Nokea
Intervention for the sexual abuse survivor is often not attempted by maternity and women's health nurses because of the concern about increasing the distress of the woman and the lack of expertise in counseling. What initial intervention is appropriate and most important in facilitating the woman's care?
- A. Initiating a referral to an expert counselor
- B. Setting limits on what the client discloses
- C. Listening and encouraging therapeutic communication skills
- D. Acknowledging the nurse's discomfort to the client as an expression of empathy
Correct Answer: C
Rationale: The survivor needs support on many levels. Therapeutic communication skills and listening are initial interventions. Referring to a counselor is appropriate but not the most important initial intervention.
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Which statement is the most comprehensive description of sexual violence?
- A. Sexual violence is limited to rape.
- B. Sexual violence is an act of force during which an unwanted and uncomfortable sexual act occurs.
- C. Sexual violence encompasses a number of sexual acts.
- D. Sexual violence includes degrading sexual comments and behaviors.
Correct Answer: C
Rationale: Sexual violence includes a range of victimization, including sexual assault, harassment, and rape. It is broader than rape alone.
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: Step-by-step rationale:
1. The correct answer is B because logging out of the EHR prior to attending to the emergency is crucial to maintain patient confidentiality.
2. By leaving the EHR open, the nurse exposed sensitive patient information to potential unauthorized access.
3. This action violates patient privacy rights and is a breach of confidentiality.
4. Choice A is incorrect as it does not address the specific issue of breaching patient confidentiality by leaving the EHR open.
5. Choice C is irrelevant as understaffing does not excuse the breach of patient confidentiality.
6. Choice D is incorrect as changing the password after the breach does not rectify the initial mistake of leaving the EHR open.
Summary: Choice B is the correct response as it directly addresses the breach of confidentiality by acknowledging the importance of logging out of the EHR to protect patient information. Choices A, C, and D are incorrect as they do not effectively address the issue of breaching patient confidentiality.
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 appropriate interventions for the identified nursing diagnosis. Firstly, in the assessment step (choice C), the nurse collects data to identify the nursing diagnosis. Next, in the diagnosis step, the nurse analyzes the data to identify the nursing diagnosis. Then, in the planning step (choice A), the nurse develops a plan of care that includes specific interventions to address the nursing diagnosis. Finally, in the intervention step (choice D), the nurse implements the planned interventions. Evaluation (choice B) is the step where the nurse assesses the effectiveness of the interventions. Therefore, choice A is correct as it is the step where the nurse determines the appropriate interventions based on the identified nursing diagnosis.
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.
The nurse is arranging education for the menopausal support group regarding the approaches to treat the symptoms. Which of the following would be components of current treatments? Select all that apply.
- A. Moderately intense exercises
- B. Balanced diet, rich in calcium
- C. Alternative medicine such as black cohosh
- D. Over-the-counter sleep aid
Correct Answer: A
Rationale: Rationale: Moderate-intensity exercises are recommended for managing menopausal symptoms like hot flashes and mood swings by improving overall health and reducing stress. Exercise can also help with weight management and bone health.
Summary:
- Balanced diet with calcium (B) is important for overall health but not specific to treating menopausal symptoms.
- Alternative medicine like black cohosh (C) may have limited evidence and can vary in effectiveness.
- Over-the-counter sleep aids (D) may help with sleep disturbances but are not specific to managing menopausal symptoms.