Nokea
An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The patient is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurses action is an example of which therapeutic communication technique?
- A. Informing
- B. Suggesting
- C. Expectation-setting
- D. Enlightening
Correct Answer: A
Rationale: Informing involves providing information to the patient regarding his or her care. Suggesting is the presentation of an alternative idea for the patients consideration relative to problem solving. This action is not characterized as expectation-setting or enlightening.
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During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise?
- A. Good Samaritan Act
- B. Nursing Interventions Classification (NIC)
- C. Patient Self-Determination Act
- D. ANA Code of Ethics
Correct Answer: D
Rationale: The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.
An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients?
- A. A postlaryngectomy patient who is attempting to pull out his tracheostomy tube
- B. A patient in hypovolemic shock trying to remove the dressing over his central venous catheter
- C. A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode
- D. A patient with depression who has just tried to commit suicide and whose medications are not achieving adequate symptom control
Correct Answer: C
Rationale: Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more likely appropriate to apply restraints in these instances.
The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains?
- A. Self-esteem
- B. Self-regulation
- C. Inference
- D. Autonomy
- E. Interpretation
Correct Answer: B,C,E
Rationale: Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills.
A medical nurse is caring for a patient who is palliative following metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this patient?
- A. The nurse tactfully regulates the number and timing of visitors as per the patients wishes.
- B. The nurse stays with the patient during his or her death.
- C. The nurse ensures that all members of the care team are aware of the patients DNR order.
- D. The nurse liaises with members of the care team to ensure continuity of care.
Correct Answer: B
Rationale: Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the patients wishes around visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.
A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patients leg is pain-free, without redness or edema. Which step of the nursing process does this reflect?
- A. Diagnosis
- B. Analysis
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurses actions do not constitute diagnosis.