Nokea
An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
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A nurse uses an institution's procedure manual to confirm how to insert a nasogastric tube. The level of critical thinking the nurse is using is:
- A. Basic critical thinking
- B. Commitment
- C. Complex critical thinking
- D. Scientific method
Correct Answer: A
Rationale: Basic critical thinking involves following established guidelines or procedures, like using a manual for nasogastric tube insertion, typical for novices relying on concrete rules. The nurse here seeks confirmation, indicating dependence on external standards rather than independent judgment. Commitment reflects decisive action based on internalized reasoning, not manual reliance. Complex critical thinking analyzes and adapts procedures (e.g., modifying technique for patient anatomy), requiring experience beyond rote steps. The scientific method tests hypotheses, not applicable to routine protocol checks. Basic critical thinking suits this scenario, as the nurse applies learned steps without deviation, a foundational level ensuring safe practice while building toward higher-order skills in dynamic clinical settings.
Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger 'That is an unacceptable behavior Roger, Stop and go to your room now.' The situation is most likely in what phase of NPR?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: This scenario fits the Working phase (C). Roger's agitation and Aida's response setting boundaries suggest an established relationship where interventions address behaviors. Pre-Orientation (A) is pre-contact, Orientation (B) builds trust, not confrontation, and Termination (D) ends care. In Peplau's Working phase, the nurse actively helps the client manage issues, as Aida does here, making C the likely phase.
A nurse must possess several characteristics to be successful in this profession. Secondary to critical thinking skills, which is of great value?
- A. Good teamwork and team-building skills
- B. A master's degree
- C. The ability to delegate responsibilities
- D. Advocating for the client at all times
Correct Answer: D
Rationale: Beyond critical thinking, advocating for the client at all times is a cornerstone of nursing success, reflecting the profession's core commitment to patient welfare. This involves ensuring clients' needs, rights, and preferences are prioritized in all care decisions, fostering trust and empowerment. Good teamwork and team-building skills are valuable for collaboration but are learned and applied contextually, not as intrinsic as advocacy. A master's degree enhances expertise but isn't required for foundational success, as many nurses excel with lesser credentials. Delegation is a skill that supports efficiency, yet it's secondary to the nurse's role as a client advocate. Advocacy drives nursing's caring ethos, addressing health needs across diverse settings and populations, making it a vital characteristic that complements critical thinking in achieving optimal outcomes and upholding professional integrity.
You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
- A. Stop working on these goals, as evaluation is the last step.
- B. Assess client's motivation for complying with the care plan.
- C. Reassess problem and then review care plan and revise as needed.
- D. Determine if the client has a knowledge deficit causing nonattainment.
Correct Answer: C
Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.
The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.
- A. Administering the epidural injection
- B. Ensuring adequate hydration
- C. Encouraging the client to void
- D. Monitoring the condition of the fetus
Correct Answer: D
Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.