Question

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

Answer 1

Correct Answers:

"I think about my grandfather's farm to reduce pain.”

Rationale :

🔸 Guided imagery involves mentally visualizing a peaceful, pleasant setting to promote relaxation and pain control.

🔸 The client's mention of imagining the grandfather's farm reflects use of personalized calming images to distract from discomfort.

🔸 This approach engages the mind-body connection, reducing sympathetic nervous system activity and pain perception.

🔸 It is a validated non-pharmacologic strategy for chronic pain and stress reduction.

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Answer 2

Correct Answers:

To a medical interpreter service on behalf of a client.

Rationale :

🔹 Sharing client information with a medical interpreter is an allowable disclosure under HIPAA because it's for the purpose of care.

🔹 The interpreter acts as a communication extension of the care team, facilitating understanding between client and provider.

🔹 This is considered part of the treatment process, not a separate or external release of information.

🔹 No written consent is required for disclosures related to treatment, payment, or healthcare operations.

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Answer 3

Correct Answers:

"Tell me more about your expectations.”

Rationale :

🟢 This response encourages open communication and exploration of the caregiver’s feelings and concerns.

🟢 It shows therapeutic presence without judgment, giving space for the caregiver to express emotions.

🟢 Reflecting and clarifying expectations helps the nurse assess the caregiver’s needs for support and respite.

🟢 This therapeutic communication technique promotes empathy and planning appropriate interventions.

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Answer 4

Correct Answers:

660

Rationale :

⚪ Formula Used:

Total Intake= Milk + Water + Gelatin

⚪ Conversions:

▶️8 oz milk = 240 mL

▶️10 oz water = 300 mL

▶️4 oz gelatin = 120 mL

(Egg, bacon, biscuits are solids—not counted)

⚪ Total:

▶️240 + 300 + 120

= 660 mL

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Answer 5

Correct Answers:

Review the client's photograph in the medical record.

Rationale :

✳️ When a client is unable to confirm identity due to cognitive impairment, a photo in the medical record is a reliable verification method.

✳️ This avoids medication errors and adheres to safety protocols in clients without ID bands.

✳️ Identification using visual confirmation must match with the current electronic or paper chart photo.

✳️ It is part of safe medication administration and reduces the risk of adverse events in vulnerable clients.

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Answer 6

Correct Answers:

A client whose grief response leads to self-destructive behaviors.

Rationale :

🔹 Exaggerated grief involves intense, prolonged emotional reactions that impair normal functioning.

🔹 Self-destructive behaviors such as substance abuse or suicidal ideation are hallmark signs of exaggerated grief.

🔹 The grief becomes overwhelming, and the client may be unable to cope with the emotional pain, leading to harmful outcomes.

🔹 Nursing interventions should include emotional support and referral to mental health services when this type of grief is suspected.

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Answer 7

Correct Answers:

Placing the restraint across the client's chest.

Rationale :

🔸 Applying a restraint across the chest is unsafe and can restrict breathing, increasing the risk of injury or death.

🔸 Proper use of a belt restraint involves placing it at the waist, over clothing, and securing it to the bed frame using a quick-release knot.

🔸 The restraint must never impede airway, breathing, or circulation and should allow for adequate mobility.

🔸 This action requires immediate intervention to protect client safety and adhere to restraint policies.

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Answer 8

Correct Answers:

"I will use disinfectant to clean the blood pressure cuff after use on a client.”

Rationale :

✳️ Cleaning non-critical items like BP cuffs with disinfectant helps prevent cross-contamination between clients.

✳️ Blood pressure cuffs can harbor pathogens, particularly in clients with infections or open wounds.

✳️ This practice aligns with standard precautions and equipment hygiene guidelines.

✳️ The statement shows a clear understanding of preventing healthcare-associated infections (HAIs).

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Answer 9

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

🟢 The nurse begins by pouring normal saline into the sterile basin to prepare the solution .

🟢 Next, the inner cannula is unlocked and removed for cleaning .

🟢 The nurse uses a small sterile brush to scrub both sides of the cannula thoroughly.

🟢 After brushing, the cannula is dried with a pipe cleaner to maintain patency.

🟢 Finally, the stoma site is cleansed with 0.9% sodium chloride to prevent infection.

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Answer 10

Correct Answers:

Avoid placing toilet tissue in the bedpan after defecation.

Rationale :

🔶 Toilet tissue can contaminate the stool specimen, affecting lab test results.

🔶 Clients should be instructed to defecate directly into the bedpan or specimen container without adding tissue.

🔶 Urinating beforehand is ideal, not after, to avoid contamination.

🔶 Proper collection ensures the validity of results, especially for tests like culture, ova and parasites, or occult blood.

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QLexNursing

1 :
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

2 :
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

3 :
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

4 :
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

5 :
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

6 :
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

7 :
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

8 :
A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

9 :
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?

10 :
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

QLexNursing

1 : A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

2 : A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

3 : A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

4 : A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

5 : A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

6 : A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

7 : A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

8 : A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

9 : A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?

10 : A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

1 :
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

2 :
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

3 :
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends.”. Which of the following is an appropriate response by the nurse?

4 :
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?

5 :
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

6 :
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

7 :
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?

8 :
A charge nurse is observing a newly licensed nurse who is caring for a group of clients. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

9 :
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?

10 :
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?