Nokea
A nurse is assessing a patient diagnosed with generalized anxiety disorder. The patient states, 'I feel constantly anxious, and I can't calm down.' Which of the following is the most appropriate nursing diagnosis?
- A. Risk for suicide
- B. Ineffective coping
- C. Anxiety
- D. Disturbed thought processes
Correct Answer: C
Rationale: Generalized anxiety disorder is characterized by chronic and excessive worry or anxiety. The nursing diagnosis of anxiety is most appropriate.
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A Filipino American patient had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were applied to increase the patient's self-esteem but after 3 weeks, the patient's eye contact did not improve. What is the most accurate analysis of this scenario?
- A. The patient's eye contact should have been directly addressed by role playing to increase comfort with eye contact.
- B. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient.
- C. The patient's poor eye contact is indicative of anger and hostility that were unaddressed.
- D. The nurse should have assessed the patient's culture before making this diagnosis and plan.
Correct Answer: D
Rationale: The amount of eye contact a person engages in is often culturally determined. In some cultures, eye contact is considered insolent, whereas in others eye contact is expected. Asian Americans, including persons from the Philippines, often prefer not to engage in direct eye contact.
Hospice care compares with palliative care because they both address
- A. Terminal illnesses, seek curative treatment
- B. Focus on symptom management, aggressive treatment
- C. Has terminal illness diagnoses, focuses on symptom management
- D. Has no terminal illness focus, symptom management diagnoses
Correct Answer: C
Rationale: Both hospice and palliative care (Option C) focus on symptom management for terminal illnesses, enhancing quality of life, not cure (A), aggressive treatment (B), or non-terminal conditions (D).
As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, 'Thank you for helping mend my broken heart.' Which is the nurse's best response?
- A. Accepting gifts violates the policies and procedures of the facility.'
- B. I'm glad you feel so much better now. Thank you for the beautiful necklace.'
- C. I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope.'
- D. Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work.'
Correct Answer: C
Rationale: Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient's gesture of appreciation, but the gift should not be accepted. See relationship to audience response question.
A nurse notices a patient sitting quietly alone, eyes downcast, and looking sad. The nurse says to the patient, 'You look like something is bothering you.' Which pattern of knowing did the nurse use to respond to the patient?
- A. Empirical knowing
- B. Personal knowing
- C. Ethical knowing
- D. Aesthetic knowing
Correct Answer: B
Rationale: Personal knowing is obtained from life experience. An example would be a client's face shows the panic. Empirical knowing is obtained from the science of nursing. An example would be a client with panic disorder begins to have an attack. Panic attack will raise pulse rate. Ethical knowing is obtained from the moral knowledge of nursing. An example is although the nurse's shift has ended, she remains with the client. Aesthetic knowing is obtained from the art of nursing. Although the client shows outward signals now, the nurse has sensed previously the client's jumpiness and subtle differences in the client's demeanor and behavior.
The nurse is attending an in-service training on safe take-down techniques for aggressive clients. Preparation for safe physical handling prepares the nurse to practice which ethical principle?
- A. Veracity
- B. Nonmaleficence
- C. Justice
- D. Autonomy
Correct Answer: B
Rationale: Nonmaleficence is the requirement to do no harm to others either intentionally or unintentionally. Safe take-down techniques are used to avoid unintentional harm to the client. Veracity is the duty to be honest or truthful. Justice refers to fairness, that is treating all people fairly and equally without regard for social or economic status, race, sex, marital status, religion, ethnicity, or cultural beliefs. Autonomy refers to the person's right to self-determination and independence.