Nokea
The nurse is caring for a client who is diagnosed with type 1 diabetes mellitus. Which nursing action would most likely improve client compliance with the therapeutic regimen?
- A. Consistently ignore negative statements made by the client.
- B. Avoid touching the client to reduce tension and uneasiness.
- C. Focus on the physical aspects of care such as insulin administration.
- D. Listen attentively to the client's perception of having a chronic illness.
Correct Answer: D
Rationale: The correct answer is D because listening attentively to the client's perception of having a chronic illness is crucial for building a therapeutic relationship and understanding their concerns, fears, and challenges. By actively listening, the nurse can address the client's emotional and psychological needs, which are essential in managing a chronic condition like type 1 diabetes. This approach fosters trust, enhances communication, and promotes client engagement in their treatment plan.
Choices A, B, and C are incorrect because ignoring negative statements, avoiding physical contact, and solely focusing on the physical aspects of care can lead to poor client-nurse communication, lack of trust, and ultimately hinder compliance with the therapeutic regimen. Ignoring negative statements may escalate resistance, avoiding physical contact may create distance, and solely focusing on physical care neglects the holistic needs of the client.
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The nurse cares for an elderly patient in a long-term care center. Which would be inappropriate for the nurse to share with the client?
- A. Reminisce about birthday celebrations and inquire about the client's traditions.
- B. Use high levels of intimacy to help the client feel more comfortable with the nurse.
- C. Establish a helping relationship based on trust by sharing a personal story with the client.
- D. Share with the client how meditation decreased nausea during chemotherapy treatment.
Correct Answer: B
Rationale: The correct answer is B because using high levels of intimacy with a client, especially in a professional setting like a long-term care center, can violate boundaries and be inappropriate. The nurse should maintain a professional and therapeutic relationship with the client. Reminiscing about birthday celebrations (A) can help establish rapport and show interest in the client's life. Sharing personal stories (C) can build trust and connection. Sharing a relevant experience about meditation (D) can provide valuable information and support. In summary, maintaining appropriate boundaries and professionalism is crucial in a nurse-client relationship.
The nurse instructs the nursing assistant to obtain temperatures on four patients and report abnormal findings immediately. Two hours later the nurse discovers that one of the patients had a fever that was not reported. The nurse is upset with the nursing assistant. Which statement, if made by the nurse, is concrete and specifically explains the nurse's feelings?
- A. "I am not dissatisfied with your performance, because we all make mistakes."
- B. "You must have misunderstood. I wanted to know about any elevated temperatures."
- C. "I am disappointed because you did not follow my directions."
- D. "You have made me so angry. Why did you not report the fever to me?"
Correct Answer: C
Rationale: The correct answer is C: "I am disappointed because you did not follow my directions." This statement is the most concrete and specifically explains the nurse's feelings of disappointment towards the nursing assistant for not reporting the fever as instructed. It directly addresses the issue at hand, which is the failure to follow directions, and conveys the nurse's emotions in a clear and concise manner.
Choice A: "I am not dissatisfied with your performance, because we all make mistakes." This choice does not address the specific issue of the nursing assistant not following instructions, and it seems to downplay the importance of the mistake.
Choice B: "You must have misunderstood. I wanted to know about any elevated temperatures." This choice shifts the blame to the nursing assistant for misunderstanding, rather than holding them accountable for not following instructions.
Choice D: "You have made me so angry. Why did you not report the fever to me?" This choice focuses on the nurse's anger rather than disappointment, and it does not
Which assessment finding for Mr. L (tracheostomy and partial laryngectomy) would be of greatest concern?
- A. Pulsation of the tracheostomy tube in synchrony with the heartbeat
- B. Increased secretions in and around the tracheostomy
- C. Increased coughing, with difficulty in expectorating secretions
- D. Presence of food particles in tracheal secretions
Correct Answer: A
Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety.
Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding.
Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding.
Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.
A nurse manager asks a colleague for advice on strategies to improve communication with staff nurses. Which response by the nurse manager's colleague is best?
- A. "Be sensitive, show respect, and be genuine."
- B. "You need to be consistently nice to the staff nurses."
- C. "Work as a staff nurse every month to develop empathy."
- D. "Staff nurses need a leader who is not emotional."
Correct Answer: A
Rationale: The correct answer is A because it emphasizes essential components of effective communication: sensitivity, respect, and genuineness. Sensitivity helps in understanding others' emotions, respect fosters a positive relationship, and genuineness promotes trust. Choice B is too simplistic and lacks depth. Choice C is impractical as working as a staff nurse monthly may not be feasible for a manager. Choice D is incorrect as emotional intelligence and empathy are crucial for effective leadership, not being emotionless. Thus, choice A is the best response due to its focus on key communication principles.
Which nonverbal action(s) would be consistent with an assertive style of communication? (Select all that apply)
- A. Relaxed posture
- B. Established eye contact
- C. Hands placed on hips
- D. Distant, soft voice
Correct Answer: A
Rationale: The correct answer is A (Relaxed posture) because assertiveness is about expressing oneself confidently while respecting others. A relaxed posture conveys confidence and self-assurance. Established eye contact (B) is also consistent with assertiveness, showing engagement and sincerity. Choices C (Hands placed on hips) and D (Distant, soft voice) are more indicative of aggression or passivity, respectively, rather than assertiveness. Placing hands on hips can come across as confrontational, while a distant, soft voice lacks the firmness and clarity associated with assertive communication.