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The nurse cares for a client with hypertension, and a nurse–client 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: The outcomes should be realistic and measurable. This is appropriate to include in the nurse-client contract because setting realistic and measurable outcomes helps in monitoring progress and evaluating the effectiveness of interventions in managing hypertension. It allows for clear communication between the nurse and the client regarding the goals of treatment.
Incorrect choices:
B: Progress should be reviewed at regular intervals - While this is important in the management of hypertension, it is a process rather than a specific component of a contract.
C: The contract should be written and signed - This is important for legal purposes but not specifically related to setting goals and outcomes.
D: The nurse should keep the information confidential - This is a standard ethical practice but not a specific component of a contract outlining activities and responsibilities.
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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.
It would be most important for the nurse to temporarily withdraw expressions of warmth to which patient?
- A. A 20-year-old patient who is angry and throwing objects.
- B. A 32-year-old patient who is withdrawn and refuses nursing care.
- C. A 48-year-old patient who is extremely anxious about surgery.
- D. A 56-year-old patient who has a history of violent behavior.
Correct Answer: D
Rationale: The correct answer is D because the patient with a history of violent behavior poses a potential risk to the nurse's safety. Temporarily withdrawing expressions of warmth is important to establish boundaries and ensure safety. Choice A involves an angry patient, but the risk of violence is higher with a history of violent behavior. Choices B and C do not indicate immediate safety concerns.
Which statement describes the affective aspect of learning effective communication strategies?
- A. "The nurse should use clear, direct statements using objective words.=
- B. "The nurse uses body language that is congruent with the verbal message.=
- C. "The nurse believes that positive communication strategies build confidence.=
- D. "The nurse practices assertive and responsible communication strategies.=
Correct Answer: C
Rationale: The correct answer is C because it addresses the emotional or attitudinal aspect of learning effective communication strategies. Believing that positive communication strategies build confidence reflects the affective domain of learning, which involves feelings, attitudes, and beliefs. This statement emphasizes the importance of mindset and attitude in communication effectiveness.
Explanation of why other choices are incorrect:
A: Choice A focuses on the behavioral aspect of communication strategies, not the affective aspect.
B: Choice B emphasizes the non-verbal communication aspect, which is related to the behavioral domain, not the affective domain.
D: Choice D highlights the behavioral aspect of using assertive and responsible communication strategies, not the affective aspect.
While admitting a patient to the medical unit, the nurse should take which action?
- A. Demonstrate human caring by hugging the patient for brief intervals.
- B. Disclose shared intimate details with other healthcare providers.
- C. Maintain a physical distance of at least 3 to 4 feet at all times.
- D. Develop the plan of care and measurable objectives with the patient.
Correct Answer: D
Rationale: The correct answer is D because developing a plan of care and measurable objectives with the patient promotes patient-centered care, encourages collaboration, and ensures the patient's active involvement in their own care. This approach respects the patient's autonomy and preferences, fosters shared decision-making, and enhances treatment adherence.
A: Demonstrating human caring by hugging the patient may not be appropriate as it can violate professional boundaries and personal space.
B: Disclosing shared intimate details with other healthcare providers breaches patient confidentiality and violates privacy rights.
C: Maintaining a physical distance of at least 3 to 4 feet at all times may be necessary for infection control but does not address the core aspect of involving the patient in their care plan.
A patient asks the nurse, "What would you do if you had cancer and had to choose between surgery and chemotherapy?" The reply that can best help the patient is:
- A. "If I were you, I would choose surgery and then consider chemo afterward."
- B. "What solutions have you considered?"
- C. "I would talk it over with my friends first."
- D. "I don't know. I'm glad it isn't my decision." Nurses can help by reminding patients of alternatives open to them and should refrain from giving advice but can encourage the patient to consider options. The nurse may be glad not to face a decision a patient must, but it is not helpful to the patient to say this.
Correct Answer: B
Rationale: Step-by-step rationale for why answer B is correct:
1. Answer B encourages patient autonomy by asking what solutions the patient has considered.
2. This response acknowledges the patient's ability to make decisions about their own healthcare.
3. By asking the patient about their considered solutions, the nurse can guide the discussion towards exploring different options.
4. This approach promotes shared decision-making between the patient and healthcare provider.
5. It empowers the patient to actively participate in their treatment planning.
6. Ultimately, answer B respects the patient's autonomy, fosters open communication, and supports informed decision-making.