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In the acronym BRAIDED, which letter is used to identify the key components of informed consent that the nurse must document?
- A. B stands for birth control.
- B. R stands for reproduction.
- C. A stands for alternatives.
- D. I stands for ineffective.
Correct Answer: C
Rationale: In BRAIDED, 'A' stands for alternatives, representing the key component of informed consent that includes information about other viable methods.
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In which step of the nursing process does the nurse determine the appropriate interventions for the identified nursing diagnosis?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Intervention
Correct Answer: A
Rationale: In the nursing process, planning is the step where the nurse determines the appropriate interventions for the identified nursing diagnosis. Firstly, after assessing the patient's needs (Assessment), the nurse analyzes the data to identify nursing diagnoses. Next, in the Planning step, the nurse sets goals, establishes priorities, and decides on specific interventions to address the nursing diagnoses. This step involves developing a comprehensive care plan tailored to the individual patient's needs. Evaluation comes after the interventions are implemented to assess the effectiveness of the care provided. The Intervention step involves carrying out the planned interventions. Thus, the correct answer is A: Planning.
The nurse is assessing a 25-year-old female patient when the patient becomes tearful. The patient states that she has thin milky discharge from her nipples and two small masses on her left breast. She has lost over 40 pounds in the past year due to intensive exercises and finds that she needs to wear a sports bra during her sessions. The patient states that she is afraid that she will become the first member of her family to have breast cancer. Besides a negative mammogram, what other symptoms would correlate with this being a benign finding? Select all that apply.
- A. Milky discharge from nipples
- B. Extensive weight loss
- C. Painful masses
- D. Mood swings
Correct Answer: A
Rationale: The correct answer is A: Milky discharge from nipples. Milky discharge from nipples is often a benign finding and can be related to hormonal changes or medications. In this case, the patient's description of thin milky discharge in the context of her age, weight loss, and fear of breast cancer makes it more likely to be benign. The other choices are incorrect because extensive weight loss and painful masses could be concerning signs of malignancy, and mood swings are not directly related to breast cancer diagnosis. Therefore, the presence of milky discharge from the nipples in this patient's case would be more indicative of a benign finding.
The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed
- C. Patient will state an absence of pain 1 hour after administration of the prescribed
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
Correct Answer: D
Rationale: The correct answer is D because it aligns with the SMART criteria for expected outcomes. Specific: It clearly states the desired pain level of 2 on a scale of 10. Measurable: It provides a quantifiable measure to assess the outcome. Achievable: The goal is realistic and attainable within a specified time frame. Relevant: It directly addresses the nursing diagnosis of acute pain related to tissue trauma. Time-bound: It includes a timeframe of 1 hour after administration for evaluation.
Choices A, B, and C are incorrect because they do not meet all the SMART criteria. Choice A only focuses on the pain level without a specific timeframe. Choice B mentions pain reduction but lacks a specific target level or timeframe. Choice C mentions pain absence but lacks a specific timeframe for evaluation.
A client is 5 months pregnant. On a routine ultrasound scan, the physician discovers that the fetus has a diaphragmatic herniThe woman becomes distraught and asks the nurse what she should do. Which response would be most suitable?
- A. Talk to the client, and refer her to a genetic counselor.
- B. Suggest that the client travel to a fetal treatment center for intrauterine surgery.
- C. Tell her that everything is going to be fine.
- D. Sit with the client, and calmly suggest that she consider terminating this pregnancy.
Correct Answer: A
Rationale: Before the client makes any decisions, she should discuss this newly discovered information with a genetic counselor. Genetic counselors can help with the diagnosis and management of families affected by genetic conditions. The discussion of potential surgery should be pursuant to genetic counseling. Telling the woman that everything is going to be fine may give her false hope and is not accurate. All options should be discussed with the genetic counselor. Furthermore, the guiding principle for genetic counseling is nondirection, which respects the right of the individual or family who are being counseled to make autonomous decisions.
A nurse is entering information on the patient’s electronic health record (EHR) and is called to assist in an emergency situation with regard to another patient in the labor and birth suite. The nurse rushes to the scene to assist; however, she leaves the chart open on the computer screen. The emergent patient situation is resolved satisfactorily, and the nurse comes back to the computer entry screen to complete charting. At the end of the shift, the nurse manager asks to speak with the nurse and tells her that she is concerned with what happened today on the unit because there was a breach in confidentiality. Which response by the nurse indicates that she understands the nurse manager’s concerns?
- A. The nurse acknowledges that she should have made sure that her patient was safe before assisting with the emergency.
- B. The nurse states that she should have logged out of the EHR prior to attending to the emergency.
- C. The nurse indicates that the unit was understaffed.
- D. The nurse indicates that the she changed her password following the clinical emergency to maintain confidentiality.
Correct Answer: B
Rationale: The correct answer is B. The nurse should have logged out of the EHR prior to attending to the emergency. By leaving the EHR open and unattended, the nurse exposed patient information to potential unauthorized access, violating patient confidentiality. Logging out would have prevented this breach.
Choice A is incorrect because the priority in an emergency is to address the immediate patient needs. Choice C is irrelevant to the breach of confidentiality. Choice D, changing the password after the incident, does not address the initial breach and is not a sufficient response to the nurse manager's concerns about maintaining confidentiality.