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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 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.
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.
The nurse cares for the mother of a child who died in the emergency room as a result of an accidental poisoning. Which response by the nurse is appropriate?
- A. Place a greater emphasis on nonverbal aspects of empathy over verbal.
- B. Accurately reflect on the mother's feelings to convey understanding and concern.
- C. Repeat exact phrases stated by the mother to aid in expressions of grief.
- D. Reflect on the expressed feelings of the mother but with the nurse's own words.
Correct Answer: B
Rationale: The correct answer is B because accurately reflecting on the mother's feelings shows understanding and empathy, validating her emotions. This approach helps establish trust and connection, essential in providing emotional support.
A: Placing greater emphasis on nonverbal aspects may not effectively convey empathy and understanding.
C: Merely repeating exact phrases may come off as insincere and robotic, lacking genuine empathy.
D: Reflecting on the mother's feelings using the nurse's own words may not accurately capture the depth of the mother's emotions and may lead to misinterpretation.
According to Swanson's theory, there are five caring processes, one of which is "being with.= Which of the responses by the nurse portrays an understanding of the concept of "being with= a client?
- A. The nurse charting in the room to spend more time with the client
- B. The nurse wearing locator badge so you can quickly respond any time patient would call front desk and ask to page you
- C. The nurse requesting one-on-one nurse staffing
- D. The nurse being emotionally present to the client
Correct Answer: D
Rationale: Step 1: Swanson's theory emphasizes the importance of "being with" a client, which involves being emotionally present and fully engaged.
Step 2: Choice D reflects the concept of "being with" as it highlights the nurse's emotional presence and connection with the client.
Step 3: The nurse actively engages with the client on an emotional level, demonstrating empathy and understanding.
Step 4: Choices A, B, and C do not capture the essence of "being with" as they focus more on physical presence or logistical aspects rather than emotional connection.
Summary: Choice D is correct because it aligns with the core principle of "being with" by emphasizing emotional presence, while the other choices lack this critical component.
Which patient would most likely be uncomfortable with close personal space during an interaction with the nurse?
- A. A 19-year-old white female patient who is standing 2 feet in front of the nurse.
- B. A 40-year-old African-American male patient who is sitting next to the nurse.
- C. A 60-year-old Latin-American female patient who is seated across from the nurse.
- D. An 82-year-old patient from France who is lying in bed with the nurse sitting next to the bed.
Correct Answer: A
Rationale: The correct answer is A because the 19-year-old white female patient standing 2 feet in front of the nurse would likely feel uncomfortable with close personal space. Younger individuals tend to value personal space more and may feel more uncomfortable with proximity. Standing 2 feet away is closer than the social distance zone, leading to potential discomfort.
Choice B is incorrect because the 40-year-old African-American male patient is sitting next to the nurse, which indicates a level of comfort with proximity.
Choice C is incorrect because the 60-year-old Latin-American female patient who is seated across from the nurse is at a comfortable distance for interaction.
Choice D is incorrect because the 82-year-old patient from France who is lying in bed with the nurse sitting next to the bed is likely in a more intimate setting where close personal space is expected.