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 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.
You may also like to solve these questions
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 cultural background and individual preferences influence personal space comfort. In this case, the 19-year-old white female patient standing only 2 feet away may feel uncomfortable with close personal space. Different cultures and age groups have varying norms regarding personal space. The other choices are less likely to be uncomfortable based on cultural norms and distance from the nurse. The 40-year-old African-American male patient sitting next to the nurse, the 60-year-old Latin-American female patient seated across, and the 82-year-old patient from France lying in bed with the nurse sitting next to them are all at a comfortable distance, thus less likely to be uncomfortable with personal space.
As a part of the F.O.C.U.S. model, the "C" stands for
- A. Communicate
- B. Connect
- C. Concern
- D. Convince
Correct Answer: A
Rationale: The correct answer is A: Communicate. In the F.O.C.U.S. model, the "C" stands for Communicate because effective communication is essential in any situation requiring focus. By communicating clearly and efficiently, individuals can convey their thoughts, ideas, and goals effectively, leading to better understanding and collaboration. This helps in achieving the desired outcomes and staying on track.
Summary of other choices:
B: Connect - While connecting with others is important, it is not the central aspect of focus in the F.O.C.U.S. model.
C: Concern - Concern may be relevant in some contexts, but it is not the primary focus in the F.O.C.U.S. model.
D: Convince - While persuasion can be a part of communication, the primary emphasis in the F.O.C.U.S. model is on effective communication rather than convincing others.
When using the telephone to communicate with a primary care provider about a patient, the student nurse should have ready: (Select all that apply.)
- A. current information relative to patient's condition change.
- B. assessment of vital signs.
- C. information on urinary output.
- D. patient's social security number or hospital identification number.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Current information on patient's condition change is crucial for effective communication with the primary care provider.
2. This allows the student nurse to provide accurate and up-to-date information for appropriate decision-making.
3. Assessment of vital signs or information on urinary output may be important, but the question specifically focuses on communication about the patient's condition change.
4. Patient's social security number or hospital identification number is not necessary for communicating about the patient's condition change.
In summary, choice A is correct as it ensures accurate communication, while the other choices are not directly related to communicating patient's condition change.
Which assessment finding for Mr. L (tracheostomy and partial laryngectomy) would be of greatest concern?
- A. Pulsation of the tracheostomy tube in synchrony with the heartbeat
- B. Increased secretions in and around the tracheostomy
- C. Increased coughing, with difficulty in expectorating secretions
- D. Presence of food particles in tracheal secretions
Correct Answer: A
Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety.
Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding.
Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding.
Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.
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.