The patient refuses a morning bath, stating a preference for evening baths. What is the best action for the nurse to take?

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Question 1 of 5

The patient refuses a morning bath, stating a preference for evening baths. What is the best action for the nurse to take?

Correct Answer: A

Rationale: The best action for the nurse is to respect the patient's preference and autonomy. By deferring the bath until evening, the nurse acknowledges and accommodates the patient's routine, promoting patient-centered care. Choice B could be seen as dismissive of the patient's preference and may not foster a therapeutic relationship. Choice C, while important, doesn't address the patient's current refusal. Choice D is not respectful of the patient's autonomy and could lead to increased resistance. Therefore, option A is the most appropriate and patient-centered approach.

Question 2 of 5

A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

Correct Answer: B

Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.

Question 3 of 5

Which client statement from the assessment data is likely to explain their noncompliance with propranolol hydrochloride (Inderal)?

Correct Answer: C

Rationale: The correct answer is C. Propranolol hydrochloride (Inderal) is known to cause side effects such as diminished sexual function, which can lead to noncompliance with the medication due to its impact on quality of life. Choices A, B, and D are less likely to be associated with propranolol hydrochloride. While diarrhea, difficulty falling asleep, and feeling jittery are possible side effects of propranolol, they are not as commonly reported as diminished sexual function. Therefore, choice C is the most likely reason for the client's noncompliance.

Question 4 of 5

A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicates a potential hazard for this test?

Correct Answer: B

Rationale: The correct answer is B, 'Allergic to shellfish.' An allergy to shellfish can indicate a sensitivity to iodine, which is used in the contrast dye for an IVP, posing a risk of an allergic reaction. Reflex incontinence (Choice A) is not directly related to the potential hazard of an IVP. Claustrophobia (Choice C) and hypertension (Choice D) are also not significant factors that indicate a potential hazard for an IVP.

Question 5 of 5

In a disaster at a child day care center, which child would the triage nurse prioritize for treatment last?

Correct Answer: B

Rationale: The toddler with severe deep abrasions covering 98% of the body would be prioritized for treatment last because these extensive injuries may require immediate attention and resources. The other choices present serious conditions but are not as severe or life-threatening as the toddler's injuries. The infant with an intermittent bulging anterior fontanel may have signs of increased intracranial pressure, requiring prompt evaluation. The preschooler's fractures, though serious, can be managed without immediate critical intervention. The school-age child with singed eyebrows and hair may have suffered burns but does not exhibit injuries as severe as the toddler's deep abrasions.

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