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The nurse cares for a client with hypertension, and a nurse3client contract is developed outlining the activities and responsibilities of each. Which would be appropriate to include in this contract? (Select all that apply)
- A. The outcomes should be realistic and measurable.
- B. Progress should be reviewed at regular intervals.
- C. The contract should be written and signed.
- D. The nurse should keep the information confidential.
Correct Answer: A
Rationale: The correct answer is A because setting realistic and measurable outcomes helps track progress and ensure treatment effectiveness. This promotes accountability and motivation for both the nurse and client. Choice B is incorrect because it is a general practice and not specific to the contract. Choice C is incorrect as the contract doesn't necessarily have to be written and signed, although it is recommended. Choice D is incorrect as confidentiality is a standard practice and not specific to the contract's content.
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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: Rationale:
C is the correct answer because actively listening to the parents talk about their lives and health concerns allows the nurse to understand their perspectives, beliefs, and values. This helps build rapport and trust, providing insight into how they approach healthcare for their child.
A: The Myers-Briggs Type Indicator survey is not relevant to understanding health beliefs and values.
B: Reading documented health histories may provide medical information but does not necessarily reveal beliefs and values.
D: Reviewing traditional health practices may be informative but does not directly assess the parents' personal beliefs and values.
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 nurse3client 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 because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.
The nurse cares for a patient with urinary incontinence after a stroke. Which response by the nurse is best?
- A. "You seem upset about this. We can work together on a bladder retraining program."
- B. "I don't mind cleaning up your mess. I am used to it because my child does this at night."
- C. "Don't be embarrassed. A lot of patients have this problem after a stroke."
- D. "I will bring you some diapers to wear instead of having you wet the bed all the time."
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy, collaboration, and a patient-centered approach. By acknowledging the patient's feelings and offering to work together on a solution, the nurse shows respect and support. This response promotes patient dignity and autonomy.
Choice B is incorrect as it is unprofessional and may be perceived as insensitive. Choice C, while acknowledging the commonality of the issue, lacks a proactive approach to address the problem. Choice D does not promote independence or address the patient's emotional needs.
When the nurse observes a resident in a long-term facility pounding his fists on his legs and grinding his teeth, the nurse will validate her perception of the patient's nonverbal expression of anger by:
- A. documenting that the patient was agitated and appeared angry.
- B. asking the male nursing assistant if it is his perception that the patient appears angry.
- C. accessing the nursing care plan to ascertain if there is a nursing diagnosis relative to anger.
- D. sitting down near the patient and saying, "You seem upset…can I help?" All perceptions based on the observation of nonverbal behavior should be validated by consulting the patient.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates active listening and empathy towards the patient's nonverbal cues. By sitting down near the patient and acknowledging his emotions, the nurse opens up a channel for communication and offers support. This approach allows the patient to express his feelings and needs, leading to better understanding and potential resolution of the underlying issue.
Other choices are incorrect because:
A: Simply documenting the observation does not address the patient's emotional state or provide any opportunity for direct communication.
B: Asking another staff member for their perception does not involve the patient directly and may not accurately reflect the patient's emotions.
C: Referring to the care plan does not involve the patient in the process and may not address the immediate emotional needs expressed through nonverbal 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.