The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Middle-aged man experiencing the acute phase of myocardial infarction (MI)

Older adult with a history of dementia admitted for dehydration

Young adult in the rehabilitative phase after arthroscopic surgery

Middle-aged woman just diagnosed with terminal lung cancer

Answer and Explanation

The Correct Answer is A

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

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Correct Answer is C

Explanation

A. Partial assistance required for daily activities: A score lower than 6 indicates some level of dependence or the need for assistance, which does not apply to a score of 6.

B. Complete dependence on others for daily activities: A score of 0 on the Katz Index would reflect complete dependence. A score of 6 indicates full independence.

C. Full independence in performing daily activities: A score of 6 on the Katz Index signifies that the individual can perform all six activities of daily living independently, demonstrating a high level of functional ability.

D. Moderate assistance required for daily activities: A score of 6 indicates total independence. A score of 3 or lower would suggest moderate assistance is required, making this option incorrect.

A. Encouraging the client to consume a high-protein diet B. Placing the client in a room with positive-pressure airflow C. Changing the client's bed linens each day D. Performing hand hygiene before, during, and after direct contact with the client

Correct Answer is D

Explanation

A. Encouraging the client to consume a high-protein diet: While a high-protein diet can support the client's immune system and promote healing, it does not directly prevent the transmission of infection. Nutritional support is important for recovery, but it is not a primary strategy for infection control.

B. Placing the client in a room with positive-pressure airflow: Positive-pressure airflow is typically used in rooms for immunocompromised patients to prevent exposure to airborne pathogens, not for clients with infections. Infected patients generally require isolation precautions, which may include negative-pressure rooms, especially for airborne or droplet precautions.

C. Changing the client's bed linens each day: Although maintaining clean linens is important for general hygiene and comfort, simply changing bed linens does not significantly prevent the transmission of infection. Effective infection control measures focus more on direct contact precautions and environmental cleanliness rather than the frequency of linen changes alone.

D. Performing hand hygiene before, during, and after direct contact with the client: Hand hygiene is one of the most effective strategies to prevent the transmission of infections in healthcare settings. Proper handwashing or use of alcohol-based hand rubs significantly reduces the risk of spreading pathogens and protects both the patient and healthcare providers from infections. This strategy is essential in breaking the chain of infection.

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The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What does a score of 6 on the Katz Index of Independence in Activities of Daily Living (ADLs) indicate?

Correct Answer is C

Explanation

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

Correct Answer is D

Explanation

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