Nokea
In the early postoperative period, what is the priority concern for Mr. L, who has a tracheostomy and partial laryngectomy?
- A. Possible infection related to chemotherapy and surgical procedure
- B. Poor nutritional intake related to dysphagia and malignancy
- C. Difficulty communicating needs because of the tracheostomy tube
- D. High risk for aspiration because of secretions and removal of epiglottis
Correct Answer: D
Rationale: The correct answer is D: High risk for aspiration because of secretions and removal of epiglottis. This is the priority concern for Mr. L due to the risk of food or liquid entering the airway, leading to aspiration pneumonia and respiratory distress. The tracheostomy and partial laryngectomy compromise the airway protection mechanism, increasing the risk of aspiration. Options A and B are not the priority as infection and poor nutrition can be managed after addressing the risk of aspiration. Option C, while important for communication, is not as immediately life-threatening as the risk of aspiration.
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The nurse cares for the mother of a child who died in the emergency room as a result of an accidental poisoning. Which response by the nurse is appropriate?
- A. Place a greater emphasis on nonverbal aspects of empathy over verbal.
- B. Accurately reflect on the mother's feelings to convey understanding and concern.
- C. Repeat exact phrases stated by the mother to aid in expressions of grief.
- D. Reflect on the expressed feelings of the mother but with the nurse's own words.
Correct Answer: B
Rationale: The correct answer is B because accurately reflecting on the mother's feelings shows understanding and empathy, validating her emotions. This approach helps establish trust and connection, essential in providing emotional support.
A: Placing greater emphasis on nonverbal aspects may not effectively convey empathy and understanding.
C: Merely repeating exact phrases may come off as insincere and robotic, lacking genuine empathy.
D: Reflecting on the mother's feelings using the nurse's own words may not accurately capture the depth of the mother's emotions and may lead to misinterpretation.
The nurse manager asks the staff nurse to work an extra shift. Which response by the staff nurse is assertive and based on rational beliefs?
- A. "I don't want you upset, so I will work extra."
- B. "Why do I always have to cover extra shifts?"
- C. "I am not able to work an extra shift."
- D. "If you can't find anyone else, I will do it."
Correct Answer: C
Rationale: The correct answer is C because it directly and assertively communicates the staff nurse's inability to work an extra shift. This response sets clear boundaries and respects the nurse's own limitations and well-being. It is based on rational beliefs as it acknowledges personal capacity without guilt or unnecessary explanations.
Explanation of other choices:
A: This choice is not assertive as it prioritizes avoiding upsetting the nurse manager over the nurse's own needs and boundaries.
B: This response is confrontational and does not address the request directly, focusing instead on questioning past occurrences.
D: While this response offers to work the extra shift as a last resort, it does not assert the nurse's own limitations clearly, leaving room for potential guilt or manipulation.
Which nonverbal action(s) would be consistent with an assertive style of communication? (Select all that apply)
- A. Relaxed posture
- B. Established eye contact
- C. Hands placed on hips
- D. Distant, soft voice
Correct Answer: A
Rationale: The correct answer is A (Relaxed posture) because assertive communication involves being confident and composed. A relaxed posture signifies confidence and comfort in oneself. Choices B (Established eye contact) can also be consistent with assertiveness as it shows engagement and confidence. Choices C (Hands placed on hips) may come across as aggressive rather than assertive. Choice D (Distant, soft voice) is more indicative of a passive communication style, lacking the firmness associated with assertiveness. In summary, choices B, C, and D are incorrect because they do not align with the confident and self-assured characteristics of assertive communication.
The home care nurse visits a mother and her newborn 2 days after discharge from the hospital. The mother states, "My baby cries all the time. I must not be a very good mother.= Which response by the nurse is nontherapeutic?
- A. "It sounds as if you are concerned about your ability to care for your baby.=
- B. "The nurse moves closer to the mother and places a hand on her shoulder."
- C. "You just need to get away for a few hours. Find a babysitter and go to a movie.=
- D. "I am not sure that I understand what you mean. Tell me more about how you feel.=
Correct Answer: C
Rationale: The correct answer is C because it dismisses the mother's feelings and suggests a temporary distraction instead of addressing her concerns. Choice A validates the mother's feelings and promotes open communication. Choice B demonstrates empathy and physical support. Choice D encourages the mother to express her emotions further for better understanding. Overall, choice C is nontherapeutic as it does not address the underlying issue of the mother's feelings of inadequacy and instead offers a superficial solution.
An experienced nurse is supervising a student nurse in an acute care setting. Which statement, if made by the experienced nurse, would be most appropriate to help the student nurse establish credibility with other nurses on the unit?
- A. "It is impossible to be credible when you are a student because you lack experience.=
- B. "Try to hide your feelings of inadequacy and portray a sense of confidence.=
- C. "Be honest with the nurses about your strengths and about areas that need improvement.=
- D. "It would help if you bring special treats for the nurses so that they will like you.=
Correct Answer: C
Rationale: The correct answer is C: "Be honest with the nurses about your strengths and about areas that need improvement." This statement promotes transparency, self-awareness, and humility, which are important traits in gaining credibility. Being honest about strengths shows confidence, while acknowledging areas for improvement demonstrates a willingness to learn and grow. This approach fosters trust and respect among colleagues.
Choice A is incorrect as it undermines the student nurse's potential for credibility based on experience. Choice B suggests masking feelings of inadequacy, which can lead to inauthentic interactions. Choice D is inappropriate as it implies trying to buy favor with treats rather than earning credibility through professional conduct.