Nokea
A patient asks the nurse to make a decision for her about whether or not to continue taking hormone replacement therapy (estrogen). Which response by the nurse is most appropriate?
- A. "You should check with a doctor; I cannot give you advice about drugs."
- B. "My friend has taken estrogen for more than 5 years without any problems."
- C. "I can answer any questions you have but it is up to you to make this decision."
- D. "Herbal supplements were much better for me than prescription-strength estrogen."
Correct Answer: C
Rationale: The correct answer is C because it emphasizes patient autonomy and informed decision-making, aligning with ethical principles. The nurse should not make decisions for the patient but should provide information and support. Choice A deflects responsibility and does not empower the patient. Choice B is anecdotal and not a reliable source of information. Choice D is not relevant to the patient's question and could potentially lead to misinformation. Ultimately, choice C encourages the patient to take an active role in their healthcare decisions, which promotes patient-centered care.
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According to the NCSBN, appropriate self-disclosure is a part of maintaining professional boundaries. Appropriate self-disclosure includes the following:
- A. Discussing intimate or personal values with patients
- B. Keeping secrets with a patient or for a patient
- C. Expressing you are the only one who truly understands patient
- D. Brief, focused, and only used if experience is similar
Correct Answer: D
Rationale: The correct answer is D because appropriate self-disclosure in a therapeutic setting should be brief, focused, and only shared if it enhances the therapeutic relationship. This helps maintain professional boundaries and keeps the focus on the patient's needs. Choice A is incorrect because discussing intimate or personal values with patients can blur boundaries and shift the focus away from the patient. Choice B is incorrect because keeping secrets with or for a patient can lead to ethical dilemmas and compromise trust. Choice C is incorrect because expressing that you are the only one who truly understands the patient can create a power imbalance and hinder the therapeutic process.
Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?
- A. Carefully monitor the access site during the administration of the medication.
- B. Hold the medication until an implanted port or central line is established.
- C. Ensure that a chemotherapy-certified nurse is assigned to care for the client.
- D. Call the pharmacy to find out if the prescribed medication has vesicant properties.
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer, A:
1. Monitoring the access site during administration allows for early detection of extravasation.
2. Early detection can prevent serious tissue damage and complications.
3. As Mr. L has a tracheostomy and partial laryngectomy, his airway is compromised, making prevention of extravasation crucial.
4. This action is within the nurse's scope of practice and promotes patient safety.
Summary:
- Choice B is incorrect as delaying treatment can impact Mr. L's health.
- Choice C is not directly related to preventing extravasation.
- Choice D, though important, does not directly address preventing extravasation during administration.
Which demonstrates the nurse's genuine concern for clients?
- A. Tell a patient who has a terminal illness that everything will be fine.
- B. Delay notifying the patient about the death of a dependent child.
- C. Provide a placebo to a patient in severe pain to assess for substance abuse.
- D. Inform the patient about a medication error along with symptoms to report.
Correct Answer: D
Rationale: The correct answer is D because informing the patient about a medication error and symptoms to report shows transparency, honesty, and prioritizes patient safety. This action also promotes trust in the nurse-patient relationship.
A: Choice A is incorrect because falsely reassuring a terminally ill patient does not demonstrate genuine concern and lacks honesty.
B: Choice B is incorrect because delaying important information about the death of a dependent child is unethical and can cause unnecessary distress to the patient.
C: Choice C is incorrect because providing a placebo without informed consent violates ethical principles and does not prioritize the patient's well-being.
The nurse sees that Mr. B (bladder cancer) has received docusate for the past 2 days. Which question is the nurse most likely to ask to evaluate the effectiveness of the docusate?
- A. "Are you experiencing any burning with urination?"
- B. "Did you have a bowel movement today or yesterday?"
- C. "Has the medication helped to relieve the nausea?"
- D. "Were you able to sleep soundly the last couple of nights?"
Correct Answer: B
Rationale: The correct answer is B. Docusate is a stool softener commonly used to prevent constipation, which is a common side effect of opioid pain medications. By asking if the patient had a bowel movement today or yesterday, the nurse can evaluate the effectiveness of docusate in facilitating bowel movements. This question directly assesses the expected outcome of the medication.
A: "Are you experiencing any burning with urination?" - This question is more relevant to urinary tract infections, not related to docusate use for constipation.
C: "Has the medication helped to relieve the nausea?" - Docusate is not typically used to relieve nausea, so this question is not relevant to evaluating its effectiveness.
D: "Were you able to sleep soundly the last couple of nights?" - This question is not directly related to the expected outcome of docusate in treating constipation.
When a patient states, "My son hasn't been to see me in months," the nurse's best verbal response is:
- A. "Don't worry; I'm sure your son will visit."
- B. "Your son hasn't been around much lately?"
- C. "My son doesn't come to visit me either."
- D. "How terrible that he doesn't visit you." Restating in different words what the patient said encourages further communication on that topic.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Reflective listening: Restating the patient's statement shows empathy and understanding.
2. Open-ended question: Encourages patient to share more without assumptions.
3. Non-judgmental: Neutral tone promotes trust and openness.
4. Validates patient's feelings: Acknowledges patient's concerns without dismissing them.
Summary:
A: Provides false reassurance, does not address the patient's feelings.
C: Shifts focus to the nurse, not patient-centered.
D: Implies judgment, may shut down communication.