Nokea
A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?
- A. Remain silent.
- B. Educate the patient that the outcome is not realistic.
- C. Explore with the patient possible consequences of the outcome.
- D. Formulate a more appropriate outcome without the patient's input.
Correct Answer: C
Rationale: The nurse should not impose outcomes on the patient; however, the nurse has a responsibility to help the patient evaluate what is in his or her best interest. Exploring possible consequences is an acceptable approach.
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An adolescent asks a nurse conducting an assessment interview, 'Why should I tell you anything? You'll just tell my parents whatever you find out.' What is the nurse's best reply regarding patient confidentiality?
- A. That is not true. What you tell us is private and held in strict confidence. Your parents have no right to know.
- B. Yes, your parents may find out what you say, but it is important that they know about your problems.
- C. What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team.
- D. It sounds as though you are not really ready to work on your problems and make changes.
Correct Answer: C
Rationale: The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse.
A patient diagnosed with major depressive disorder has lost 20 pounds in 1 month. The patient has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this priority: 'Patient will refrain from gestures and attempts to harm self'?
- A. Implement suicide prevention interventions.
- B. Frequently offer high-calorie snacks and fluids.
- C. Assist the patient to identify three personal strengths.
- D. Observe patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
Why is it important for a nurse to possess an appropriate degree of assertiveness?
- A. Reduces interpersonal stress.
- B. Builds effective team relationships.
- C. Supports development of technical nursing skills.
- D. Reduces potential for the increased risk of client injury.
- E. Supports the delivery of effective, appropriate nursing care.
Correct Answer: A,B,D,E
Rationale: Assertiveness is one of the most important skills for nurses in the workplace to reduce their interpersonal stress, build effective team relationships, and to provide sufficient nursing care. A nurse's ability to be assertive is key not only to preventing medical errors but also to reducing patients' risk and improving nursing care.
Select the best outcome for a patient with this nursing diagnosis: impaired social interaction, related to sociocultural dissonance as evidenced by stating, 'Although I'd like to, I don't join in because I don't speak the language very well.' What should the focus of an appropriate outcome be?
- A. Demonstrating improved social skills
- B. Expressing a desire to interact with others
- C. Becoming more independent in decision making
- D. Selecting and participating in one group activity per day
Correct Answer: D
Rationale: The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable.
When a nurse assesses an older adult patient, the patient's answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. What would be an appropriate question for the nurse to ask in this situation?
- A. Are you having difficulty hearing when I speak?
- B. How can I make this assessment interview easier for you?
- C. I notice you are frowning. Are you feeling annoyed with me?
- D. You're having trouble focusing on what I'm saying. What is distracting you?
Correct Answer: A
Rationale: The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations.