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A nurse using active listening techniques would:
- A. use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard.
- B. avoid the use of eye contact to allow the patient to express herself without feeling stared at or demeaned.
- C. anticipate what the speaker is trying to say and help the patient express herself when she has difficulty with finishing a sentence.
- D. ask probing questions to direct the conversation and obtain the information needed as efficiently as possible. Eye contact is a culturally learned behavior and in some cases may not be appropriate. Probing questions or finishing the patient's sentence is not part of active listening and is detrimental to an interview.
Correct Answer: A
Rationale: Answer A is correct because active listening involves using nonverbal cues such as leaning forward, focusing on the speaker's face, and nodding slightly to show that you are engaged and understanding the message. Leaning forward demonstrates interest, focusing on the face shows attentiveness, and nodding indicates acknowledgment. These actions encourage the speaker to continue sharing and feel heard.
Choices B, C, and D are incorrect:
B: Avoiding eye contact can make the speaker feel ignored or disconnected, which goes against the principles of active listening.
C: Anticipating what the speaker is trying to say and finishing their sentences is not active listening; it can be seen as interrupting and not allowing the speaker to express themselves fully.
D: Asking probing questions and directing the conversation towards obtaining specific information efficiently is not active listening. It can come across as controlling the conversation rather than actively listening to the speaker.
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Ms. C (bowel resection) repeatedly refuses to perform a return demonstration of any aspect of colostomy care. Despite steady improvement and independent resumption of other ADLs, she protests, "I'm too weak. You'll have to do it for me." At this point, what is the priority nursing concept to consider in planning interventions for Ms. C?
- A. Mobility
- B. Tissue integrity
- C. Functional ability
- D. Coping
Correct Answer: C
Rationale: The correct answer is C: Functional ability. This is because the priority nursing concept to consider in planning interventions for Ms. C is her ability to independently perform colostomy care. By refusing to demonstrate, she may be indicating a lack of functional ability to manage this aspect of self-care. This is essential for her long-term independence and quality of life. Mobility (choice A) is important but not the priority in this case. Tissue integrity (choice B) is also crucial but not as immediate as ensuring functional ability. Coping (choice D) is important for emotional well-being but does not address the primary issue of functional ability for self-care.
The nurse explains that the therapeutic nurse-patient relationship differs from the social relationship because:
- A. a social relationship does not have goals or needs to be met.
- B. the nurse-patient relationship ends when the patient is discharged.
- C. the focus is mainly on the nurse in the nurse-patient relationship.
- D. a social relationship does not require trust or sharing of life experiences. The nurse-patient relationship is limited to the patient's stay in the facility and is focused on the patient. A social relationship may have goals or needs and does require trust and sharing of life experiences.
Correct Answer: C
Rationale: The correct answer is C because in a therapeutic nurse-patient relationship, the focus is mainly on the nurse being therapeutically beneficial to the patient. This relationship is professional, goal-oriented, and centered on the patient's needs and well-being. The nurse's primary role is to provide care, support, and help the patient achieve their health goals. Unlike a social relationship, where the focus is mutual and not solely on the nurse, the therapeutic relationship is asymmetrical, with the nurse taking on a more authoritative and guiding role. This ensures that the patient receives the necessary care and support during their healthcare journey.
Choices A, B, and D are incorrect because a social relationship can have goals or needs to be met, the nurse-patient relationship extends beyond the patient's discharge, and trust and sharing of life experiences are essential components of the nurse-patient relationship.
The nurse is performing a well-child assessment on a 15-month-old child. The child's mother and father are present. Which action by the nurse will best determine the health beliefs and values of the parents?
- A. Have the parents independently complete the Myers-Briggs Type Indicator survey.
- B. Read the documented health histories of the child's parents and grandparents.
- C. Actively listen to the parents talk about their lives and health concerns.
- D. Review the traditional health practices of the ethnic group identified by the parents.
Correct Answer: C
Rationale: The correct answer is C: Actively listen to the parents talk about their lives and health concerns. This action allows the nurse to directly learn about the parents' health beliefs and values. By listening attentively, the nurse can understand the parents' perspectives, concerns, and priorities regarding their child's health. This approach promotes trust and open communication, enabling the nurse to provide individualized and culturally sensitive care.
Explanation for why the other choices are incorrect:
A: Having the parents complete the Myers-Briggs Type Indicator survey is not relevant to determining their health beliefs and values.
B: Reading the health histories of the child's parents and grandparents may provide some background information but may not reflect their current health beliefs and values.
D: Reviewing traditional health practices of the ethnic group identified by the parents assumes that all individuals within that group hold the same beliefs, which may not be accurate.
The nurse is interviewing a Native American client. It is most important for the nurse to take which action?
- A. Maintain eye contact to show respect and interest.
- B. Assess whether the client is comfortable with eye contact.
- C. Avoid prolonged eye contact with this client.
- D. Sit next to the patient to avoid any eye contact.
Correct Answer: B
Rationale: The correct answer is B: Assess whether the client is comfortable with eye contact. This is important because different cultures have varying views on eye contact, and it is crucial to respect the client's preferences. By assessing the client's comfort level with eye contact, the nurse can establish rapport and demonstrate cultural sensitivity.
A: Maintaining eye contact may not be culturally appropriate for some Native American clients, so it is important to assess their comfort level first.
C: Avoiding prolonged eye contact assumes all Native American clients have the same preferences, which is not accurate.
D: Sitting next to the patient to avoid eye contact may be perceived as distancing or disrespectful in some cultures.
the HCP because the client deserves to have adequate pain relief.
- A. Wait until the change of medication occurs and then monitor the client's response.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates a proactive approach to ensuring the client receives adequate pain relief. By waiting until the medication change occurs and then monitoring the client's response, the healthcare provider can assess the effectiveness of the new medication and make any necessary adjustments promptly. This approach prioritizes the client's well-being by addressing their pain management needs in a timely and thorough manner. Choices B, C, and D are not as effective as they do not involve actively monitoring the client's response to the medication change, which is crucial in ensuring optimal pain relief for the client.