A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?

Correct Answer: B

Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.

Correct Answer: D

Rationale: Option D, "The insulation on your nerve cells is damaged, which slows the impulses to the muscles," is the most accurate explanation for multiple sclerosis. Multiple sclerosis is a chronic autoimmune disorder where the body's immune system mistakenly attacks the myelin sheath, the protective covering of nerve fibers in the central nervous system. This damage disrupts the normal flow of electrical impulses along the nerves, leading to various symptoms such as muscle weakness, coordination problems, and balance issues. By understanding that the insulation on her nerve cells is damaged, the patient can better comprehend why she is experiencing symptoms like muscle weakness and falls.

Correct Answer: C

Rationale: During a lumbar puncture procedure, it is important to position the patient correctly to facilitate the procedure and minimize the risk of complications. Placing the patient on their side with their knees drawn up to their chest helps open up the spaces in the lower spine, making it easier for the healthcare provider to access the appropriate area for the procedure. This position also helps to minimize the risk of post-procedure complications such as spinal headaches. Monitoring the patient's vital signs is important but does not specifically relate to the nursing intervention during the lumbar puncture procedure. Labeling laboratory specimens in numerical order is also a routine task but not directly related to the procedure itself. Thus, the correct intervention during the lumbar puncture procedure is positioning the patient on their side with knees drawn up to the chest.

Correct Answer: C

Rationale: After thoracentesis, it is important to position the client on the unaffected side to prevent leakage of fluid into the thoracic cavity. Placing the client on the unaffected side helps to promote proper drainage and reduce the risk of complications such as pneumothorax or fluid leakage. This position also allows for adequate lung expansion and facilitates proper re-expansion of the lung on the side where the fluid was removed. It is essential to follow this positioning to optimize outcomes and minimize risks associated with the procedure.

Correct Answer: D

Rationale: Acute bacterial conjunctivitis is commonly known as "pinkeye." This condition is characterized by inflammation of the conjunctiva (the thin transparent layer covering the white part of the eye and the inside of the eyelids) due to a bacterial infection. It is a common eye condition that can cause symptoms such as redness, swelling, itching, and a discharge from the eye. Treatment often involves antibiotic eye drops or ointments to help clear the infection. It is important for patients with pinkeye to practice good hygiene, avoid sharing towels or pillows, and wash hands frequently to prevent the spread of infection to others.