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The nurse is providing care to a 75-year-old female patient diagnosed with osteoporosis. Which of the following would be the priority nursing diagnosis?
- A. At risk for falls related to impaired balance
- B. Knowledge deficit related to new medication regimen
- C. Impaired physical mobility related to pain and skeletal changes
- D. Ineffective health maintenance related to continued immobility
Correct Answer: A
Rationale: The correct answer is A: At risk for falls related to impaired balance. This is the priority nursing diagnosis because falls can lead to serious injury in elderly patients with osteoporosis. Impaired balance is a significant risk factor for falls in this population. Choice B is not the priority as safety takes precedence over knowledge deficit. Choice C may be secondary to the risk of falls. Choice D is not the priority as preventing falls and ensuring patient safety are more critical in this case.
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Which actions by the nurse indicate compliance with the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)
- A. The nurse posts an update about a patient on Facebook.
- B. The nurse gives the report to the oncoming nurse in a private area.
- C. The nurse gives information about the patient’s status over the phone to the patient’s friend.
- D. The nurse logs off any computer screen showing patient data before leaving the computer unattended.
Correct Answer: B
Rationale: The correct answer is B because giving the report to the oncoming nurse in a private area ensures patient information is shared securely, maintaining patient confidentiality as required by HIPAA. Posting patient updates on social media (A) violates patient privacy. Sharing patient information with a friend (C) breaches confidentiality. Leaving computer screens unattended with patient data visible (D) risks unauthorized access. B is the only choice that aligns with HIPAA regulations by prioritizing patient privacy and security.
The nurse states to the newly pregnant patient, “Tell me how you feel about being pregnant.” Which communication technique is the nurse using with this patient?
- A. Clarifying
- B. Paraphrasing
- C. Reflection
- D. Structuring
Correct Answer: C
Rationale: The correct answer is C: Reflection. The nurse is using the communication technique of reflection by restating the patient's feelings back to her. This technique helps the patient feel heard and understood, promoting a therapeutic relationship. Clarifying (A) involves seeking further information, paraphrasing (B) involves restating the patient's words, and structuring (D) involves organizing the conversation - none of which are demonstrated in the scenario.
In which step of the nursing process does the nurse determine the appropriate interventions for the identified nursing diagnosis?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Intervention
Correct Answer: A
Rationale: In the nursing process, planning is the step where the nurse determines appropriate interventions for the identified nursing diagnosis. Firstly, in the assessment step (choice C), the nurse collects data to identify the nursing diagnosis. Next, in the diagnosis step, the nurse analyzes the data to identify the nursing diagnosis. Then, in the planning step (choice A), the nurse develops a plan of care that includes specific interventions to address the nursing diagnosis. Finally, in the intervention step (choice D), the nurse implements the planned interventions. Evaluation (choice B) is the step where the nurse assesses the effectiveness of the interventions. Therefore, choice A is correct as it is the step where the nurse determines the appropriate interventions based on the identified nursing diagnosis.
A nurse is caring for a patient with pyelonephritis. What does the nurse identify as the most common cause?
- A. Escherichia coli
- B. Neisseria gonorrhoeae
- C. Chlamydia trachomatis
- D. Candida albicans
Correct Answer: A
Rationale: The correct answer is A: Escherichia coli. In pyelonephritis, bacteria typically ascend from the lower urinary tract to the kidneys. E. coli is the most common cause due to its prevalence in the gastrointestinal tract and ability to cause urinary tract infections. Neisseria gonorrhoeae and Chlamydia trachomatis are more commonly associated with sexually transmitted infections, not pyelonephritis. Candida albicans is a fungal infection and is not a common cause of pyelonephritis.
A nurse is working with an active labor patient who is in preterm labor and has been designated as high risk. The patient is very apprehensive and asks the nurse, “Is everything going to be all right?” The nurse replies, “Yes, everything will be okay.” Following delivery via an emergency cesarean birth, the newborn undergoes resuscitation and does not survive. The patient is distraught over the outcome and blames the nurse for telling her that everything would be okay. Which ethical principle did the nurse violate?
- A. Autonomy N R I G B.C M U S N T O
- B. Fidelity
- C. Beneficence
- D. Accountability
Correct Answer: C
Rationale: The correct answer is C: Beneficence. The nurse violated the ethical principle of beneficence by providing false reassurance to the patient, leading to unrealistic expectations and potential harm. Beneficence is about acting in the best interest of the patient and ensuring their well-being. By misleading the patient, the nurse failed to uphold this principle.
A: Autonomy is the right of the patient to make their own decisions. The nurse did not directly violate the patient's autonomy in this scenario.
B: Fidelity is about being faithful to commitments and promises. The nurse did not violate fidelity, as there was no explicit promise made that was broken.
D: Accountability is about taking responsibility for one's actions. While accountability is important, it is not the primary ethical principle violated in this case.