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 A

Explanation

A. Droplet: Pertussis, also known as whooping cough, is transmitted through respiratory droplets when an infected person coughs or sneezes. Therefore, droplet precautions are necessary to prevent the spread of the infection to others. This includes wearing a surgical mask when within 3 feet of the client and ensuring the client wears a mask when outside of their room.

B. Contact: Contact precautions are used for infections that can be spread through direct or indirect contact with the patient or contaminated surfaces. While there may be some overlap, contact precautions are not the primary focus for pertussis transmission.

C. Protective: Protective precautions (also known as reverse isolation) are utilized to protect immunocompromised patients from infections. This is not applicable for a patient with pertussis, as the focus is on preventing the spread of the infection rather than protecting the patient from pathogens.

D. Airborne: Airborne precautions are used for infections that are transmitted via airborne droplet nuclei, such as tuberculosis or measles. Pertussis does not fall under this category, as it is primarily transmitted through larger respiratory droplets.

E. Full semen: This option is not a recognized type of precaution. The correct term should focus on standard and transmission-based precautions relevant to infectious diseases.

A. Reduced chest width B. Decreased muscle mass C. Thickened vertebral disks D. Increased force of isometric contraction

Correct Answer is B

Explanation

A. Reduced chest width: While aging can lead to changes in the thoracic cavity, such as a decreased ability to expand the chest due to loss of elasticity in lung tissue, reduced chest width is not a primary musculoskeletal change associated with aging. The focus should be on musculoskeletal changes rather than respiratory or thoracic changes.

B. Decreased muscle mass: This is a significant and well-documented age-related change in the musculoskeletal system. Sarcopenia, or the loss of muscle mass and strength with aging, affects mobility and function in older adults. This change should be included in the presentation as it is relevant to the musculoskeletal system and impacts overall health and activity levels.

C. Thickened vertebral disks: With aging, vertebral disks typically degenerate and lose hydration, which can lead to thinning rather than thickening. This degeneration contributes to decreased height and may increase the risk of spinal issues, so thickening is not an accurate representation of age-related changes.

D. Increased force of isometric contraction: Aging generally leads to a decrease in muscle strength and function, including the force of isometric contractions. This decline can affect the ability to perform daily activities and maintain independence, making this statement inaccurate in the context of age-related changes.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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