Nokea
A nurse with five years of experience working in a hospital unit is promoted as a mentor and preceptor to a new nursing staff. This is an example of:
- A. Collegiality
- B. Competence
- C. Advocacy
- D. Integration
Correct Answer: A
Rationale: Collegiality is the action of forming relationships and supporting others through work experiences. In this scenario, the nurse being promoted as a mentor and preceptor exemplifies collegiality by fostering an encouraging educational relationship with the new nursing staff. The nurse demonstrates appropriate nursing care, teaches skills, and supports the professional growth of others. Choice B, 'Competence,' refers to having the necessary skills and knowledge, but in this context, the focus is on the supportive and educational role of the nurse. Choice C, 'Advocacy,' involves speaking up for patients' rights and needs, which is not directly demonstrated in the scenario. Choice D, 'Integration,' does not directly relate to the situation described, where the emphasis is on mentoring and guiding new staff.
You may also like to solve these questions
A client on lithium has diarrhea and vomiting. What should the nurse do first?
- A. Recognize this as a drug interaction
- B. Give the client Cogentin
- C. Reassure the client that these are common side effects of lithium therapy
- D. Hold the next dose and obtain an order for a stat serum lithium level
Correct Answer: D
Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.
What is the highest priority for post ECT care?
- A. Observe for confusion
- B. Monitor respiratory status
- C. Reorient to time, place, and person
- D. Document the client's response to the treatment
Correct Answer: B
Rationale: The highest priority for post ECT care is to monitor respiratory status. This is crucial because a life-threatening side effect of ECT is respiratory arrest. While observing for confusion and reorienting the client are important aspects of post ECT care, they are not as critical as ensuring the client's respiratory status is stable. Documenting the client's response to treatment is also important for maintaining accurate medical records, but it is not the highest priority immediately post ECT.
A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially the nurse should plan this for a manic client:
- A. Set realistic limits to the client's behavior
- B. Repeat verbal instructions as often as needed
- C. Allow the client to express feelings to relieve tension
- D. Assign staff to be with the client at all times to help maintain control
Correct Answer: A
Rationale: For a manic client who is hyperactive and may engage in injurious activities, setting realistic limits to the client's behavior is crucial to ensure safety. A quiet environment with firm and consistent limits helps in managing the client's behavior effectively. While repeating verbal instructions can be helpful due to the client's distractibility, it is not the priority compared to setting limits for safety concerns. Allowing the client to express feelings is important, but it should be done through non-destructive methods. Assigning staff to be with the client at all times is not realistic or feasible in the clinical setting and does not address the core issue of managing the client's behavior and ensuring safety.
The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
- A. To tell the client this is not true; that we all have a purpose in life.
- B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
- C. To reassure the client that you know how the client is feeling and that things will get better.
- D. To identify recent behaviors or accomplishments that demonstrate skill ability.
Correct Answer: C
Rationale: The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.
As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
- A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments.
- B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
- C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments.
- D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
Correct Answer: D
Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.