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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"Determine the client's ability to use the call light." - This is the correct answer. Assessing the client's ability to use the call light is the first step in fall prevention. If the client can effectively use the call light, they can request assistance when needed, reducing the risk of falls. It's essential to assess their communication and mobility abilities.
Choice B rationale:
"Create a schedule with an assistive personnel to do hourly rounding for the client." - While hourly rounding is a valuable fall prevention strategy, assessing the client's ability to use the call light should be the initial step to ensure immediate access to help. Rounding can complement this measure.
Choice C rationale:
"Move the bedside table with the client's personal items close to the bed." - While ensuring the client's personal items are within reach is important for their comfort and convenience, it is not the first step in fall prevention. Assessing the client's ability to request assistance takes precedence.
Choice D rationale:
"Apply rubber-soled slippers before ambulation." - Providing appropriate footwear is important for fall prevention, but it is not the first precaution to implement. Assessing the client's ability to use the call light and communicate their needs comes before addressing ambulation.
Correct Answer is B
Explanation
Choice A rationale:
Hydrogen peroxide. Hydrogen peroxide is not the recommended solution for disinfecting surfaces following a blood spill. While it can be used to clean wounds and may have some disinfectant properties, it is not as effective as bleach in destroying bloodborne pathogens.
Choice B rationale:
Bleach. Bleach is the appropriate choice for disinfecting surfaces contaminated with blood. A 10% bleach solution (1 part bleach to 9 parts water) is effective at killing bloodborne pathogens such as HIV and hepatitis B and C viruses. It should be used in healthcare settings to ensure proper disinfection after a blood spill.
Choice C rationale:
Isopropyl alcohol. Isopropyl alcohol is an effective disinfectant for some purposes, but it may not be as effective as bleach against bloodborne pathogens. It is commonly used for cleaning and disinfecting skin before medical procedures but is not the recommended choice for disinfecting surfaces following a blood spill.
Choice D rationale:
Chlorhexidine. Chlorhexidine is an antiseptic solution often used for skin disinfection before surgical procedures or invasive medical interventions. It is not typically used for disinfecting surfaces contaminated with blood.
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