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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The presence of any of these risk factors means that ______.
- A. Risk modification will have no effect on disease prevention
- B. The chances of getting the disease are increased
- C. A person with risk factors can get the disease
- D. The disease is guaranteed not to get disease
Correct Answer: B
Rationale: The presence of risk factors indicates an increased likelihood or susceptibility to developing a particular disease. While risk modification and healthy lifestyle choices can help reduce the risk, having these risk factors still increases the overall chances of getting the disease compared to individuals without the same risk factors. It is essential for individuals with risk factors to be proactive in managing their health to mitigate the increased risk.
In order not to frighten small children, it is best to examine things that are uncomfortable or frightening to them last so as not to lose their cooperation. This means the LAST thing to do in a child is, which of the following, EXCEPT________.
- A. Inspection of the throat with a throat stick.
- B. Inspection of the ears with an otoscope
- C. Auscultation of the heart
- D. Undressing the child
Correct Answer: C
Rationale: When examining a child, especially one who may already be feeling scared or uncomfortable, it is important to prioritize the order of procedures to help maintain their cooperation and reduce their anxiety. Undressing the child is typically done first to ensure a thorough examination can be performed, and it is a less invasive procedure compared to others. Inspection of the throat with a throat stick and inspection of the ears with an otoscope are common procedures that may cause mild discomfort but are often tolerated well by children. Auscultation of the heart is usually done after these initial steps and is not typically as uncomfortable or frightening for children compared to other procedures. Therefore, auscultation of the heart should not be the last thing to do when examining a child to avoid frightening them.
The patient 's wife is-so anxious about the condition of her husband. The MOST appropriate INITIAL intervention for the nurse to make is to ________.
- A. describe her husband 's medical treatment since admission
- B. reassure her that the important fact is her presence
- C. explain the nature of the injury and reassure her that husband's condition is stable
- D. allow her to verbalize her feelings and concerns
Correct Answer: C
Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.
A patient admitted to the ICU develops delirium characterized by acute onset confusion and agitation. What intervention should the healthcare team prioritize to manage the patient's delirium?
- A. Administer antipsychotic medications to reduce agitation.
- B. Implement environmental modifications to promote orientation.
- C. Refer the patient to a psychiatrist for further evaluation.
- D. Prescribe benzodiazepines for sedation and calming effect.
Correct Answer: B
Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.
A 45-year-old woman presents with heavy menstrual bleeding and iron deficiency anemia. On pelvic examination, the uterus is enlarged, and multiple irregularly shaped masses are palpated. Which condition is most likely to be responsible for these findings?
- A. Leiomyomas (uterine fibroids)
- B. Endometrial hyperplasia
- C. Endometrial polyps
- D. Adenomyosis
Correct Answer: A
Rationale: The clinical presentation of heavy menstrual bleeding, iron deficiency anemia, an enlarged uterus, and irregularly shaped masses palpated on pelvic examination is most indicative of leiomyomas, also known as uterine fibroids. Leiomyomas are benign smooth muscle tumors that commonly occur in women of reproductive age. They can lead to heavy menstrual bleeding and iron deficiency anemia due to their size and location within the uterus. On pelvic examination, leiomyomas can be felt as irregularly shaped masses within the uterine wall. This presentation is classic for leiomyomas and distinguishes them from conditions such as endometrial polyps, endometrial hyperplasia, and adenomyosis.