Nokea
The nurse cares for a patient who has type 2 diabetes mellitus and does not consistently follow the dietary restrictions and exercise recommendations. The patient takes a daily oral hypoglycemic agent as prescribed. Which statement by the nurse is most appropriate?
- A. "It is great that you take your medicine as prescribed."
- B. "It wouldn't be that hard to walk a few blocks every other day."
- C. "You are definitely not one of my good patients."
- D. "It is a waste of time to help you because you will never change."
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Acknowledges adherence to medication, reinforcing positive behavior.
2. Encourages patient compliance without judgment or criticism.
3. Focusing on the patient's effort in taking medication can lead to discussions about improving other aspects of diabetes management.
Summary:
B: While exercise is important, this choice may come across as dismissive and not addressing the patient's current behavior.
C: This choice is judgmental and may damage the therapeutic relationship.
D: This choice is defeatist and does not promote any positive change or motivation.
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The nurse greets a patient who is admitted to the hospital. Which action by the nurse displays warmth and concern?
- A. Use a soft and relaxed tone of voice when speaking.
- B. Maintain a distance of 6 to 8 feet from the patient.
- C. Avoid attentive behaviors when interacting with the patient.
- D. Engage in a verbal exchange without physical contact.
Correct Answer: A
Rationale: The correct answer is A because using a soft and relaxed tone of voice conveys warmth and concern, making the patient feel welcomed and cared for. It helps build rapport and comfort. Maintaining a distance of 6 to 8 feet (B) may create a sense of coldness and detachment. Avoiding attentive behaviors (C) will make the patient feel neglected and uncared for. Engaging in verbal exchange without physical contact (D) lacks the personal touch needed to show warmth and concern.
The first-semester nursing student tells the team leader that her clinical assignment for the day is to take vital signs and obtain a client history that will take about 1 or 2 hours to complete. Which clients would the leader recommend that she approach to fulfill her assignment? (Select all that apply.)
- A. Mr. N (non-Hodgkin lymphoma)
- B. Mr. L (tracheostomy and partial laryngectomy)
- C. Mr. B (bladder cancer)
- D. Ms. C (bowel resection and colostomy)
Correct Answer: B
Rationale: The correct answer is B because Mr. L, who has a tracheostomy and partial laryngectomy, will likely require vital signs monitoring and a detailed client history due to his complex respiratory and communication needs. This assignment will provide the student with valuable experience in caring for clients with specialized needs.
Incorrect choices:
A: Mr. N (non-Hodgkin lymphoma) - While Mr. N may require vital signs monitoring, his condition does not necessarily involve complex care needs that would warrant a 1-2 hour history-taking session.
C: Mr. B (bladder cancer) - Vital signs monitoring and history-taking for a client with bladder cancer may not require as much time as the scenario suggests, as the care needs may not be as complex as those of a client with a tracheostomy and laryngectomy.
D: Ms. C (bowel resection and colostomy) - While Ms. C may require vital signs monitoring and history-taking
The home health nurse visits a client with heart failure who has increased dyspnea and peripheral edema and weight gain. The nurse suspects the client is not restricting fluids as prescribed. Which action by the nurse is most appropriate?
- A. Teach the client about the consequences of not following the fluid restrictions.
- B. Ask the client to report the amount of fluid intake for the past 24 hours.
- C. Provide the client with sugarless candy or gum to decrease the thirst sensation.
- D. Consult with the healthcare provider about increasing the dose of the diuretic.
Correct Answer: B
Rationale: The most appropriate action for the nurse is to ask the client to report the amount of fluid intake for the past 24 hours. This is the correct answer because it directly addresses the issue of non-compliance with fluid restrictions. By assessing the actual fluid intake, the nurse can identify the extent of the problem and provide targeted interventions.
Option A is not the best choice as teaching about consequences may not address the immediate issue. Option C does not address the root cause of the problem but only provides a temporary solution. Option D is not appropriate as increasing the diuretic dose should be done in collaboration with the healthcare provider after assessing the client's current condition.
The nurse cares for a client who is scheduled for a breast biopsy. Which is the main purpose of the client–nurse relationship?
- A. To develop a mutually satisfying experience for the client and nurse.
- B. To assist the client in achieving and maintaining optimal health.
- C. To provide excellent client service and improve quality of care.
- D. To allow the client to receive important health information.
Correct Answer: B
Rationale: The correct answer is B: To assist the client in achieving and maintaining optimal health. The main purpose of the client-nurse relationship is to promote the client's health and well-being. The nurse's role is to support the client in achieving their health goals and maintaining good health. This goes beyond just providing care during a specific procedure like a breast biopsy. Options A, C, and D are incorrect because while they may be components of the client-nurse relationship, they do not encompass the main purpose of promoting optimal health.
The nurse provides care to a client from Nigeria who is visiting the United States. Which should the nurse use to communicate with this client?
- A. Review the predominant health beliefs of the Nigerian population.
- B. Appraise the client's health beliefs and behaviors with a cultural assessment.
- C. Consult with other nurses who have taken care of clients from other countries.
- D. Use standard communication techniques to establish a helping relationship.
Correct Answer: B
Rationale: The correct answer is B because conducting a cultural assessment allows the nurse to understand the client's individual health beliefs and behaviors. This approach promotes culturally competent care by tailoring interventions to the client's specific needs. Option A is incorrect as it assumes all Nigerians have the same health beliefs. Option C is not necessary as the nurse can directly assess the client. Option D does not consider the importance of cultural competence in communication. Conducting a cultural assessment ensures effective communication and respectful care.