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According to the ANA's Standards of Clinical Nursing Practice, there are several steps within the nursing process that surround patient care. However, one of the most important steps is the one in which the nurse partners with the patient, family, and other caregivers to create an acceptable path that meets the patient's needs and is specific to the disease process. This important step is identified as:
- A. Evaluation
- B. Planning
- C. Implementation
- D. Nursing diagnosis
Correct Answer: B
Rationale: The correct answer is B: Planning. In the nursing process, planning is a crucial step where the nurse collaborates with the patient, family, and caregivers to develop a comprehensive care plan tailored to the patient's needs and specific disease process. This step involves setting goals, determining interventions, and creating a roadmap for the patient's care. Planning ensures that the care provided is individualized, evidence-based, and addresses the patient's unique circumstances. Evaluation (A) comes after planning to assess the effectiveness of interventions. Implementation (C) involves carrying out the planned interventions. Nursing diagnosis (D) is an earlier step where the nurse identifies the patient's health problems and needs. Planning stands out as the most important step as it guides the entire care process.
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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 cares for a female patient who is trying to gain understanding of her life and her diagnosis of metastatic breast cancer. Which approach by the nurse would best meet this patient's needs?
- A. Suggest the patient join a breast cancer support group.
- B. Provide the patient with reading material on death and dying.
- C. Contact the patient's spiritual leader to request daily visits.
- D. Listen to the patient's stories about her past experiences.
Correct Answer: D
Rationale: The correct answer is D because actively listening to the patient's stories about her past experiences allows for emotional expression, validation, and building trust. It promotes therapeutic communication and helps the patient gain understanding and cope with her diagnosis. Choice A focuses on group support, which may not address the patient's individual needs. Choice B is not appropriate as it may induce unnecessary fear. Choice C assumes the patient has specific spiritual beliefs and may not be welcomed.
The home health nurse cares for a patient who is diagnosed with chronic obstructive pulmonary disease. Which response(s) and behavior(s) by the nurse would indicate that bonding between nurse and patient has occurred? (Select all that apply)
- A. Expects the patient to meet the goals for exercise as determined by the nurse.
- B. Listens to the patient describe the feelings of anxiety related to severe dyspnea.
- C. Develops teaching plan based on the learning preferences of the patient.
- D. Refrains from touching the patient unless performing physical assessment techniques.
Correct Answer: B
Rationale: The correct answer is B because actively listening to the patient describe their feelings of anxiety related to severe dyspnea demonstrates empathy and a deeper connection between the nurse and patient. This behavior shows understanding and support, fostering trust and rapport. It indicates that the nurse is attentive to the patient's emotional needs, which is essential for effective care in chronic conditions like COPD.
Option A is incorrect because expecting the patient to meet exercise goals set by the nurse does not necessarily indicate bonding. It may reflect a more authoritative approach rather than a collaborative relationship. Option C, while important for individualized education, does not specifically indicate bonding unless it involves understanding the patient's preferences on a personal level. Option D is incorrect because refraining from touching the patient may be necessary in some situations, but it does not directly relate to establishing a bond.
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.
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.