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A pregnant woman states, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?
- A. It was a nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman's fears.
- B. It was a therapeutic response. The nurse should have shared her own experience with the patient to make her feel better.
- C. It was a nontherapeutic response. The nurse is essentially giving the message to the woman that labour cannot be tolerated without medication.
- D. It was a therapeutic response. By providing false assurance, the nurse created a sense of security and opened the door for more discussion.
Correct Answer: B
Rationale: The correct answer is B because the nurse's response was therapeutic by sharing her own experience to empathize with the patient. This helps establish a connection and validate the patient's feelings. It shows understanding without dismissing the patient's concerns.
A is incorrect because the nurse did not provide false reassurance but offered a comforting perspective.
C is incorrect as the nurse did not imply that medication was necessary but rather highlighted its availability as an option.
D is incorrect since the response did not provide false assurance but rather shared personal experience to offer support.
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A patient tells the nurse that she believes in "the hot"“cold theory, where illness is caused by hot or cold entering the body." Which of the following responses from the nurse would be most appropriate?
- A. I do not believe in this theory, but tell me about it.
- B. I know that this is your belief, but the cause is actually a virus.
- C. I did not take this in school, so it's unfamiliar to me.
- D. I have not heard of this theory. Tell me more.
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Administering antiemetics as needed.
- B. Encouraging early ambulation to prevent complications.
- C. Providing wound care and dressing changes.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery.
Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case.
Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications.
Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.
A nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
- A. Shortness of breath and weight gain.
- B. Increased urine output and fatigue.
- C. Dizziness and hypotension.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.
When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?
- A. Identifying existing levels of wellness
- B. Evaluating previous problems and goals
- C. Identifying potential problems the individual may develop
- D. Focusing on strengths and reflecting an individual's transition to higher levels of wellness
Correct Answer: C
Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.
A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following signs of an asthma exacerbation?
- A. Decreased work of breathing.
- B. Increased wheezing and shortness of breath.
- C. Improved oxygen saturation.
- D. Decreased sputum production.
Correct Answer: B
Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.