A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure?

Correct Answer: D

Rationale: The correct answer is D, placing a washcloth between the skin and tourniquet. This helps protect the client's skin by providing a barrier to prevent direct pressure and friction from the tourniquet. It reduces the risk of skin damage and potential irritation. A: Lowering the extremity below the level of the heart is not necessary for protecting the skin during catheter insertion. B: Applying warm compresses may not necessarily protect the skin and can potentially increase the risk of skin damage. C: Tapping the skin lightly and avoiding slapping is unrelated to protecting the skin during the procedure.

Correct Answer: A

Rationale: The correct answer is A: White blood cell count. Clozapine can cause agranulocytosis, a potentially life-threatening side effect characterized by severe neutropenia. Evaluating the white blood cell count before starting clozapine therapy establishes a baseline for comparison. Regular monitoring of WBC count is essential to promptly recognize and manage this serious adverse reaction. Summary: - Choice A (White blood cell count) is correct because it helps in monitoring for agranulocytosis. - Choices B, C, and D are incorrect as they do not directly relate to the specific side effect of clozapine therapy.

Correct Answer: D

Rationale: The correct answer is D: Displacement. Displacement is a defense mechanism where one transfers their emotions or impulses from the original source to a less threatening target. In this scenario, the patient is redirecting their anger from their spouse to the nurse, a less threatening target. This behavior allows the patient to avoid dealing directly with the conflict. A: Denial involves refusing to accept reality. B: Projection is attributing one's own unacceptable feelings or thoughts to others. C: Sublimation is channeling unacceptable impulses into socially acceptable actions.

Correct Answer: B

Rationale: The correct answer is B: to provide comfort measures. Palliative care focuses on improving the quality of life for patients with serious illnesses by providing relief from symptoms and addressing physical, emotional, and spiritual needs. Assisted suicide (option A) is not a focus of palliative care. Aggressively treating the disease (option C) may not align with the goals of palliative care, which prioritize quality of life over aggressive treatment. Aggressively treating symptoms (option D) is important in palliative care but does not encompass the holistic approach of providing comfort measures. Overall, the priority of palliative care is to provide comfort and support to enhance the patient's well-being.

Correct Answer: D

Rationale: The correct answer is D: Hold her hand. This action best depicts the 'Caring' aspect of SENC (Support, Encourage, Nurture, and Coach). By holding her hand, you are providing physical comfort and emotional support, showing empathy and understanding. This gesture conveys a sense of presence and solidarity, helping the client feel heard and valued. Calling the parents back (A) may not be appropriate without the client's consent. Referring to the Chaplain (B) may not address the immediate emotional needs. Crying with the client (C) may blur professional boundaries and not necessarily provide the necessary support.