Nokea
The hospital nurse educator develops an educational session for staff nurses on how to clearly record data in a patient's electronic medical record. Which key point should the nurse educator include in the teaching plan? (Select all that apply)
- A. A patient who is at high risk for falls will require more frequent documentation.
- B. The nurse should avoid labels (e.g., good, drug seeking, and lazy) to describe patients.
- C. Detailed and specific documentation is only required if a malpractice suit is expected.
- D. Each entry by the nurse in the electronic medical record should be clear and concise.
Correct Answer: A
Rationale: The correct answer is A because documenting the frequency of assessments and interventions for high-risk patients, such as those at risk for falls, is crucial for patient safety and care coordination. By documenting more frequently for high-risk patients, nurses can ensure timely interventions and prevent adverse events. This practice aligns with the principles of patient-centered care and risk management.
Choices B, C, and D are incorrect:
B: Avoiding labels in documentation is important for professionalism and ethical practice, but it is not directly related to the frequency of documentation for high-risk patients.
C: Detailed and specific documentation is required for all patients to ensure comprehensive care, not just for potential malpractice suits.
D: While clear and concise documentation is essential, this choice does not specifically address the need for more frequent documentation for high-risk patients.
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The nurse manager asks the staff nurse to work an extra shift. Which response by the staff nurse is assertive and based on rational beliefs?
- A. "I don't want you upset, so I will work extra."
- B. "Why do I always have to cover extra shifts?"
- C. "I am not able to work an extra shift."
- D. "If you can't find anyone else, I will do it."
Correct Answer: C
Rationale: The correct answer is C because it directly and assertively communicates the staff nurse's inability to work an extra shift. This response sets clear boundaries and respects the nurse's own limitations and well-being. It is based on rational beliefs as it acknowledges personal capacity without guilt or unnecessary explanations.
Explanation of other choices:
A: This choice is not assertive as it prioritizes avoiding upsetting the nurse manager over the nurse's own needs and boundaries.
B: This response is confrontational and does not address the request directly, focusing instead on questioning past occurrences.
D: While this response offers to work the extra shift as a last resort, it does not assert the nurse's own limitations clearly, leaving room for potential guilt or manipulation.
The nurse tells a patient, "For the last 2 days we have talked about whether to notify your daughter of your upcoming surgery in 2 days. You have indicated you do not want to be a burden to her, but you also would like to have her here. You may have to decide rather quickly because of the time constraint." The nurse is using the technique of:
- A. focusing.
- B. reflection.
- C. restatement.
- D. summarizing. Summarizing presents the problem and possible solutions with the attendant difficulties. This technique "unclutters" the problem and presents it back to the patient for his or her choice of a solution.
Correct Answer: D
Rationale: The correct answer is D: summarizing. Summarizing involves presenting the problem and potential solutions to the patient in a clear and concise manner. In this scenario, the nurse is summarizing the patient's thoughts and concerns about notifying their daughter of the upcoming surgery. By doing so, the nurse is helping the patient to make a decision by clarifying the situation and potential options. This technique allows the patient to reflect on the information presented and make an informed choice.
A: Focusing involves directing the conversation to a specific topic or issue.
B: Reflection involves restating the patient's feelings or thoughts to show understanding.
C: Restatement involves repeating the patient's words to confirm understanding.
Therefore, the correct answer is D because summarizing is the technique being used in this scenario to help the patient make a decision regarding notifying their daughter about the upcoming surgery.
The nurse cares for a patient who is scheduled for abdominal surgery. Which action, if taken by the nurse, is most appropriate?
- A. Mandate the use of a complementary therapy such as guided imagery.
- B. Administer opioids for pain rated more than 3 (on a 0 to 10 pain scale).
- C. Ask the patient about expectations for postoperative pain management.
- D. Provide pain management based on a standardized nursing care plan.
Correct Answer: C
Rationale: The correct answer is C. Asking the patient about expectations for postoperative pain management is most appropriate as it involves assessing the patient's preferences and needs, ensuring individualized care. Option A is incorrect as mandating complementary therapy may not align with the patient's preferences or needs. Option B is incorrect as administering opioids based solely on pain rating may not consider individual variations in pain tolerance. Option D is incorrect as providing pain management solely based on a standardized care plan may not address the patient's specific needs and preferences.
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 nurse–client 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. It is crucial for healthcare professionals to maintain professional boundaries with patients to ensure ethical practice and prevent potential harm. By telling the patient that the relationship must remain professional, the nurse sets clear boundaries and maintains the integrity of the therapeutic relationship. This approach protects both the patient and the nurse from potential ethical violations.
Choice A is incorrect because encouraging the behavior could lead to boundary violations and harm the therapeutic relationship. Choice B is not the most appropriate immediate action as it does not address the situation directly with the patient. Choice D is also not the best course of action as transferring the patient does not address the underlying issue of maintaining professional boundaries.
According to Kimble and Bamford-Wade, what distinguishes the behavior of one caring and competent nurse from another nurse who is simply competent but not engaged with the patient?
- A. Immediacy, the availability of the nurse
- B. Warmth, the hallmark of compassion
- C. Attention, the focus of the nurse
- D. Communication, the instructional side of the nurse
Correct Answer: B
Rationale: The correct answer is B: Warmth, the hallmark of compassion. Kimble and Bamford-Wade emphasize that warmth, which signifies compassion, is the key factor that distinguishes a caring and competent nurse from one who is solely competent but lacks engagement with the patient. This is because warmth builds trust, fosters connection, and shows genuine concern for the patient's well-being. Immediacy (A) may be important for timely care, attention (C) is vital but doesn't capture the emotional aspect, and communication (D) is essential but focuses more on the delivery of information rather than the emotional connection that warmth provides.