Nokea
The author describes the patient journey as driving down a country road and somehow getting lost. At that moment and time, all that is needed is clear directions about how to get to your destination, not about types of entertainment in the area. The same is true for patients. Accordingly, a part of each nursing assessment should include:
- A. Patient's need for information and level of understanding
- B. Detailed overview of disease process
- C. Specific examples from other patients with same disease
- D. Nurse's feelings about newest treatment modality
Correct Answer: A
Rationale: Step 1: Understanding the patient's need for information and level of understanding is crucial to providing appropriate care.
Step 2: Clear directions are necessary to guide patients, just like clear information is needed to guide their healthcare decisions.
Step 3: Assessing the patient's need for information helps tailor education to their level of understanding.
Step 4: This choice directly aligns with the analogy of providing clear directions for patients on their healthcare journey.
Summary: Choice A is correct as it emphasizes the importance of assessing the patient's need for information and understanding, which is essential for guiding them effectively. Choices B, C, and D are incorrect as they do not directly address the patient's need for information and understanding in the analogy provided.
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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.
The nurse cares for a patient who becomes confused and a vest restraint is applied. The nurse should take which action when notifying the patient's family?
- A. Avoid discussing the treatment plan to reduce anxiety and worry.
- B. Ask another nurse who has rapport with the family to be present.
- C. Use medical terms to demonstrate competence.
- D. Assume that the family wants a detailed explanation.
Correct Answer: B
Rationale: The correct answer is B because having another nurse who has a good relationship with the family present can help facilitate effective communication and address any concerns or questions the family may have. This approach can help build trust and provide emotional support during a potentially difficult situation.
A: Avoiding discussing the treatment plan can lead to confusion and distrust.
C: Using medical terms may confuse or intimidate the family and hinder effective communication.
D: Assuming the family wants a detailed explanation may not be accurate and can result in information overload.
A hospital nurse is concerned about the demands of providing safe care to clients who are seriously ill. The nurse manager should suggest which intervention to effectively help the nurse balance the demanding work in the hospital setting?
- A. Delegate more tasks to the unlicensed nursing personnel on the unit.
- B. Request a transfer to another nursing care unit with patients who are stable.
- C. Write down stories in a journal about how caring makes a difference for patients.
- D. Use an assertive communication style for every patient3nurse interaction.
Correct Answer: B
Rationale: The correct answer is B: Request a transfer to another nursing care unit with patients who are stable.
Rationale:
1. By transferring to a unit with stable patients, the nurse can reduce the demands of caring for seriously ill clients.
2. This intervention helps in balancing the workload and provides a less stressful environment for the nurse.
3. It allows the nurse to focus on providing safe care without being overwhelmed by the demands of seriously ill patients.
Incorrect choices:
A: Delegating more tasks to unlicensed nursing personnel may not address the root cause of the nurse's concern and could potentially compromise patient safety.
C: Writing stories in a journal may be a helpful coping mechanism but does not directly address the nurse's workload concerns.
D: Using an assertive communication style is important but may not be the most effective solution for balancing the demands of caring for seriously ill clients.
The nurse cares for an adult client diagnosed with type 1 diabetes mellitus. Which is essential in building mutuality in the nurse3 client relationship?
- A. The nurse controls the relationship by retaining the power to make judgments about diabetes education.
- B. The nurse teaches diabetes management by involving the client in making decisions about self care.
- C. The nurse has expert knowledge of diabetes and formulates appropriate learning outcomes for the client.
- D. The nurse demonstrates trust and respect by solving problems for the client when issues occur with self-management.
Correct Answer: B
Rationale: The correct answer is B because it promotes mutual respect and collaboration in the nurse-client relationship. By involving the client in decision-making about self-care, the nurse empowers the client to take ownership of their health and fosters a sense of partnership. This approach enhances the client's autonomy and self-efficacy, leading to better adherence to the diabetes management plan.
Choice A is incorrect as it implies a power dynamic where the nurse controls the relationship, which can hinder trust and collaboration. Choice C is incorrect because while expert knowledge is valuable, it does not necessarily build mutuality unless shared in a collaborative manner. Choice D is incorrect as solving problems for the client may undermine their ability to develop problem-solving skills and independence in managing their condition.