational structure and authority within the clinical environment.
Choice D rationale
Encouraging nurses to perform activities without supervision describes a laissez-faire leadership style. This "hands-off" approach provides the team with complete autonomy and minimal guidance from the leader. This is the opposite of autocratic leadership, where the leader is highly involved in directing every aspect of the work. Laissez-faire leadership can be effective with highly experienced and self-directed teams but lacks the centralized control and direction inherent in the autocratic leadership model.
Correct Answer is A
Explanation
Choice A rationale
The mode of transmission refers to how a pathogen travels from a reservoir to a new host, such as through droplets or airborne particles. Placing a surgical mask on a patient with an active respiratory infection physically contains the infectious agents at the source. This prevents the dispersal of pathogens into the environment during coughing or sneezing, thereby directly interrupting the pathway through which the microorganism moves from the client to others.
Choice B rationale
Hand hygiene is a critical component of infection control, but it primarily targets the portal of entry or the means of transfer via the hands of the healthcare worker. While it reduces the risk of cross-contamination, it does not stop the primary respiratory transmission from the patient’s lungs to the air. In the context of a respiratory infection, containing the source via masking is a more direct way to break the specific mode of transmission link.
Choice C rationale
Administering antibiotics focuses on treating the infectious agent within the reservoir or host. By reducing the microbial load, it eventually makes the person less infectious. However, this action does not immediately break the mode of transmission link itself. Instead, it works on the etiologic agent or reservoir link of the chain. It is a secondary measure compared to physical barriers that stop the active movement of pathogens during the infectious phase.
Choice D rationale
Providing a nutritious, high-protein diet is an intervention aimed at the susceptible host link of the chain of infection. Adequate nutrition, particularly protein intake, supports the immune system, promotes tissue repair, and enhances the body’s natural defense mechanisms against invading pathogens. While this makes the client more resilient, it does nothing to prevent the actual transmission of the respiratory pathogens from the current host to other individuals in the vicinity.
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