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.
You may also like to solve these questions
A 36-year-old woman who is in traction for a fractured femur that she received in an auto accident is found crying quietly. The nurse can best address this situation by saying:
- A. "What's the matter? Why are you crying? Are you in pain?"
- B. "Stop crying and tell me what your problem is."
- C. "This could have been much worse. You're lucky no one was killed."
- D. "You are upset. Can you tell me what's wrong?"
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's emotions, shows empathy, and encourages open communication. By stating "You are upset. Can you tell me what's wrong?" the nurse validates the patient's feelings and invites her to express her concerns. This approach fosters trust and allows the nurse to address the underlying issues causing the patient's distress.
Choice A is incorrect as it assumes the patient is in pain without confirmation and may come off as dismissive. Choice B is inappropriate as it lacks empathy and demands the patient to stop crying, which can further escalate the situation. Choice C is insensitive as it diminishes the patient's feelings by comparing her situation to a potential worse outcome, which is not helpful in addressing her emotional distress.
According to Swanson's theory, there are five caring processes, one of which is "knowing.= What are the other four?
- A. Communication, assertiveness, responsibility, and caring
- B. Maintaining belief, being with, doing for, and enabling
- C. Understanding, action, information, and comfort
- D. Maintaining belief, being with, enabling, and supporting
Correct Answer: B
Rationale: The correct answer is B: Maintaining belief, being with, doing for, and enabling. Swanson's theory of caring includes these four processes along with "knowing." Maintaining belief refers to having faith in the patient's ability to get through the situation. Being with involves being present and showing emotional support. Doing for means providing physical care and assistance. Enabling focuses on empowering the patient to make decisions and take control of their health.
Choice A is incorrect because it includes communication, assertiveness, and responsibility, which are not part of Swanson's caring processes. Choice C is incorrect as it includes understanding, action, information, and comfort, which do not align with Swanson's theory. Choice D is incorrect because it includes supporting, which is not one of the caring processes identified by Swanson.
The team leader is reviewing the pain management plan for Mr. U. He is having significant pain related to the cancer and the pulmonary resection. Which option would be the best for Mr. U?
- A. Mr. U is instructed to ask for pain medication whenever he needs it.
- B. Mr. U is to receive around-the-clock fixed doses of opioid analgesics.
- C. Mr. U should be offered the nonopioid medication first to see it if works.
- D. Mr. U has a high risk for respiratory distress, so opioids are not prescribed.
Correct Answer: B
Rationale: The correct answer is B because Mr. U is experiencing significant pain related to cancer and pulmonary resection, which typically requires continuous pain management. Around-the-clock fixed doses of opioid analgesics provide consistent pain relief and can be adjusted based on his pain levels. This approach ensures adequate pain control without the need for Mr. U to wait until the pain becomes severe before asking for medication. Option A may lead to undertreatment of pain. Option C delays effective pain relief for Mr. U who is already experiencing significant pain. Option D is incorrect as opioids can be safely administered with proper monitoring, even in patients at high risk for respiratory distress.
When the nurse observes a resident in a long-term facility pounding his fists on his legs and grinding his teeth, the nurse will validate her perception of the patient's nonverbal expression of anger by:
- A. documenting that the patient was agitated and appeared angry.
- B. asking the male nursing assistant if it is his perception that the patient appears angry.
- C. accessing the nursing care plan to ascertain if there is a nursing diagnosis relative to anger.
- D. sitting down near the patient and saying, "You seem upset…can I help?" All perceptions based on the observation of nonverbal behavior should be validated by consulting the patient.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates active listening and empathy towards the patient's nonverbal cues. By sitting down near the patient and acknowledging his emotions, the nurse opens up a channel for communication and offers support. This approach allows the patient to express his feelings and needs, leading to better understanding and potential resolution of the underlying issue.
Other choices are incorrect because:
A: Simply documenting the observation does not address the patient's emotional state or provide any opportunity for direct communication.
B: Asking another staff member for their perception does not involve the patient directly and may not accurately reflect the patient's emotions.
C: Referring to the care plan does not involve the patient in the process and may not address the immediate emotional needs expressed through nonverbal behavior.
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: Rationale:
C is the correct answer because actively listening to the parents talk about their lives and health concerns allows the nurse to understand their perspectives, beliefs, and values. This helps build rapport and trust, providing insight into how they approach healthcare for their child.
A: The Myers-Briggs Type Indicator survey is not relevant to understanding health beliefs and values.
B: Reading documented health histories may provide medical information but does not necessarily reveal beliefs and values.
D: Reviewing traditional health practices may be informative but does not directly assess the parents' personal beliefs and values.