A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day.
The nurse interrupts the bath and obtains a healthy meal for the client.
This action by the nurse is an example of which of the following?

Countertransference.

Promoting trust.

Boundary crossing.

Veracity.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Countertransference is not the appropriate concept in this scenario. Countertransference refers to the nurse's emotional response to the client, which may be based on the nurse's unresolved issues and can negatively affect the therapeutic relationship. In this case, the nurse's actions are not driven by unresolved issues but by a desire to meet the client's basic needs.

Choice B rationale: Promoting trust is the most suitable explanation for the nurse's actions. By interrupting the bath and providing a healthy meal to a newly admitted client who hasn't eaten all day, the nurse is demonstrating empathy, compassion, and a commitment to meeting the client's physiological needs. This action helps build trust between the nurse and the client, as the client can see that their well-being is a priority.

Choice C rationale: Boundary crossing refers to actions that may blur or violate professional boundaries between a nurse and a client. While the nurse is going beyond the routine bath to provide a meal, this action is justified by the client's immediate need and doesn't constitute an inappropriate boundary crossing. The nurse is still maintaining professionalism in caring for the client.

Choice D rationale: Veracity is the principle of truth-telling and honesty in healthcare. It doesn't directly apply to this situation since the nurse's actions are not about providing information or disclosing something to the client. Instead, the nurse's primary concern is the client's nutritional well-being.

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Correct Answer is B

Explanation

Choice A rationale:

Positioning the client supine with legs elevated is not an appropriate intervention for a client with ascites due to cirrhosis. It may help with other conditions, but in ascites, it can increase pressure on the abdomen and worsen fluid accumulation.

Choice C rationale:

Restricting the client's sodium intake to 3g per day is a valid intervention for a client with ascites due to cirrhosis. However, measuring the abdominal girth daily is a more immediate and actionable intervention to monitor the progression of ascites and adjust treatment accordingly.

Choice D rationale:

Keeping the client's daily protein intake below 0.8 g/kg is not the standard practice for managing ascites in cirrhosis. In fact, adequate protein intake is important to prevent malnutrition in these clients, so protein restriction is not recommended unless specifically indicated by a healthcare provider.

A. "My partner and I will use petroleum jelly with latex condoms.” B. "My partner and I will both use a condom during intercourse.” C. "I will be able to remove my contraceptive sponge immediately after intercourse.” D. "My partner will use condoms with spermicides.”

Correct Answer is D

Explanation

The correct answer is choice D: "My partner will use condoms with spermicides.”

Choice A rationale:

"My partner and I will use petroleum jelly with latex condoms.” This statement is incorrect because petroleum jelly can degrade latex condoms, making them more likely to break. It’s important to use water-based or silicone-based lubricants with latex condoms to maintain their integrity and effectiveness.

Choice B rationale:

"My partner and I will both use a condom during intercourse.” Using two condoms at once, also known as ‘double-bagging’, is not recommended as it can increase the friction between the condoms and lead to breakage. Therefore, this statement does not indicate an understanding of proper condom use.

Choice C rationale:

"I will be able to remove my contraceptive sponge immediately after intercourse.” The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness, but not more than 30 hours in total. Immediate removal does not provide the necessary time for the spermicide in the sponge to deactivate the sperm.

Choice D rationale:

"My partner will use condoms with spermicides.” This statement is correct. Condoms with spermicides provide an additional layer of contraceptive protection by combining the barrier method with a chemical that deactivates sperm. This indicates an understanding of the teaching on effective contraceptive practices.

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A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis.Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls.Which of the following fall precautions should the nurse plan to implement first?

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

A nurse is assisting with the care of a newborn following a vaginal delivery.Which of the following actions should the nurse perform first?

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?

A nurse is caring for a client who has bulimia nervosa.Which of the following actions should the nurse take first?

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day.
The nurse interrupts the bath and obtains a healthy meal for the client.
This action by the nurse is an example of which of the following?