Nokea
A patient is attracted to the nurse and attempts to initiate a social relationship. It is most appropriate for the nurse to take which action?
- A. Encourage the client's behavior to develop a trusting nurse3client relationship.
- B. Inform the charge nurse of the situation and ask for a different patient assignment.
- C. Tell the patient that the relationship must remain professional at all times.
- D. Determine if the patient can be transferred to another nursing care unit.
Correct Answer: C
Rationale: The correct answer is C because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.
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The nurse has selected an outcome for the patient to eat all of the food on the breakfast tray each day. Assessing that the patient has eaten all of the breakfast, the nurse would give positive feedback by saying:
- A. "Wow! That breakfast must have been pretty good."
- B. "I like pancakes too. Everyone on the hall seemed to enjoy them."
- C. "I hope you can keep all that breakfast down."
- D. "Hurray! You finished your whole meal! What would you like for tomorrow?" Giving positive feedback increases the likelihood of the desired behavior to be repeated. Commenting on the tastiness of the food or the fact that others liked it is not responding directly to the patient's having eaten the whole meal.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's achievement of finishing the whole meal, provides positive reinforcement, and invites the patient to make choices for the next meal, encouraging continued compliance with the desired outcome. This response directly reinforces the behavior that was targeted, making it more likely for the patient to repeat the behavior in the future. Choices A, B, and C do not specifically address the patient's accomplishment of eating all the food, therefore they do not provide effective positive feedback for reinforcing the desired behavior.
The nurse cares for a client with abdominal pain who is scheduled for exploratory surgery. Which statement(s), if made by the nurse, indicates that the client's rights in the helping relationship have been violated? (Select all that apply)
- A. "I do not have time right now to help you call your family."
- B. "I am available to answer questions that you may have about your surgery."
- C. "You seem frightened. I will stay with you until your family arrives."
- D. "Your neighbors called, and I told them that you will have surgery."
Correct Answer: A
Rationale: The correct answer is A because by stating, "I do not have time right now to help you call your family," the nurse is not respecting the client's autonomy and right to involve their family in decision-making. This violates the client's right to information and support.
Choices B and C are incorrect because they demonstrate the nurse's willingness to provide information, support, and emotional care, which align with the client's rights in the helping relationship.
Choice D is incorrect as it shows the nurse informing the client about the neighbors' call, which may not necessarily violate the client's rights unless the client explicitly expressed a desire for privacy.
The nurse cares for a patient who becomes confused and a vest restraint is applied. The nurse should take which action when notifying the patient's family?
- A. Avoid discussing the treatment plan to reduce anxiety and worry.
- B. Ask another nurse who has rapport with the family to be present.
- C. Use medical terms to demonstrate competence.
- D. Assume that the family wants a detailed explanation.
Correct Answer: B
Rationale: The correct answer is B because having another nurse who has a good relationship with the family present can help facilitate effective communication and provide emotional support. This can help alleviate the family's concerns and build trust in the care being provided.
Avoiding discussing the treatment plan (A) may lead to increased anxiety and worry for the family. Using medical terms (C) may confuse the family further and hinder effective communication. Assuming that the family wants a detailed explanation (D) without confirming their preferences may not be the most appropriate approach.
When using the telephone to communicate with a primary care provider about a patient, the student nurse should have ready: (Select all that apply.)
- A. current information relative to patient's condition change.
- B. assessment of vital signs.
- C. information on urinary output.
- D. patient's social security number or hospital identification number.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Current information on patient's condition change is crucial for effective communication with the primary care provider.
2. This allows the student nurse to provide accurate and up-to-date information for appropriate decision-making.
3. Assessment of vital signs or information on urinary output may be important, but the question specifically focuses on communication about the patient's condition change.
4. Patient's social security number or hospital identification number is not necessary for communicating about the patient's condition change.
In summary, choice A is correct as it ensures accurate communication, while the other choices are not directly related to communicating patient's condition change.
The team leader is reviewing what the HCP has just prescribed for Mr. N (non-Hodgkin lymphoma). What will the team leader question?
- A. Administer filgrastim 5 mcg/kg subcutaneously every day
- B. Catheterize to obtain a urinalysis specimen.
- C. Flush the IV saline lock every shift.
- D. Monitor vital signs every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer filgrastim 5 mcg/kg subcutaneously every day. The rationale for this is that filgrastim is a medication commonly prescribed for patients with non-Hodgkin lymphoma to stimulate the production of white blood cells. Therefore, the team leader should question the dosage, route of administration, and frequency to ensure it aligns with the prescribed treatment plan.
Incorrect choices:
B: Catheterize to obtain a urinalysis specimen - This is not relevant to the prescribed treatment for non-Hodgkin lymphoma.
C: Flush the IV saline lock every shift - Important for maintaining IV access but not directly related to the prescribed medication.
D: Monitor vital signs every 4 hours - Monitoring vital signs is important but not the primary concern when reviewing a prescribed medication for non-Hodgkin lymphoma.