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It is not enough for the nurse to listen, but she also has, to validate what she has heard. The importance of validation are the following EXCEPT _____
- A. perceptions influence the interpretation of a message
- B. most patients are cognitively impaired
- C. Eye contact does not necessarily send the same message
- D. assists clarifying thoughts
Correct Answer: B
Rationale: The importance of validation in the context of communication and nursing care does not include the assumption that most patients are cognitively impaired. It would be more appropriate to approach patient interactions with the assumption that patients are capable of understanding and coherent communication. Validation is important because it helps ensure that the nurse has truly understood the patient's message, prevents misinterpretation, and fosters a sense of empathy and trust in the nurse-patient relationship. Additionally, validating the patient's thoughts and feelings can help clarify confused thoughts and promote effective communication. The other options (A, C, and D) are all valid reasons emphasizing the significance of validation in effective communication.
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Which of these measures will help stabilize mentally the parents of Nurse Lailanie?
- A. Establish a regular routine
- B. Repaint or buy a new furniture
- C. Move to small apartment
- D. Correct bad behaviors gently
Correct Answer: A
Rationale: Establishing a regular routine can be very helpful in stabilizing the mental state of parents. Consistency and structure in day-to-day activities can provide a sense of predictability and control, which can help reduce anxiety and stress. By having a routine, the parents can feel more organized, efficient, and better equipped to manage their responsibilities and emotions. Additionally, a regular routine can promote better sleep patterns, healthier habits, and overall well-being. This measure is practical, achievable, and can have positive effects on the mental stability of Nurse Lailanie's parents.
A woman in active labor demonstrates signs of cephalopelvic disproportion (CPD), with the fetal head failing to descend despite strong contractions. What nursing action should be prioritized to address this abnormal labor presentation?
- A. Perform a pelvic exam to assess for CPD.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Prepare for immediate instrumental delivery.
Correct Answer: D
Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.
A patient with a history of chronic obstructive pulmonary disease (COPD) is prescribed prednisone for an acute exacerbation. Which instruction is important for the nurse to include in patient education about prednisone therapy?
- A. "Take prednisone with antacids to minimize gastrointestinal upset."
- B. "Avoid abruptly stopping prednisone therapy."
- C. "Increase your intake of potassium-rich foods while taking prednisone."
- D. "Prednisone may cause weight loss, so monitor your weight regularly."
Correct Answer: B
Rationale: It is crucial for patients with COPD who are prescribed prednisone to be educated about the importance of not abruptly stopping the medication. Prednisone is a type of corticosteroid that should be tapered off gradually under the guidance of a healthcare provider to prevent potential withdrawal symptoms and adrenal insufficiency. Suddenly stopping prednisone can lead to serious adverse effects, including fatigue, weakness, joint pain, fever, dizziness, and potentially life-threatening complications. Therefore, adherence to the prescribed tapering schedule is essential to ensure the safe and effective management of COPD exacerbations with prednisone therapy.
A patient presents with acute pain, swelling, and deformity of the ankle following a twisting injury. X-ray reveals a fracture involving the distal fibula with associated widening of the ankle mortise. Which type of ankle fracture is most likely?
- A. Maisonneuve fracture
- B. Pilon fracture
- C. Tillaux fracture
- D. Trimalleolar fracture
Correct Answer: D
Rationale: A trimalleolar fracture is characterized by fractures involving the lateral malleolus (distal fibula), medial malleolus (distal tibia), and the posterior tubercle of the distal tibia. This fracture pattern results in instability of the ankle joint and is often associated with widening of the ankle mortise on X-ray. The deformity and swelling seen in this patient are indicative of a trimalleolar fracture and are typically caused by a high-energy injury, such as a forceful twisting motion. Treatment for trimalleolar fractures often involves surgical intervention to stabilize the ankle joint and restore normal function.
Which of the following would the nurse expect to see as symptoms in a child with ADHD?
- A. Moody, sullen and pouting behavior
- B. Interrupts others and can't take turns
- C. Excessive running, climbing and. fidgeting
- D. Easily distracted and forgetful
Correct Answer: C
Rationale: Children with ADHD often display hyperactive and impulsive behaviors, such as excessive running, climbing, and fidgeting. These behaviors are characteristic symptoms of the hyperactive-impulsive subtype of ADHD. Children with ADHD may struggle to sit still, have difficulty engaging in quiet activities, and often seem on the go. Therefore, the nurse would expect to see signs of excessive movement and restlessness in a child with ADHD.