Nokea
A client states, 'People think I'm no good, you know what I mean?' Which of these responses would be most therapeutic?
- A. Well people often take their own feelings of inadequacy out on others.'
- B. I think you're good. So you see, there's one person who likes you.'
- C. I'm not sure what you mean. Tell me a bit more about that.'
- D. Let's discuss this to see the reasons you create this impression on people.'
Correct Answer: C
Rationale: I'm not sure what you mean. Tell me a bit more about that.' This therapeutic communication technique elicits more information, especially when delivered in an open, non-judgmental fashion.
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The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?
- A. Focus on the child's needs and recovery
- B. Explain the cause of the child's illness
- C. Acknowledge that early care would have been better
- D. Accept their feelings without judgment
Correct Answer: D
Rationale: Accept their feelings without judgment. Parents often blame themselves for their child's illness. Feeling helpless and angry is normal and these feelings must be accepted.
A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first
- A. focus on reality orientation to place and person
- B. assist with the report of the client's complaint to the police
- C. obtain more details of the client's claim of abuse
- D. document the statement on the client's chart with a report to the manager
Correct Answer: C
Rationale: Obtain more details of the client's claim of abuse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse to ensure appropriate action and protection for the client.
A nurse is reviewing a patient's ECG report. The patient exhibits a flat T wave, depressed ST segment and short QT interval. Which of the following medications can cause all of the above effects?
- A. Morphine
- B. Atropine
- C. Procardia
- D. Digitalis
Correct Answer: D
Rationale: Digitalis can cause all of the listed ECG changes, including flat T waves, depressed ST segments, and shortened QT intervals, due to its effects on cardiac electrophysiology.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
The nurse confides to a coworker that when reporting a change in the client's condition to the HCP, the HCP stated, "It seems that every time you work, there is some catastrophe. Can't you problem-solve earlier so this doesn't happen!" What is the coworker's best response?
- A. "This HCP responds to everyone the same. You did everything right; don't feel bad."
- B. "You should obtain our hospital policy and initiate the steps to report the HCP."
- C. "Let the nurse manager know; I think our manager is already dealing with the HCP."
- D. "Let's go to the medical director, who should be told about this HCP's angry response."
Correct Answer: B
Rationale: Reporting the HCP's uncivil behavior per hospital policy is the best response to address and document the issue appropriately.