Prep U

The nurse is caring for a terminally ill client who immigrated from Mexico. Which nursing intervention regarding spiritual care is appropriate?

Ask the client if a spiritual leader is desired. The appropriate response is to ask the client if a spiritual leader is desired, which is observant of the client's preferences. The nurse should not generalize that a Latino client is Roman Catholic, nor should the nurse refrain from inquiring about spiritual needs.

The nurse is caring for an older client who is ordered restraints. What is the priority nursing action?

Offer the client bathroom privileges and assistance Restraints for patients 18 years and older must be removed every four hours, six hours is too long. Choosing the least restrictive restraint will help to prevent injury and skin breakdown on bony prominences. Keeping arm restraints loose can potentially harm the client. Paper tape is insufficient to secure restraints. The nurse must attend to the client's basic needs regardless of whether he or she is restrained.

he nurse is teaching a black client about common health conditions. Which statement by the client most directly addresses a health problem with an increased incidence in this population group?

"It is important to monitor my blood pressure." Monitoring the blood pressure is important for identifying the risk for hypertension and stroke, which are common health conditions among the black population. The other statements are correct for preventing diabetes, breast cancer, and osteoporosis, but these diseases are not disproportionately common health conditions for the population.

Which definition of culture is most accurate?

A belief system that guides behavior Culture is a belief system that the members of the culture hold, to varying degrees, consciously or unconsciously, as absolute truth. That belief system guides everyday behavior and makes it routine. Culture is not simply a cluster of individuals with no commonality. Culture is not a grouping of people based on altruism. Members of a culture are not completely uniform.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. The client should be released from the restraint as soon as he or she is no longer a risk to self or others. Decisions should be based on the client's present status, not on his or her history. Restraints must be ordered by a health care provider and the least restrictive device should be used.

A nurse is preparing a teaching session about heart failure for a group of older adults. When planning this session, which action would be important for the nurse to integrate into the session? Select all that apply.

-Keep outside distractions to a minimum. -Allow for extra time to answer questions. -Plan sessions that are short in duration. -Tie in new information with things the group is familiar with.

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate Clients with hearing impairment pose unique challenges for communication. Assessing how the client communicates best is important. For example, if a deaf client can read and write, writing can facilitate communication. If the client knows sign language, the nurse could use a person trained in sign language. Using hand gestures and exaggerated facial movements does not allow for adequate acquisition of knowledge.

A nurse is discharging a client terminates the nurse-client relationship. Which action should the nurse perform in this phase?

examine goals of the relationship to determine whether they were achieved In the termination phase, the nurse and client examine the goals of the nurse-client relationship for indications of their attainment, or for evidence of progress toward them. If goals were not attained, the nurse should help the client establish a relationship with a new nurse. Making formal introductions and making a contract regarding the relationship occur in the orientation phase. Providing assistance to achieve goals occurs in the working phase.