Nokea
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.
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Ms. G (breast lumpectomy) continues to be anxious and tearful, and she says that she has changed her mind about the surgery, saying, "I'm going to go home. I just can't deal with everything that is going on right now. I need some time to think about things." What is the best response?
- A. "It's okay to change your mind. You have the right to make your own decisions."
- B. "Please reconsider. This surgery is very important, and your health is the priority."
- C. "Would you like me to call your HCP, so you can discuss your concerns?"
- D. "I see you are very concerned. What things are you dealing with and thinking about?"
Correct Answer: A
Rationale: The correct answer is A because it acknowledges Ms. G's autonomy and respects her right to make decisions about her own body. By validating her feelings and choices, it helps build trust and rapport. Choice B is incorrect as it disregards Ms. G's emotional state and can come off as dismissive. Choice C assumes Ms. G needs immediate medical intervention without exploring her concerns further. Choice D, although showing empathy, does not directly address Ms. G's decision to change her mind about the surgery.
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.
According to Swanson's theory, there are five caring processes, one of which is "being with.= Which of the responses by the nurse portrays an understanding of the concept of "being with= a client?
- A. The nurse charting in the room to spend more time with the client
- B. The nurse wearing locator badge so you can quickly respond any time patient would call front desk and ask to page you
- C. The nurse requesting one-on-one nurse staffing
- D. The nurse being emotionally present to the client
Correct Answer: D
Rationale: Step 1: Swanson's theory emphasizes the importance of "being with" a client, which involves being emotionally present and fully engaged.
Step 2: Choice D reflects the concept of "being with" as it highlights the nurse's emotional presence and connection with the client.
Step 3: The nurse actively engages with the client on an emotional level, demonstrating empathy and understanding.
Step 4: Choices A, B, and C do not capture the essence of "being with" as they focus more on physical presence or logistical aspects rather than emotional connection.
Summary: Choice D is correct because it aligns with the core principle of "being with" by emphasizing emotional presence, while the other choices lack this critical component.
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.
During the initial interview of a patient, the nurse should: (Select all that apply.)
- A. assess the language capabilities of the patient.
- B. use open-ended questions.
- C. limit the interview to approximately 30 minutes.
- D. assess comprehension abilities of the patient.
Correct Answer: A
Rationale: The correct answer is A: assess the language capabilities of the patient. This is crucial to ensure effective communication and understanding. By assessing language capabilities, the nurse can tailor communication strategies appropriately. Option B is helpful but not as essential as language assessment. Option C is incorrect as the interview duration should be based on patient needs, not a set time limit. Option D is relevant, but assessing comprehension abilities alone may not be sufficient if language barriers exist.