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The home health nurse visits a client with heart failure who has increased dyspnea and peripheral edema and weight gain. The nurse suspects the client is not restricting fluids as prescribed. Which action by the nurse is most appropriate?
- A. Teach the client about the consequences of not following the fluid restrictions.
- B. Ask the client to report the amount of fluid intake for the past 24 hours.
- C. Provide the client with sugarless candy or gum to decrease the thirst sensation.
- D. Consult with the healthcare provider about increasing the dose of the diuretic.
Correct Answer: B
Rationale: The most appropriate action for the nurse is to ask the client to report the amount of fluid intake for the past 24 hours. This is the correct answer because it directly addresses the issue of non-compliance with fluid restrictions. By assessing the actual fluid intake, the nurse can identify the extent of the problem and provide targeted interventions.
Option A is not the best choice as teaching about consequences may not address the immediate issue. Option C does not address the root cause of the problem but only provides a temporary solution. Option D is not appropriate as increasing the diuretic dose should be done in collaboration with the healthcare provider after assessing the client's current condition.
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The nurse caring for a patient who is concerned about her 10-pound weight loss relative to her chemotherapy tells the patient, "Lucky you! Every cloud has a silver lining." The nurse's statement is an example of which type of communication block?
- A. Defensive response
- B. Asking probing questions
- C. Using clichés
- D. Changing the subject
Correct Answer: C
Rationale: The correct answer is C: Using clichés. The nurse's statement, "Lucky you! Every cloud has a silver lining," is a cliché that minimizes the patient's concerns about her weight loss and chemotherapy. Clichés are overused phrases that lack originality and can be dismissive or unhelpful in communication. In this case, the nurse's response does not address the patient's emotional or physical needs and fails to provide meaningful support.
Incorrect choices:
A: Defensive response - This choice involves reacting defensively to the patient's concerns, which is not demonstrated in the nurse's statement.
B: Asking probing questions - This choice involves seeking further information from the patient, which is not reflected in the nurse's cliché response.
D: Changing the subject - This choice involves diverting the conversation away from the patient's concerns, which is not explicitly done in the given scenario.
The nurse cares for a client who is scheduled for a breast biopsy. Which is the main purpose of the client–nurse relationship?
- A. To develop a mutually satisfying experience for the client and nurse.
- B. To assist the client in achieving and maintaining optimal health.
- C. To provide excellent client service and improve quality of care.
- D. To allow the client to receive important health information.
Correct Answer: B
Rationale: The correct answer is B: To assist the client in achieving and maintaining optimal health. The main purpose of the client-nurse relationship is to promote the client's health and well-being. The nurse's role is to support the client in achieving their health goals and maintaining good health. This goes beyond just providing care during a specific procedure like a breast biopsy. Options A, C, and D are incorrect because while they may be components of the client-nurse relationship, they do not encompass the main purpose of promoting optimal health.
The nurse plans to delegate a client's personal hygiene to a nursing assistant. Which statement if made by the nurse to the nursing assistant is assertive?
- A. "Would you mind helping the client with a bath when you have time? If not, I will skip my lunch and do it myself."
- B. "You never get your work done and are always on the phone. You need to help the client right now with a bath, or I will write you up."
- C. "The client needs help with bathing. I want you to assist the client now, and you can go to lunch when you are finished."
- D. "I have important work to complete this morning. You will assist the client with a bath. Do not take a break until you have finished."
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. The statement in choice C is assertive because it clearly states the task, timeline, and expectation without being aggressive or demeaning.
2. It communicates the need for assistance with the client's bath and sets a clear priority.
3. It provides a specific instruction for the nursing assistant to assist the client immediately and then take a break.
4. This approach demonstrates effective delegation and ensures the client's needs are met promptly and respectfully.
Summary:
A: This choice is not assertive as it presents a conditional statement and implies a personal sacrifice by the nurse if the task is not completed.
B: This choice is aggressive and threatening, which is not appropriate in a professional setting.
D: This choice is directive but lacks consideration for the nursing assistant's well-being and does not communicate the urgency of the task for the client.
According to the Workplace Bullying Institute, nurses are also exposed to this type of behavior within their professional environment. In teaching the possibility to an incoming graduate nurse, you know that the nurse understands when he or she includes which of the following as abusive conduct? (Select all that apply)
- A. Threats
- B. Humiliation
- C. Intimidation
- D. Physical abuse
Correct Answer: A
Rationale: The correct answer is A: Threats. Threats are considered abusive conduct in the context of workplace bullying. Nurses may be subjected to threats that create a hostile work environment. Threats can instill fear and distress in the victim, affecting their well-being and performance.
Summary of why other choices are incorrect:
B: Humiliation - While humiliation is a form of abuse, the question specifically asks about abusive conduct in the context of workplace bullying for nurses.
C: Intimidation - Intimidation is another form of abusive behavior, but the question focuses on identifying abusive conduct in the workplace environment for nurses.
D: Physical abuse - While physical abuse is a serious issue, the question pertains to identifying abusive conduct within the professional environment for nurses, where physical abuse may not be as common as other forms of bullying behavior.
A nurse openly and genuinely discusses thoughts and feelings about sexually transmitted infections with a group of college students. Which benefit(s) may occur for these college students? (Select all that apply)
- A. The college students are reluctant to continue discussions with the nurse.
- B. The college students develop a trusting relationship with the nurse.
- C. The college students question the nurse's credibility.
- D. The college students believe the information is reliable and accurate.
Correct Answer: B
Rationale: The correct answer is B because openly discussing thoughts and feelings about sexually transmitted infections can help build trust between the nurse and college students. This trust can lead to the students feeling more comfortable seeking information and support from the nurse. Choice A is incorrect because open communication typically fosters ongoing discussions, not reluctance. Choice C is incorrect because open discussions can enhance credibility by showing transparency and expertise. Choice D is incorrect because open dialogue does not guarantee the accuracy of information, but it can facilitate a more informed discussion.