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 shows active listening and empathy. This helps the client feel heard and supported. Increasing physical distance (A) may create a barrier. Interrupting the client (C) can be perceived as disrespectful. Initiating a physical assessment (D) is inappropriate as it may seem insensitive and dismissive of the client's concerns.
You may also like to solve these questions
The nurse cares for a client with hypertension, and a nurse3client contract is developed outlining the activities and responsibilities of each. Which would be appropriate to include in this contract? (Select all that apply)
- A. The outcomes should be realistic and measurable.
- B. Progress should be reviewed at regular intervals.
- C. The contract should be written and signed.
- D. The nurse should keep the information confidential.
Correct Answer: A
Rationale: The correct answer is A because setting realistic and measurable outcomes helps track progress and ensure treatment effectiveness. This promotes accountability and motivation for both the nurse and client. Choice B is incorrect because it is a general practice and not specific to the contract. Choice C is incorrect as the contract doesn't necessarily have to be written and signed, although it is recommended. Choice D is incorrect as confidentiality is a standard practice and not specific to the contract's content.
A patient is attracted to the nurse and attempts to initiate a social relationship. It is most appropriate for the nurse to take which action?
- A. Encourage the client's behavior to develop a trusting nurse3client relationship.
- B. Inform the charge nurse of the situation and ask for a different patient assignment.
- C. Tell the patient that the relationship must remain professional at all times.
- D. Determine if the patient can be transferred to another nursing care unit.
Correct Answer: C
Rationale: The correct answer is C because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.
When the nurse observes a resident in a long-term facility pounding his fists on his legs and grinding his teeth, the nurse will validate her perception of the patient's nonverbal expression of anger by:
- A. documenting that the patient was agitated and appeared angry.
- B. asking the male nursing assistant if it is his perception that the patient appears angry.
- C. accessing the nursing care plan to ascertain if there is a nursing diagnosis relative to anger.
- D. sitting down near the patient and saying, "You seem upset…can I help?" All perceptions based on the observation of nonverbal behavior should be validated by consulting the patient.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates active listening and empathy towards the patient's nonverbal cues. By sitting down near the patient and acknowledging his emotions, the nurse opens up a channel for communication and offers support. This approach allows the patient to express his feelings and needs, leading to better understanding and potential resolution of the underlying issue.
Other choices are incorrect because:
A: Simply documenting the observation does not address the patient's emotional state or provide any opportunity for direct communication.
B: Asking another staff member for their perception does not involve the patient directly and may not accurately reflect the patient's emotions.
C: Referring to the care plan does not involve the patient in the process and may not address the immediate emotional needs expressed through nonverbal behavior.
The home care nurse is assigned to make the first home visit to a new client who has been discharged from the hospital. After initial introductions, the nurse should take which action to convey respect?
- A. Ask the client to develop a list of needs to discuss at the next visit.
- B. Wear a name badge that clearly identifies the home care agency.
- C. Provide contact information for several other clients who can serve as references.
- D. Tell the client that information obtained will not be shared with others.
Correct Answer: B
Rationale: The correct answer is B because wearing a name badge that clearly identifies the home care agency conveys professionalism and respect. It helps establish trust and credibility with the client. This action also ensures transparency and allows the client to easily identify and verify the nurse's credentials.
Choices A, C, and D are incorrect:
A: Asking the client to develop a list of needs for the next visit is not about conveying respect but rather about gathering information. It does not focus on establishing a professional and respectful relationship.
C: Providing contact information for other clients as references is inappropriate and breaches confidentiality. It does not demonstrate respect for the client's privacy.
D: Assuring the client that information obtained will not be shared with others is expected as part of maintaining confidentiality and privacy. However, it does not specifically address conveying respect during the initial visit.
The nursing staff are making suggestions about how to help Ms. C (bowel resection) overcome her reluctance to perform colostomy care. Which suggestion will the team leader try first?
- A. Verbally reexplain the procedure and give her written material.
- B. Have a family member come in and do it for her.
- C. Continue to do it for her until she is ready.
- D. Ask her to hold the clamp while the bag is being emptied.
Correct Answer: A
Rationale: The correct answer is A because it involves providing Ms. C with information and resources to help her understand and feel more comfortable with the colostomy care procedure. Verbally reexplaining the procedure and providing written material will empower her with knowledge and autonomy. Choice B undermines her independence and may not address her reluctance. Choice C promotes dependency rather than encouraging her to take ownership of her care. Choice D involves a hands-on approach that may not address her underlying concerns or fears about the procedure. Overall, choice A is the most appropriate initial step to support Ms. C in overcoming her reluctance.