Nokea
A nurse is teaching a group of nursing students about the importance of professional boundaries in nursing practice. What statement by a student indicates understanding of this concept?
- A. "It's okay to share personal information with patients to build rapport."
- B. "Maintaining professional boundaries helps protect both patients and nurses."
- C. "Establishing friendships with patients enhances trust and communication."
- D. "Being emotionally involved with patients improves patient outcomes."
Correct Answer: B
Rationale: Option B, "Maintaining professional boundaries helps protect both patients and nurses," indicates an understanding of the importance of professional boundaries in nursing practice. Professional boundaries define the limits of the nurse-patient relationship and help ensure that interactions are safe, therapeutic, and based on the patient's best interest. By maintaining these boundaries, nurses can uphold ethical standards, prevent harm, and maintain trust with patients. It also helps prevent issues such as transference, countertransference, and breaches of confidentiality. Overall, understanding and respecting professional boundaries are essential for promoting the well-being of both patients and healthcare providers.
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A patient with a history of type 2 diabetes mellitus is prescribed insulin glargine (Lantus) once daily. Which statement indicates understanding of insulin glargine administration?
- A. "I will inject insulin glargine 30 minutes before meals."
- B. "I will shake the insulin vial vigorously before drawing the dose."
- C. "I will rotate injection sites within the same body region."
- D. "I will administer insulin glargine with a rapid-acting insulin."
Correct Answer: C
Rationale: Insulin glargine (Lantus) is a long-acting insulin that is typically administered once daily at the same time each day to help maintain a steady level of insulin in the body. It is important to rotate injection sites within the same body region (such as the abdomen, thigh, or upper arm) to prevent lipodystrophy (lumpiness or dents in the skin) and to ensure consistent absorption of the insulin. Proper rotation of injection sites helps to prevent tissue damage and ensures optimal insulin absorption, improving the effectiveness of insulin therapy. It is not necessary to inject insulin glargine before meals, vigorously shake the vial, or administer it with a rapid-acting insulin.
A postpartum client who delivered via cesarean section expresses concerns about breastfeeding difficulties and worries about insufficient milk supply. What nursing intervention should be prioritized to address the client's concerns?
- A. Providing education on techniques to improve latch and milk transfer
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding to prevent discomfort
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: A
Rationale: The correct nursing intervention to prioritize in this situation is providing education on techniques to improve latch and milk transfer. Cesarean section deliveries can sometimes pose challenges for breastfeeding initiation, but with proper education and support, many women can successfully breastfeed following a C-section. By teaching the client techniques to improve latch and milk transfer, the nurse can help address the client's concerns about breastfeeding difficulties and worries about insufficient milk supply. This proactive approach empowers the client to overcome breastfeeding challenges and increase their confidence in their ability to breastfeed successfully. Referring the client to a lactation consultant for specialized support may also be beneficial, but providing initial education on latch and milk transfer is crucial in this early postpartum period. Recommending formula feedings or discouraging breastfeeding may not be appropriate interventions, as they can affect the establishment of breastfeeding and undermine the client's breastfeeding goals.
Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of ______.
- A. confidentiality
- B. duty
- C. beneficence
- D. veracity
Correct Answer: A
Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.
Amitriptyline, an antidepressant is the drug of choice in treating Bulimia. What is a COMMON side effect of this drug?
- A. Anticholinergic effects
- B. Cholinergic effects
- C. Urinary frequency
- D. Diarrhea
Correct Answer: A
Rationale: Amitriptyline, being a tricyclic antidepressant, commonly causes anticholinergic side effects. These effects include dry mouth, constipation, blurred vision, urinary retention, and confusion. Anticholinergic effects are due to the drug's inhibition of the neurotransmitter acetylcholine, which can lead to the symptoms mentioned above. These side effects can be bothersome for patients taking amitriptyline, but they are generally manageable and often improve over time as the body adjusts to the medication. In the case of bulimia treatment, the benefits of using amitriptyline to address the underlying psychological issues often outweigh the side effects.
What is the PRIORITY of care for patient diagnosed with Guillain-Barre Syndrome?
- A. Maintenance of respiratory function
- B. Prevention of decubitus
- C. Control of urinary tract infection
- D. Replacement of fluid and electrolytes
Correct Answer: A
Rationale: The priority of care for a patient diagnosed with Guillain-Barre Syndrome is the maintenance of respiratory function. Guillain-Barre Syndrome can cause paralysis, including respiratory muscles, leading to respiratory failure. Ensuring adequate ventilation and oxygenation is crucial to prevent complications such as respiratory failure and the need for mechanical ventilation. Monitoring for signs of respiratory distress, such as shortness of breath, decreased oxygen saturation, and diminished lung sounds, is essential in providing prompt intervention and support for the patient's respiratory needs. Other aspects of care, such as prevention of decubitus ulcers, control of urinary tract infections, and replacement of fluid and electrolytes, are also important but not as immediate or life-threatening as ensuring adequate respiratory function in these patients.