Nokea
Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?
- A. The approximate length of the surgery
- B. The type of anticoagulants that will be prescribed
- C. The time of the next meal of solid food
- D. The length of time until the client can return to work
Correct Answer: A
Rationale: The correct answer is A: The approximate length of the surgery. This is the priority topic to instruct the client on admission because knowing the duration of the surgery helps manage the client's expectations and anxiety levels. Understanding the length of the procedure also allows the client to plan for post-operative care and recovery.
Choice B: The type of anticoagulants is important but not as critical on admission as knowing the surgery duration. Choice C: The time of the next meal is important for preoperative fasting but not as crucial as understanding the surgery length. Choice D: The length of time until the client can return to work is important, but it is a secondary concern compared to the immediate surgical procedure.
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Which of the following is an example of a living will?
- A. A client's son has been appointed to make his healthcare decisions if he becomes incapacitated
- B. A client has designated which of his children will receive his home and property before he dies
- C. A client has instructions that he does not want to be resuscitated through chest compressions if his heart stops beating
- D. A client designates what type of burial or cremation services he would want after his death
Correct Answer: C
Rationale: The correct answer is C because a living will is a legal document that outlines a person's preferences for medical treatment in case they are unable to communicate their wishes. In this case, the client's instruction not to be resuscitated through chest compressions if his heart stops beating is an example of a living will. This choice specifically addresses medical treatment preferences during a critical health situation.
Choices A, B, and D are incorrect because they all involve decisions or instructions that pertain to events or actions after the client's death, rather than specifying medical treatment preferences while the client is alive. Choice A involves appointing someone to make healthcare decisions, choice B involves designating inheritance of property, and choice D involves specifying burial or cremation services. These choices do not align with the purpose of a living will, which is to provide guidance for medical treatment decisions during the client's lifetime.
Which example best describes the concept of beneficence?
- A. A nurse provides pain medication for a client in the recovery room who is experiencing pain
- B. A client has an advanced directive in place stating that he does not want intubation if he needs CPR
- C. At the request of the client, a nurse does not inform the family about his cancer diagnosis
- D. A nurse withholds narcotic medication for a client in pain, knowing that he is currently disoriented
Correct Answer: A
Rationale: The correct answer is A because beneficence refers to the ethical principle of doing good and promoting the well-being of the patient. Providing pain medication to a client in the recovery room aligns with this principle as it aims to alleviate suffering and improve the client's comfort. This action demonstrates a commitment to the client's best interests and upholds the duty of care.
Choice B is incorrect because it relates to autonomy, where the client's wishes regarding medical treatment are respected. Choice C is incorrect as it violates the principle of veracity by withholding important information from the family. Choice D is incorrect as it goes against beneficence by not addressing the client's pain adequately.
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
- A. The adolescent gives away a DVD player and a cherished autographed picture of a performer.
- B. The adolescent runs out of group therapy, swearing at the group leader, and then goes to her room.
- C. The adolescent becomes angry while speaking on the phone and slams down the receiver.
- D. The adolescent gets angry with her roommate when the roommate borrows her clothes without asking.
Correct Answer: A
Rationale: The correct answer is A because giving away cherished possessions can be a sign of preparing for suicide. This behavior may indicate a lack of concern for material possessions due to a belief that they won't be needed in the future. Choice B shows anger and isolation, not necessarily suicidal ideation. Choice C demonstrates anger but no indication of suicidal thoughts. Choice D shows anger towards the roommate, not self-harm intentions.
A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?
- A. Contact the state board of nursing licensure to report the offense
- B. Review the state scope of practice standards for nurses
- C. Ask another nurse to perform the task to learn the procedure
- D. Contact the house supervisor to make the decision on whether the nurse should perform the task
Correct Answer: B
Rationale: The correct answer is B: Review the state scope of practice standards for nurses. This is the appropriate response as it allows the nurse to understand her legal boundaries and responsibilities. By reviewing the state scope of practice standards, the nurse can ensure she is acting within the limits of her licensure and avoid potential legal or ethical issues.
Choice A is incorrect because reporting the offense to the state board of nursing licensure should not be the initial response without first verifying the scope of practice standards. Choice C is incorrect as it does not address the issue of the nurse operating outside her scope of practice. Choice D is incorrect as the house supervisor may not have the necessary knowledge of the nurse's scope of practice.
A nurse is caring for an in-patient client in the hospital who is from another country and who fasts for temporary periods in order to promote his own spiritual growth. The nurse responds by saying, 'You need to eat something while you are here. Food and proper nutrition are extremely important for your health.' What social philosophy is the nurse demonstrating?
- A. Ethnocentrism
- B. Relativism
- C. Stereotyping
- D. Xenocentrism
Correct Answer: A
Rationale: The correct answer is A: Ethnocentrism. Ethnocentrism is the belief in the inherent superiority of one's own culture or ethnic group. In this scenario, the nurse is imposing their own cultural beliefs about food and nutrition onto the patient, without considering or respecting the patient's cultural or spiritual practices. This demonstrates a lack of cultural sensitivity and understanding, as the nurse is prioritizing their own cultural norms over the patient's beliefs.
Summary of other choices:
B: Relativism - Relativism would involve acknowledging and respecting the patient's cultural practices and beliefs, which the nurse is not doing in this case.
C: Stereotyping - Stereotyping involves making assumptions about individuals based on their cultural background, which is not explicitly demonstrated in this scenario.
D: Xenocentrism - Xenocentrism is the opposite of ethnocentrism, where one believes that other cultures are superior to their own. This is not evident in the nurse's behavior.