Nokea
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 address any concerns or questions the family may have. This approach can help build trust and provide emotional support during a potentially difficult situation.
A: Avoiding discussing the treatment plan can lead to confusion and distrust.
C: Using medical terms may confuse or intimidate the family and hinder effective communication.
D: Assuming the family wants a detailed explanation may not be accurate and can result in information overload.
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The nurse cares for an adult client diagnosed with type 1 diabetes mellitus. Which is essential in building mutuality in the nurse3 client relationship?
- A. The nurse controls the relationship by retaining the power to make judgments about diabetes education.
- B. The nurse teaches diabetes management by involving the client in making decisions about self care.
- C. The nurse has expert knowledge of diabetes and formulates appropriate learning outcomes for the client.
- D. The nurse demonstrates trust and respect by solving problems for the client when issues occur with self-management.
Correct Answer: B
Rationale: The correct answer is B because it promotes mutual respect and collaboration in the nurse-client relationship. By involving the client in decision-making about self-care, the nurse empowers the client to take ownership of their health and fosters a sense of partnership. This approach enhances the client's autonomy and self-efficacy, leading to better adherence to the diabetes management plan.
Choice A is incorrect as it implies a power dynamic where the nurse controls the relationship, which can hinder trust and collaboration. Choice C is incorrect because while expert knowledge is valuable, it does not necessarily build mutuality unless shared in a collaborative manner. Choice D is incorrect as solving problems for the client may undermine their ability to develop problem-solving skills and independence in managing their condition.
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 instructs a client who is diagnosed with hypertension about weight reduction and dietary guidelines. Which action by the nurse would most likely improve the client's willingness to lose weight and eat healthy foods?
- A. Avoid interacting with the client during meals to prevent embarrassment.
- B. Ignore the client's requests for foods that are high in fat or calories.
- C. Give genuine praise to the client for trying to improve dietary habits.
- D. Warn the client that individuals who are overweight will be treated differently.
Correct Answer: C
Rationale: The correct answer is C because giving genuine praise to the client for trying to improve dietary habits can positively reinforce their efforts and motivation to continue making healthy choices. This positive reinforcement can help the client feel supported and encouraged in their weight reduction and dietary goals.
Choice A is incorrect because avoiding interaction during meals may make the client feel isolated and unsupported. Choice B is incorrect because ignoring the client's requests for high-fat or high-calorie foods may lead to feelings of deprivation and resistance to dietary changes. Choice D is incorrect because warning the client about potential negative consequences of being overweight can induce fear and may not be effective in promoting long-term behavior change.
A home health patient with a bleeding ulcer informs the nurse that she ate a bowl of chili with jalapenos. An inappropriate communication block with a judgmental tone by the nurse would be:
- A. "Well, you have had this problem long enough to know what will happen—you certainly can't blame me!"
- B. "I don't think that was a smart thing for you to do considering your ulcer."
- C. "Well, you better watch your stool for evidence of blood so you can notify your primary care provider."
- D. "Oh, poo! A bowl of chili every now and then won't make a lot of difference to your ulcer." Judgmental response is a block to effective communication in which the nurse is judging the patient's action. It implies that the patient must take on the nurse's values and is demeaning to the patient.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates a judgmental tone towards the patient's actions. The nurse is passing a negative judgment on the patient by stating that eating chili with jalapenos was not a smart decision considering the ulcer. This response can make the patient feel guilty or ashamed, hindering effective communication.
Choice A shows frustration and blame towards the patient, which can lead to a defensive response. Choice C is directive and lacks empathy, focusing solely on the medical aspect without considering the patient's feelings. Choice D dismisses the patient's concerns and minimizes the impact of the action, which can be perceived as condescending.
In summary, choice B is the correct answer as it highlights the importance of maintaining a non-judgmental and supportive attitude in patient communication.
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.