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A patient is non-compliant with prescribed medications and treatment plans. What is the nurse's best approach to address non-compliance?
- A. Dismiss the patient's reasons for non-compliance and assert the importance of following the prescribed regimen.
- B. Listen actively to the patient's reasons for non-compliance, address any barriers or concerns, and collaborate on finding solutions.
- C. Ignore the patient's non-compliance and proceed with implementing the treatment plan regardless.
- D. Tell the patient that non-compliance is unacceptable and they must adhere to the prescribed regimen.
Correct Answer: B
Rationale: The nurse's best approach to address non-compliance with prescribed medications and treatment plans is to actively listen to the patient's reasons for non-compliance. By acknowledging and addressing any barriers or concerns the patient may have, the nurse can work collaboratively with the patient to find effective solutions. This approach promotes open communication, trust, and a patient-centered care plan that takes into consideration the patient's individual needs and circumstances. Dismissing the patient's reasons (choice A), ignoring the non-compliance (choice C), or resorting to a confrontational approach (choice D) are less effective strategies that may lead to further resistance and hinder the patient's willingness to engage in their treatment.
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A woman in active labor experiences irregular and ineffective uterine contractions, resulting in prolonged cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?
- A. Encourage the mother to ambulate and change positions frequently.
- B. Administer intravenous opioids to enhance pain relief and relaxation.
- C. Initiate continuous electronic fetal monitoring to assess fetal well-being.
- D. Prepare for immediate cesarean section due to labor dystocia.
Correct Answer: A
Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.
To help the patient with his breathing difficulty, the nurse places him in which position?
- A. Prone
- B. Sim's lateral
- C. Fowler's
- D. Supine
Correct Answer: C
Rationale: Fowler's position is the correct position to help a patient experiencing breathing difficulty. In Fowler's position, the patient is sitting up at a 45- to 60-degree angle with the legs either straight or bent. This position allows for maximum chest expansion, helping to improve ventilation and oxygenation. It is commonly used to assist patients with respiratory distress, including difficulties with breathing. Placing the patient in Fowler's position can alleviate the feeling of breathlessness and facilitate easier breathing by promoting better lung expansion.
Which of the following nursing actions should the nurse TEACH the patient's care giver regarding tracheostomy care?
- A. Remove the tracheostomy tube if obstruction occurs
- B. Leave the tracheostomy ties in place until the physician change them
- C. Remove and clean the inner cannula daily
- D. Never put a covering over the tracheostomy stoma
Correct Answer: C
Rationale: Cleaning the inner cannula daily helps prevent the accumulation of secretions and debris, which can lead to blockages and infections. It is an essential aspect of tracheostomy care to maintain the patency of the airway and prevent complications. Caregivers should be taught how to safely remove, clean, and reinsert the inner cannula as part of routine tracheostomy care.
Which of the following is the MOST common emotional response among women during the First trimester of pregnancy?
- A. Ambivalence
- B. Acceptance
- C. Depression
- D. Jealousy
Correct Answer: A
Rationale: Ambivalence is the most common emotional response among women during the first trimester of pregnancy. This is because the news of being pregnant might evoke a mix of emotions, including joy and apprehension. Women may feel uncertain about their readiness for the responsibility of motherhood, have concerns about changes in their body, or worry about the impact on their career or relationships. Ambivalence is a natural response to a significant life change, and many women experience conflicting feelings before fully accepting and embracing their pregnancy.
Should the investigation of the fall go further, which of the following is the best source of factual information ?
- A. incident report.
- B. nurse's notes in the chart
- C. anecdotal record
- D. process recording
Correct Answer: A
Rationale: The incident report is the best source of factual information to investigate the fall further. Incident reports are official documents that provide a detailed account of what happened leading up to and during an incident. They include factual information such as the date, time, location, individuals involved, and details of the event. By reviewing the incident report, investigators can gather accurate information to determine the cause of the fall and any contributing factors. This document serves as an essential tool in conducting a thorough investigation into the fall and helps in identifying preventive measures to avoid similar incidents in the future.