Nokea
Nursing behaviors associated with the implementation phase of the nursing process are concerned with:
- A. participating in the mutual identification of patient outcomes.
- B. gathering accurate and sufficient patient-centered data.
- C. comparing patient responses and expected outcomes.
- D. carrying out interventions and coordinating care.
Correct Answer: D
Rationale: During the implementation phase of the nursing process, nurses focus on executing interventions and coordinating care. This involves utilizing available resources, performing necessary interventions, exploring alternatives when needed, and collaborating with other healthcare team members to ensure comprehensive care delivery. Choice A is incorrect as it pertains more to the planning phase where patient outcomes are identified. Choice B is incorrect as it relates to data collection, which is primarily a part of the assessment phase. Choice C is incorrect as it involves evaluating patient responses against expected outcomes, which is part of the evaluation phase.
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During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?
- A. Assign an unlicensed assistive person to transport the client via a wheelchair.
- B. Remind the client to walk carefully down the stairs until reaching a lower floor.
- C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
- D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.
Correct Answer: B
Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.
An 8-year-old is admitted to the hospital after being sexually abused by an adult family member. The child is withdrawn and appears frightened. Which describes the best plan for the initial nursing encounter to convey concern and support?
- A. Introduce self and explain to the child that she or he is safe now here in the hospital.
- B. Introduce self and tell the child that you would like to sit with the child for a little while.
- C. Introduce self and then ask the child to express how she or he feels about the events leading up to this hospital admission.
- D. Introduce self, explain your role, and ask the child to act out the sexual encounter with the abuser with the use of art therapy.
Correct Answer: B
Rationale: Victims of sexual abuse may exhibit fear and anxiety regarding what has just occurred. In addition, they may fear that the abuse could be repeated. When initiating contact with a child victim of sexual abuse who demonstrates a fear of others, it is best to convey a willingness to spend time and move slowly to initiate activities that may be perceived as threatening. After a rapport is established, the nurse may explore the child's feelings or use various therapeutic modalities to encourage the recounting of the sexual encounter. Option 2 conveys a plan for an initial encounter that establishes trust by sitting with the child in a nonthreatening atmosphere. Option 1 does not convey concern and support by the nurse. Options 3 and 4 may be implemented after trust and rapport are established.
The spouse of a combat veteran asks the nurse how to respond when the client yells and wants to be left alone. Which response by the nurse to the client's spouse is best?
- A. You have not done anything wrong. Your spouse is probably experiencing war memories.
- B. Do what is asked. Make the environment quiet and keep your distance until your spouse is less upset.
- C. Approach your spouse calmly and slowly, saying your name and current location.
- D. Touch your spouse's arm gently and ask what is causing the anger.
Correct Answer: B
Rationale: Respecting the veteran’s need for space by keeping the environment quiet and maintaining distance reduces stimulation and potential escalation, especially during possible PTSD episodes. Approaching or touching may increase agitation, and reassurance is less actionable.
Which of the following mental health situations is considered a psychiatric emergency?
- A. Seasonal Affective Disorder (SAD)
- B. Depression with melancholic features
- C. Major depressive episode with psychotic features
- D. Bipolar depression
Correct Answer: C
Rationale: A major depressive episode with psychotic features is considered a psychiatric emergency because it poses a significant risk to the individual's safety. Psychotic features in depression can include hallucinations, delusions, or other severe symptoms that require immediate intervention. While Seasonal Affective Disorder (SAD) and depression with melancholic features are serious conditions, they do not inherently represent an acute emergency that necessitates immediate hospitalization. Bipolar depression, although severe, does not inherently involve psychotic symptoms that would classify it as a psychiatric emergency requiring immediate intervention. It's crucial to recognize the urgency and severity of major depressive episodes with psychotic features to ensure appropriate and timely treatment.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
- A. Encourage the client to increase ambulation in the room.
- B. Offer the client a high-carbohydrate snack for energy.
- C. Force fluids to thin the client's pulmonary secretions.
- D. Determine if pain is causing the client's tachypnea.
Correct Answer: D
Rationale: When a postoperative client's respiratory rate increases, it is essential to determine the underlying cause. Pain, anxiety, and fluid accumulation in the lungs can lead to tachypnea (increased respiratory rate). Therefore, the priority intervention is to assess if pain is the contributing factor. Encouraging increased ambulation may worsen oxygen desaturation in a client with a rising respiratory rate. Offering a high-carbohydrate snack is not indicated as it can increase carbon metabolism; instead, consider providing an alternative energy source like Pulmocare liquid supplement. Forcing fluids may exacerbate respiratory congestion in a client with a compromised cardiopulmonary system, potentially leading to fluid overload. Therefore, determining the role of pain in tachypnea is crucial for appropriate management.