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An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?
- A. Verbally redirect the client, and then limit one-on-one interaction.
- B. Involve the hospitals security division as soon as possible.
- C. Notify the client that documenting personal staff information is against hospital policy.
- D. Continue professional attempts to establish a positive working relationship with the client.
Correct Answer: C
Rationale: The most appropriate nursing action is to choose option C: Notify the client that documenting personal staff information is against hospital policy. This response is effective in addressing the situation because it clearly communicates boundaries to the client and informs them of the hospital's policy. By doing so, the client is made aware that their behavior is not acceptable and that there are consequences for violating the policy. This action also helps to protect the staff members' privacy and security.
Option A: Verbally redirect the client and then limit one-on-one interaction, may not effectively address the issue of the client recording personal staff information. Option B: Involve the hospital's security division as soon as possible, is a more drastic measure that may escalate the situation unnecessarily. Option D: Continue professional attempts to establish a positive working relationship with the client, is not appropriate in this scenario as the client's behavior is threatening and abusive.
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A female nurse is caring for a traditional Arab American male client. When planning effective care for this client, the nurse should be aware of which of the following cultural considerations? Select all that apply.
- A. Limited touch is acceptable only between members of the same sex.
- B. Conversing individuals of this culture stand far apart and do not make eye contact.
- C. Devout Muslim men may not shake hands with women.
- D. The man is the head of the household and women take on a subordinate role.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. In traditional Arab American culture, limited touch is acceptable only between members of the same sex due to modesty and respect for personal boundaries.
2. This cultural consideration is important for the nurse to provide appropriate care that respects the client's cultural beliefs and preferences.
3. Understanding this aspect helps the nurse establish trust and build rapport with the male client while upholding cultural sensitivity and respect.
Summary:
- Choice B is incorrect as Arab American individuals may stand close and make eye contact during conversations.
- Choice C is incorrect as devout Muslim men may opt for not shaking hands with women due to religious beliefs, not solely based on gender.
- Choice D is incorrect as gender roles in traditional Arab American culture can vary and may not always follow a strict hierarchical structure.
Which client statement reflects an understanding of the effect of circadian rhythms on a person?
- A. When I dream about my mothers horrible train accident, I become hysterical. B. I get really irritable during my menstrual cycle.C. Im a morning person. I get my best work done in the a.m.
- B. Every February, I tend to experience periods of sadness.
Correct Answer: C
Rationale: The correct answer is C because the client statement "I'm a morning person. I get my best work done in the a.m." reflects an understanding of circadian rhythms. Circadian rhythms are the body's internal clock that regulates the sleep-wake cycle and influences energy levels and productivity throughout the day. Being a morning person indicates that this individual's peak productivity aligns with their body's natural circadian rhythm, which typically results in better performance during the morning hours.
Choice A is incorrect as it relates to a traumatic dream triggering hysteria, not circadian rhythms. Choice B is incorrect as it mentions experiencing sadness in February, which is more likely related to seasonal affective disorder rather than circadian rhythms.
Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? Select all that apply.
- A. Encouraging members to provide feedback to each other about individual progress
- B. Ensuring that rules established by the group do not interfere with goal fulfillment
- C. Working with group members to establish rules that will govern the group
- D. Emphasizing the need for and importance of confidentiality within the group
Correct Answer: A
Rationale: The correct answer is A: Encouraging members to provide feedback to each other about individual progress. In the orientation phase of group development, it is crucial for the nurse leader to foster open communication and trust within the group. Encouraging members to provide feedback helps promote mutual understanding and support, which can enhance cohesion and collaboration. This also helps in identifying individual strengths and areas for improvement.
Explanation of why the other choices are incorrect:
B: Ensuring that rules established by the group do not interfere with goal fulfillment - This choice could be more suitable for the norming or performing phase, where balancing rules with achieving goals is essential.
C: Working with group members to establish rules that will govern the group - This is more relevant for the initial phase of group development, not specifically the orientation phase.
D: Emphasizing the need for and importance of confidentiality within the group - While confidentiality is important throughout group development, it may not be the primary focus during the orientation phase.
A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate?
- A. Im confident you know whats best for you.
- B. This may not be the best time for you to make such an important decision.
- C. Your children will be terribly disappointed.
- D. Tell me why you want to make this change.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions and gently suggests caution in making a big decision during a vulnerable time. It shows empathy and encourages the client to reconsider the decision later. Choice A lacks exploration of client's feelings, Choice C introduces unnecessary guilt, and Choice D focuses on the change rather than the emotional state.
A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction?
- A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing.
- B. The Nurse Practice Act lists education requirements for licensure and reciprocity.
- C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs).
- D. The Nurse Practice Act lists the general authority and powers of the state board of nursing.
Correct Answer: B
Rationale: The correct answer is B because education requirements for licensure and reciprocity are typically not included in the Nurse Practice Act. The Act primarily focuses on defining the scope of practice, authority of the state board, regulations, and standards for nursing practice. Education requirements are usually outlined in separate regulations or guidelines by the state board of nursing or accrediting bodies. Therefore, if a student statement mentions education requirements as part of the Nurse Practice Act, it indicates a need for further instruction as it is not accurate.
A: This statement is correct as the Nurse Practice Act often includes definitions of important terms to provide clarity and understanding.
C: This statement is correct as the Act does describe the scope of practice for registered nurses to ensure safe and competent care.
D: This statement is correct as the Act typically outlines the general authority and powers of the state board of nursing to regulate and oversee nursing practice.