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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Move the client's limbs through their complete range of motion: This action describes passive range-of-motion exercises, where the nurse assists the client in moving their limbs. While this is beneficial for clients who cannot move independently, it does not align with the plan for isometric exercises, which focus on muscle contraction without joint movement.
B. Have the client move each limb independently through its complete range of motion: This describes active range-of-motion exercises, which involve the client actively moving their limbs. Although these exercises are important for maintaining joint flexibility and preventing stiffness, they are not isometric exercises, which are intended to be performed without changing the length of the muscle.
C. Ask the client to move her arms and legs while applying slight resistance: This action combines movement with resistance training, which is not consistent with isometric exercises. Isometric exercises focus solely on muscle contraction without joint movement or changing muscle length, making this option inappropriate for the prescribed plan of care.
D. Instruct the client to tighten muscle groups for a short period, and then relax: This accurately describes isometric exercises, where the client contracts specific muscle groups (e.g., arms, legs, abdomen) without moving the joints. These exercises help maintain muscle strength and prevent atrophy while the client is on bedrest. The nurse should guide the client to perform these contractions for a few seconds, followed by relaxation, as directed by the plan of care.
Correct Answer is ["A","C","E"]
Explanation
A. Bathe a client who had an amputation 2 days ago: This task can be delegated to assistive personnel (AP). APs are trained to assist with activities of daily living, including bathing, under the supervision of nursing staff. The nurse should ensure that the AP is aware of any special considerations related to the client's recent amputation.
B. Review a low-sodium diet for a client who has hypertension: This task should not be delegated to APs, as it requires nursing knowledge and understanding to educate the client effectively. Discussing dietary modifications involves assessing the client's understanding and providing education, which falls under the nursing scope of practice.
C. Feed a client who had a stroke 3 months ago: This task can be delegated to APs, provided that the client is stable and the AP has been trained to assist clients with feeding. However, the nurse should assess the client's swallowing ability and any specific precautions related to the stroke before delegating this task.
D. Explain oral hygiene to a client receiving chemotherapy: This task should not be delegated to APs because it involves providing specific education and instructions regarding oral care, which requires nursing judgment and knowledge about the implications of chemotherapy on oral health.
E. Assist a client to ambulate using a gait belt: This task can be delegated to APs. Assisting with ambulation is within the scope of practice for APs, especially when proper techniques and safety measures, such as using a gait belt, are followed. The nurse should ensure that the AP has received appropriate training to assist with ambulation safely.
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