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the HCP because the client deserves to have adequate pain relief.
- A. Wait until the change of medication occurs and then monitor the client's response.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates a proactive approach to ensuring the client receives adequate pain relief. By waiting until the medication change occurs and then monitoring the client's response, the healthcare provider can assess the effectiveness of the new medication and make any necessary adjustments promptly. This approach prioritizes the client's well-being by addressing their pain management needs in a timely and thorough manner. Choices B, C, and D are not as effective as they do not involve actively monitoring the client's response to the medication change, which is crucial in ensuring optimal pain relief for the client.
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The home care nurse visits a mother and her newborn 2 days after discharge from the hospital. The mother states, "My baby cries all the time. I must not be a very good mother.= Which response by the nurse is nontherapeutic?
- A. "It sounds as if you are concerned about your ability to care for your baby.=
- B. "The nurse moves closer to the mother and places a hand on her shoulder."
- C. "You just need to get away for a few hours. Find a babysitter and go to a movie.=
- D. "I am not sure that I understand what you mean. Tell me more about how you feel.=
Correct Answer: C
Rationale: The correct answer is C because it dismisses the mother's feelings and suggests a temporary distraction instead of addressing her concerns. Choice A validates the mother's feelings and promotes open communication. Choice B demonstrates empathy and physical support. Choice D encourages the mother to express her emotions further for better understanding. Overall, choice C is nontherapeutic as it does not address the underlying issue of the mother's feelings of inadequacy and instead offers a superficial solution.
According to a study by Robinson (2014), three parts of our true presence (how we connect with patients) are found in being:
- A. Friendly, kind, and sweet
- B. Genuine, gifted, and creative
- C. Humorous, partial, and grateful
- D. Genuine, attentive, and immersed
Correct Answer: D
Rationale: The correct answer is D: Genuine, attentive, and immersed. This is because being genuine helps establish trust and rapport with patients, being attentive shows active listening and care, and being immersed means being fully engaged in the interaction. These qualities enhance the connection with patients and create a conducive environment for effective communication and care.
Explanation of other choices:
A: Friendly, kind, and sweet - While these qualities are positive, they do not fully capture the depth of true presence required for effective patient connection.
B: Genuine, gifted, and creative - Being genuine is essential, but being gifted and creative are not directly related to establishing a strong connection with patients.
C: Humorous, partial, and grateful - Humor can be beneficial, but being partial and grateful may not always align with maintaining professionalism and unbiased care for all patients.
It would be most important for the nurse to temporarily withdraw expressions of warmth to which patient?
- A. A 20-year-old patient who is angry and throwing objects.
- B. A 32-year-old patient who is withdrawn and refuses nursing care.
- C. A 48-year-old patient who is extremely anxious about surgery.
- D. A 56-year-old patient who has a history of violent behavior.
Correct Answer: D
Rationale: The correct answer is D because the patient with a history of violent behavior poses a potential risk to the nurse's safety. Temporarily withdrawing expressions of warmth is important to establish boundaries and ensure safety. Choice A involves an angry patient, but the risk of violence is higher with a history of violent behavior. Choices B and C do not indicate immediate safety concerns.
While admitting a patient to the medical unit, the nurse should take which action?
- A. Demonstrate human caring by hugging the patient for brief intervals.
- B. Disclose shared intimate details with other healthcare providers.
- C. Maintain a physical distance of at least 3 to 4 feet at all times.
- D. Develop the plan of care and measurable objectives with the patient.
Correct Answer: D
Rationale: The correct answer is D because developing a plan of care and measurable objectives with the patient promotes patient-centered care, encourages collaboration, and ensures the patient's active involvement in their own care. This approach respects the patient's autonomy and preferences, fosters shared decision-making, and enhances treatment adherence.
A: Demonstrating human caring by hugging the patient may not be appropriate as it can violate professional boundaries and personal space.
B: Disclosing shared intimate details with other healthcare providers breaches patient confidentiality and violates privacy rights.
C: Maintaining a physical distance of at least 3 to 4 feet at all times may be necessary for infection control but does not address the core aspect of involving the patient in their care plan.
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