Nokea
Ms. C (bowel resection) repeatedly refuses to perform a return demonstration of any aspect of colostomy care. Despite steady improvement and independent resumption of other ADLs, she protests, "I'm too weak. You'll have to do it for me." At this point, what is the priority nursing concept to consider in planning interventions for Ms. C?
- A. Mobility
- B. Tissue integrity
- C. Functional ability
- D. Coping
Correct Answer: C
Rationale: The correct answer is C: Functional ability. This is because the priority nursing concept to consider in planning interventions for Ms. C is her ability to independently perform colostomy care. By refusing to demonstrate, she may be indicating a lack of functional ability to manage this aspect of self-care. This is essential for her long-term independence and quality of life. Mobility (choice A) is important but not the priority in this case. Tissue integrity (choice B) is also crucial but not as immediate as ensuring functional ability. Coping (choice D) is important for emotional well-being but does not address the primary issue of functional ability for self-care.
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A non-Hispanic white nurse provides care to mostly Hispanic patients. It would be most important for the nurse to take which action?
- A. Discover cultural influences on healthcare perceptions and behaviors.
- B. Assist the patients to adapt to American culture and health beliefs.
- C. Avoid confrontation of underlying issues of discrimination.
- D. Improve communication by learning how to speak Spanish.
Correct Answer: A
Rationale: Step 1: Understanding cultural influences is crucial for providing effective care to diverse patients.
Step 2: By discovering healthcare perceptions and behaviors, the nurse can tailor care to meet the patients' needs.
Step 3: This approach promotes cultural competence and improves patient outcomes.
Step 4: Other choices are incorrect as they do not address the core issue of cultural understanding and sensitivity.
When interacting with an older adult patient, the nurse would enhance communication by:
- A. speaking slowly in order to allow the patient to process the message.
- B. addressing him by his first name to encourage a therapeutic relationship.
- C. standing in the doorway rather than entering the room to give the older adult patient more privacy.
- D. speaking in simple sentences, as if to a child. When interacting with an older adult, the nurse should try not to speak too quickly or expect an immediate answer because the older adult may take more time to process the message. Do not use baby talk or speak to them as if they were children.
Correct Answer: A
Rationale: The correct answer is A because speaking slowly allows the older adult patient to process the message at their own pace, considering potential hearing or cognitive impairments. Speaking slowly also shows respect and patience.
Option B is incorrect because using the first name may not be culturally appropriate or may not align with the patient's preference for formality.
Option C is incorrect because standing in the doorway may be seen as disrespectful and inhibit effective communication by creating physical barriers.
Option D is incorrect because speaking in simple sentences is important, but speaking as if to a child may be patronizing and disrespectful to the older adult patient.
The nurse is performing a well-child assessment on a 15-month-old child. The child's mother and father are present. Which action by the nurse will best determine the health beliefs and values of the parents?
- A. Have the parents independently complete the Myers-Briggs Type Indicator survey.
- B. Read the documented health histories of the child's parents and grandparents.
- C. Actively listen to the parents talk about their lives and health concerns.
- D. Review the traditional health practices of the ethnic group identified by the parents.
Correct Answer: C
Rationale: The correct answer is C: Actively listen to the parents talk about their lives and health concerns. This action allows the nurse to directly learn about the parents' health beliefs and values. By listening attentively, the nurse can understand the parents' perspectives, concerns, and priorities regarding their child's health. This approach promotes trust and open communication, enabling the nurse to provide individualized and culturally sensitive care.
Explanation for why the other choices are incorrect:
A: Having the parents complete the Myers-Briggs Type Indicator survey is not relevant to determining their health beliefs and values.
B: Reading the health histories of the child's parents and grandparents may provide some background information but may not reflect their current health beliefs and values.
D: Reviewing traditional health practices of the ethnic group identified by the parents assumes that all individuals within that group hold the same beliefs, which may not be accurate.
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.
It would be most important for the nurse to temporarily withdraw expressions of warmth to which patient?
- A. A 20-year-old patient who is angry and throwing objects.
- B. A 32-year-old patient who is withdrawn and refuses nursing care.
- C. A 48-year-old patient who is extremely anxious about surgery.
- D. A 56-year-old patient who has a history of violent behavior.
Correct Answer: D
Rationale: The correct answer is D because the patient with a history of violent behavior poses a potential risk to the nurse's safety. Temporarily withdrawing expressions of warmth is important to establish boundaries and ensure safety. Choice A involves an angry patient, but the risk of violence is higher with a history of violent behavior. Choices B and C do not indicate immediate safety concerns.