Nokea
The nurse cares for a client with abdominal pain who is scheduled for exploratory surgery. Which statement(s), if made by the nurse, indicates that the client's rights in the helping relationship have been violated? (Select all that apply)
- A. "I do not have time right now to help you call your family."
- B. "I am available to answer questions that you may have about your surgery."
- C. "You seem frightened. I will stay with you until your family arrives."
- D. "Your neighbors called, and I told them that you will have surgery."
Correct Answer: A
Rationale: The correct answer is A because by stating, "I do not have time right now to help you call your family," the nurse is not respecting the client's autonomy and right to involve their family in decision-making. This violates the client's right to information and support.
Choices B and C are incorrect because they demonstrate the nurse's willingness to provide information, support, and emotional care, which align with the client's rights in the helping relationship.
Choice D is incorrect as it shows the nurse informing the client about the neighbors' call, which may not necessarily violate the client's rights unless the client explicitly expressed a desire for privacy.
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When the patient says, "I don't want to go home," the nurse's best therapeutic verbal response would be:
- A. "I'm sure everything will be fine once you get home."
- B. "You don't want to go home?"
- C. "Doesn't your family want you to come home?"
- D. "I felt like that when I had surgery last year." The use of reflecting encourages the patient to expand on his or her feelings or thoughts.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and empathy by reflecting the patient's statement. It shows the nurse is engaged and seeking to understand the patient's feelings. Choice A dismisses the patient's concerns. Choice C implies the patient is being pressured by their family. Choice D shifts the focus to the nurse's experience, not the patient's feelings.
The nurse has selected an outcome for the patient to eat all of the food on the breakfast tray each day. Assessing that the patient has eaten all of the breakfast, the nurse would give positive feedback by saying:
- A. "Wow! That breakfast must have been pretty good."
- B. "I like pancakes too. Everyone on the hall seemed to enjoy them."
- C. "I hope you can keep all that breakfast down."
- D. "Hurray! You finished your whole meal! What would you like for tomorrow?" Giving positive feedback increases the likelihood of the desired behavior to be repeated. Commenting on the tastiness of the food or the fact that others liked it is not responding directly to the patient's having eaten the whole meal.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's achievement of finishing the whole meal, provides positive reinforcement, and invites the patient to make choices for the next meal, encouraging continued compliance with the desired outcome. This response directly reinforces the behavior that was targeted, making it more likely for the patient to repeat the behavior in the future. Choices A, B, and C do not specifically address the patient's accomplishment of eating all the food, therefore they do not provide effective positive feedback for reinforcing the desired behavior.
The nurse is aware that the purpose of therapeutic communication is to:
- A. gather as much information as possible about the patient's problem.
- B. direct the patient to communicate about his deepest concerns.
- C. focus on the patient and the patient needs to facilitate interaction.
- D. gain specific medical information and history of illness.
Correct Answer: C
Rationale: The correct answer is C because therapeutic communication aims to focus on the patient and their needs to facilitate a therapeutic interaction. This involves active listening, empathy, and creating a supportive environment for the patient to express their thoughts and feelings. Gathering information (choice A) is important but not the sole purpose of therapeutic communication. Directing the patient to communicate about deepest concerns (choice B) may not always be appropriate or helpful. Lastly, gaining specific medical information and history of illness (choice D) is part of a comprehensive assessment but not the primary goal of therapeutic communication.
The nurse cares for a patient who becomes confused and a vest restraint is applied. The nurse should take which action when notifying the patient's family?
- A. Avoid discussing the treatment plan to reduce anxiety and worry.
- B. Ask another nurse who has rapport with the family to be present.
- C. Use medical terms to demonstrate competence.
- D. Assume that the family wants a detailed explanation.
Correct Answer: B
Rationale: The correct answer is B because having another nurse who has a good relationship with the family present can help facilitate effective communication and provide emotional support. This can help alleviate the family's concerns and build trust in the care being provided.
Avoiding discussing the treatment plan (A) may lead to increased anxiety and worry for the family. Using medical terms (C) may confuse the family further and hinder effective communication. Assuming that the family wants a detailed explanation (D) without confirming their preferences may not be the most appropriate approach.
Which facial feature, if displayed by the nurse, best conveys warmth?
- A. Small pupils and a fixed gaze
- B. Furrowed brow and a wrinkled forehead
- C. Pursed lips and a forced smile
- D. Relaxed muscles and a concerned expression
Correct Answer: D
Rationale: The correct answer is D because relaxed muscles and a concerned expression convey warmth. Relaxed muscles suggest a sense of ease and approachability, while a concerned expression shows empathy and care. Small pupils and a fixed gaze (A) can indicate tension or distance. Furrowed brow and a wrinkled forehead (B) often signify stress or frustration. Pursed lips and a forced smile (C) may come across as insincere. Overall, D best conveys warmth through a combination of physical relaxation and emotional concern.