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The nurse cares for a client who does not follow dietary recommendations for treatment of heart failure. Which statement, if made by the nurse, demonstrates respect for the client?
- A. "It doesn't make any difference to me whether you decide to eat healthy or not.=
- B. "You will get more attention from your physician, if you follow diet restrictions.=
- C. "I care about you even if you are not following your dietary restrictions.=
- D. "Have you noticed that patients who eat healthy foods receive better healthcare?=
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and respect for the client's autonomy. By stating "I care about you even if you are not following your dietary restrictions," the nurse acknowledges the client's choice while still showing concern for their well-being. This response fosters a supportive and non-judgmental relationship with the client.
Choices A, B, and D are incorrect because they either show indifference, use coercion, or imply a comparison between patients based on their dietary choices. These responses do not prioritize the client's feelings, choices, or autonomy, which is essential in providing patient-centered care.
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When communicating with an adolescent, the nurse should be very sensitive to avoid:
- A. asking embarrassing questions.
- B. offering advice.
- C. interrupting frequently.
- D. using active listening. An adolescent needs time to talk. The nurse should use active listening, avoid interrupting, and show acceptance. The nurse should try not to give advice.
Correct Answer: B
Rationale: The correct answer is B because offering advice can come off as dismissive to adolescents who value autonomy and independence. Adolescents prefer to feel heard and understood rather than being told what to do. Providing unsolicited advice can hinder trust and communication. Asking embarrassing questions (A) can be inappropriate but can still be necessary for assessment. Interrupting frequently (C) disrupts the flow of communication. Using active listening (D) is important but does not directly relate to avoiding sensitive topics with adolescents.
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.
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.
When an office nurse asks the patient to repeat information that he has just given to the patient over the telephone, the nurse is:
- A. testing the patient's intelligence and memory.
- B. acting in a cautious way to avoid charges of negligence.
- C. verifying that the patient understands the information.
- D. saving the extra time it would take to mail the information. Obtaining feedback from a patient to ascertain that the patient understands instructions is an important part of the communication process, especially over the phone, when the nurse does not have nonverbal cues.
Correct Answer: C
Rationale: The correct answer is C because asking the patient to repeat the information verifies their understanding. This is crucial in healthcare to ensure accurate communication and patient safety. Choice A is incorrect as it focuses on intelligence rather than comprehension. Choice B is incorrect as it assumes the nurse is motivated by avoiding negligence rather than patient care. Choice D is incorrect as saving time should not compromise patient understanding.Verifying patient comprehension fosters effective communication and prevents errors.
In the early postoperative period, what is the priority concern for Mr. L, who has a tracheostomy and partial laryngectomy?
- A. Possible infection related to chemotherapy and surgical procedure
- B. Poor nutritional intake related to dysphagia and malignancy
- C. Difficulty communicating needs because of the tracheostomy tube
- D. High risk for aspiration because of secretions and removal of epiglottis
Correct Answer: D
Rationale: The correct answer is D: High risk for aspiration because of secretions and removal of epiglottis. This is the priority concern for Mr. L due to the risk of food or liquid entering the airway, leading to aspiration pneumonia and respiratory distress. The tracheostomy and partial laryngectomy compromise the airway protection mechanism, increasing the risk of aspiration. Options A and B are not the priority as infection and poor nutrition can be managed after addressing the risk of aspiration. Option C, while important for communication, is not as immediately life-threatening as the risk of aspiration.