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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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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.
A patient states, "I'm so worried that I might have cancer." The nurse responds, "It is time for you to eat breakfast." The nurse's response is an example of:
- A. using clichés.
- B. judgmental response.
- C. changing the subject.
- D. giving false reassurance. Changing the subject is a block to effective communication in which the patient is deprived of the chance to verbalize concerns.
Correct Answer: C
Rationale: The correct answer is C: changing the subject. The nurse's response shifts the conversation away from the patient's expression of worry about having cancer to a completely unrelated topic - eating breakfast. This technique blocks effective communication as it disregards the patient's concerns and prevents further exploration of the underlying issue. By redirecting the conversation, the nurse fails to address the patient's emotional needs and misses an opportunity to provide support and reassurance. Choices A, B, and D are incorrect as they do not accurately reflect the nurse's response in this scenario.
The nurse discusses smoking cessation with a client. Which action, if taken by the nurse, would most likely result in a behavior change?
- A. The nurse should advise the client to contact the national telephone quitline.
- B. The nurse should recommend nicotine replacement and behavioral interventions.
- C. The nurse should collaborate with the client to develop an individualized plan of action.
- D. The nurse should implement a strategy that has been validated by research.
Correct Answer: C
Rationale: The correct answer is C: The nurse should collaborate with the client to develop an individualized plan of action. This is the most likely action to result in a behavior change because it involves actively involving the client in the process, taking into account their unique needs, preferences, and circumstances. By collaborating with the client, the nurse can tailor the smoking cessation plan to be more personalized and therefore more effective.
Choice A (contact the national telephone quitline) may be helpful but lacks individualization. Choice B (recommend nicotine replacement and behavioral interventions) is a good approach but may not address the client's specific needs. Choice D (implement a strategy validated by research) is important but may not be as effective if it does not consider the client's individual factors. Overall, choice C is the best option as it promotes client engagement and customization for a higher chance of successful behavior change.
An aspect of computer use in patient care in which the LPN may need to be proficient includes:
- A. input of data such as requests for radiographs or laboratory services.
- B. programming the computer to record data from primary care provider and other health care workers.
- C. educating patients how to use hospital computers to access information such as discharge instructions or information relative to specific medications.
- D. scheduling admissions, discharges, and nurse staffing to keep the unit at the best occupancy and utilization.
Correct Answer: A
Rationale: The correct answer is A because LPNs are often responsible for inputting patient data such as requests for radiographs or lab services into the computer system. This task requires proficiency in navigating electronic health records to accurately document patient information. Option B is incorrect as LPNs typically do not program computers but rather use pre-existing systems. Option C is incorrect because educating patients on computer use is usually the responsibility of other healthcare professionals. Option D is also incorrect as scheduling admissions and nurse staffing is typically managed by unit coordinators or nurse managers, not LPNs. In summary, the LPN's role in computer use for patient care primarily involves inputting data accurately and efficiently.
A patient is irritable and complains to the nurse about difficulty sleeping last night. Which response by the nurse is most appropriate?
- A. "I know you will sleep better tonight.=
- B. "Tell me more about what happened last night.=
- C. "Did you drink too much caffeine yesterday?=
- D. "No one sleeps well in the hospital.=
Correct Answer: B
Rationale: The correct response is B. Asking the patient to elaborate on what happened last night allows the nurse to gather more information about the situation, which is crucial for assessing the patient's sleep difficulties accurately. It shows active listening and empathy, building rapport and trust with the patient. Options A, C, and D are incorrect because they do not address the patient's concerns effectively or gather relevant information to provide appropriate care. Option A makes an assumption without understanding the root cause of the sleep issue. Option C assumes the cause of sleep difficulty without exploring further. Option D dismisses the patient's concerns without providing support or understanding.