Nokea
Myra said 'I saw my dead grandmother here at my bedside a while ago' Budek responded 'Really? That is hard to believe, How do you feel about it?' What technique did Budek used?
- A. Disproving
- B. Disagreeing
- C. Voicing Doubt
- D. Presenting Reality
Correct Answer: C
Rationale: Budek's 'Really? That is hard to believe uses voicing doubt (C), gently questioning Myra's perception (hallucination) while exploring feelings. Disproving (A) or disagreeing (B) outright rejects (e.g., 'That's not true'). Presenting reality (D) corrects (e.g., 'She's not here'). Voicing doubt, per schizophrenia care, balances reality-testing with empathy, making C correct.
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The nurse is caring for a client with a fractured tibia placed in an external fixator. Which of the following should be included in the plan of care?
- A. Keeping the leg flat at all times
- B. Checking the pin sites for signs of infection
- C. Massaging the leg to promote circulation
- D. Ambulating the client within 12 hours of application
Correct Answer: B
Rationale: Checking pin sites for infection (redness, drainage) is critical in external fixator care for a fractured tibia, preventing osteomyelitis flat legs, massage, or early ambulation risk stability or healing. Nurses monitor this, ensuring site care and antibiotics if needed, supporting bone recovery.
The purpose of assessment is to:
- A. Establish a database concerning the client
- B. Delegate nursing responsibility
- C. Teach the client about his or her health
- D. Implement nursing care
Correct Answer: A
Rationale: Assessment's purpose is to establish a client database, collecting subjective (e.g., pain reports) and objective (e.g., blood pressure) data to understand health status comprehensively. This informs all nursing process steps diagnosis, planning, implementation, evaluation ensuring care is evidence-based. Delegating responsibility is a management task, not assessment's goal, which focuses on data, not task assignment. Teaching clients about health occurs later, using assessment findings, not defining its purpose. Implementing care follows planning, not assessment, which precedes action. By building a detailed picture e.g., a patient's asthma triggers assessment equips nurses to address needs accurately, making it the essential first step and primary purpose in delivering tailored, effective care.
Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is a human being. What major ingredient of a therapeutic communication is Nurse Aida using?
- A. Empathy
- B. Positive regard
- C. Comfortable sense of self
- D. Self awareness
Correct Answer: B
Rationale: Nurse Aida uses positive regard (B), valuing Roger as a human despite his behavior, a key therapeutic communication ingredient per Rogers. Empathy (A) involves feeling with the client, not just valuing them. Comfortable sense of self (C) is the nurse's confidence, and self-awareness (D) is understanding one's reactions. Positive regard fosters acceptance, crucial for trust and healing, aligning with Aida's stance, making B correct.
What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Monitoring I&O ensures fluid balance with hyperosmotic enteral feeding.
Which of the following statement best describe advocacy in nursing?
- A. Ignoring patient needs
- B. Supporting patient rights
- C. A routine task
- D. A medical order
Correct Answer: B
Rationale: Advocacy is supporting patient rights (B), per nursing e.g., voicing wishes. Not ignoring (A), not routine (C), not order (D) rights-focused. B best defines advocacy's protective role, like for Mr. Gary's choices, making it correct.