Nokea
The community health nurse is listening to a client talk about a personal problem. Which of these actions by the nurse is most appropriate?
- A. The nurse should increase the physical distance from the client.
- B. The nurse should lean toward the client and make eye contact.
- C. The nurse should periodically interrupt the client to ask questions.
- D. The nurse should initiate the physical assessment to distract the client.
Correct Answer: B
Rationale: The correct answer is B because leaning towards the client and making eye contact demonstrates active listening and empathy, helping to build rapport and trust. This non-verbal communication shows the client that the nurse is engaged and attentive, creating a safe space for them to share their personal problem. Increasing physical distance (A) may convey disinterest or lack of connection. Periodically interrupting the client (C) can disrupt the flow of conversation and hinder the client's ability to express themselves. Initiating a physical assessment (D) would be inappropriate as it could feel intrusive and insensitive given the context of the client discussing a personal problem. Overall, choice B fosters a supportive environment for effective communication and client-centered care.
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The nurse is caring for a patient who is concerned about living alone. The best response by the nurse is:
- A. "Where have you considered living?"
- B. "Why don't you live with your family?"
- C. "I think you should live with your family."
Correct Answer: A
Rationale: The correct answer is A because it shows empathy by asking for the patient's thoughts first, respecting their autonomy. It promotes open communication and understanding of the patient's concerns. Choice B may come off as judgmental or invasive. Choice C imposes the nurse's opinion on the patient, disregarding their feelings. Choice D is incomplete.
Mr. U (pulmonary resection) has developed a tension pneumothorax. He is currently receiving high-flow oxygen via nonrebreather mask but continues to experience respiratory distress. What is the priority action?
- A. Remove the occlusive dressing around the chest wound.
- B. Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
- C. Initiate cardiopulmonary resuscitation (CPR).
- D. Call for the crash cart and intubation equipment.
Correct Answer: B
Rationale: The correct answer is B: Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
Rationale:
1. Tension pneumothorax is a life-threatening emergency where air accumulates in the pleural space, causing lung collapse and increased pressure in the chest.
2. The standard treatment for tension pneumothorax is needle thoracostomy, which involves inserting a large-bore needle into the chest to release the trapped air.
3. In this scenario, Mr. U is in respiratory distress despite receiving high-flow oxygen, indicating a significant problem with ventilation that requires immediate intervention.
4. Performing a needle thoracotomy will rapidly decompress the tension pneumothorax, relieving pressure on the heart and lungs, and improving respiratory function.
5. This action takes precedence over other options such as removing the occlusive dressing, initiating CPR, or calling for intubation equipment, as immediate decompression is crucial in managing tension pneumoth
The nursing student tearfully reports to the leader, "I took some flowers into Mr. N's (non- Hodgkin lymphoma) room to cheer him up, and he told me that he didn't think he was supposed to have flowers. I took them out of the room right away, and then I realized I had made a mistake." What should the team leader do first?
- A. Direct the student to read the isolation precautions before entering the room.
- B. Call the nursing instructor and report the student for making an error.
- C. Acknowledge and praise the student for taking responsibility for the mistake.
- D. Write an incident report and have the student and instructor sign it.
Correct Answer: C
Rationale: The correct answer is C because it is important to acknowledge and praise the student for taking responsibility for the mistake. By doing this, the team leader can encourage a culture of accountability and learning from errors. This approach supports the student's professional growth and self-awareness.
Option A is incorrect because the immediate focus should be on addressing the emotional response of the student and providing support rather than assigning blame. Option B is inappropriate as it could undermine the student's confidence and discourage future initiative. Option D is premature as it prioritizes paperwork over supporting the student's learning and emotional well-being.
The nurse is interviewing a Native American client. It is most important for the nurse to take which action?
- A. Maintain eye contact to show respect and interest.
- B. Assess whether the client is comfortable with eye contact.
- C. Avoid prolonged eye contact with this client.
- D. Sit next to the patient to avoid any eye contact.
Correct Answer: B
Rationale: The correct answer is B: Assess whether the client is comfortable with eye contact. This is important because different cultures have varying views on eye contact, and it is crucial to respect the client's preferences. By assessing the client's comfort level with eye contact, the nurse can establish rapport and demonstrate cultural sensitivity.
A: Maintaining eye contact may not be culturally appropriate for some Native American clients, so it is important to assess their comfort level first.
C: Avoiding prolonged eye contact assumes all Native American clients have the same preferences, which is not accurate.
D: Sitting next to the patient to avoid eye contact may be perceived as distancing or disrespectful in some cultures.
Which statement, if made by the nurse, could positively affect the course of the patient's situation by suggestibility?
- A. "Breastfeeding will provide time to bond with your baby."
- B. "Breastfeeding will take longer than giving your baby a bottle."
- C. "You will need to be careful about taking medications while breastfeeding."
- D. "Breastfeeding mothers can develop infections that are serious."
Correct Answer: A
Rationale: The correct answer is A because it focuses on the positive aspect of breastfeeding, which is bonding with the baby. This statement can positively influence the patient's attitude and motivation towards breastfeeding. Choice B is incorrect as it introduces a negative aspect of breastfeeding. Choice C is unrelated to the positive impact of breastfeeding. Choice D introduces fear and negativity, which can hinder the patient's confidence in breastfeeding.