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The nurse cares for a patient who is scheduled for abdominal surgery. Which action, if taken by the nurse, is most appropriate?
- A. Mandate the use of a complementary therapy such as guided imagery.
- B. Administer opioids for pain rated more than 3 (on a 0 to 10 pain scale).
- C. Ask the patient about expectations for postoperative pain management.
- D. Provide pain management based on a standardized nursing care plan.
Correct Answer: C
Rationale: The correct answer is C. Asking the patient about expectations for postoperative pain management is most appropriate as it involves assessing the patient's preferences and needs, ensuring individualized care. Option A is incorrect as mandating complementary therapy may not align with the patient's preferences or needs. Option B is incorrect as administering opioids based solely on pain rating may not consider individual variations in pain tolerance. Option D is incorrect as providing pain management solely based on a standardized care plan may not address the patient's specific needs and preferences.
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According to Swanson's theory, there are five caring processes, one of which is "knowing." What are the other four?
- A. Communication, assertiveness, responsibility, and caring
- B. Maintaining belief, being with, doing for, and enabling
- C. Understanding, action, information, and comfort
- D. Maintaining belief, being with, enabling, and supporting
Correct Answer: B
Rationale: The correct answer is B: Maintaining belief, being with, doing for, and enabling.
- Maintaining belief: Involves believing in the patient's capacity for self-care.
- Being with: Being present and connecting emotionally with the patient.
- Doing for: Providing assistance and meeting the patient's needs.
- Enabling: Encouraging and supporting the patient to reach their full potential.
Other choices are incorrect:
- A: Communication, assertiveness, responsibility, and caring do not align with Swanson's caring processes.
- C: Understanding, action, information, and comfort are not the caring processes in Swanson's theory.
- D: Maintaining belief, being with, enabling, and supporting is partly correct but lacks the "doing for" process.
Ms. C (bowel resection) repeatedly refuses to perform a return demonstration of any aspect of colostomy care. Despite steady improvement and independent resumption of other ADLs, she protests, "I'm too weak. You'll have to do it for me." At this point, what is the priority nursing concept to consider in planning interventions for Ms. C?
- A. Mobility
- B. Tissue integrity
- C. Functional ability
- D. Coping
Correct Answer: C
Rationale: The correct answer is C: Functional ability. This is because the priority nursing concept to consider in planning interventions for Ms. C is her ability to independently perform colostomy care. By refusing to demonstrate, she may be indicating a lack of functional ability to manage this aspect of self-care. This is essential for her long-term independence and quality of life. Mobility (choice A) is important but not the priority in this case. Tissue integrity (choice B) is also crucial but not as immediate as ensuring functional ability. Coping (choice D) is important for emotional well-being but does not address the primary issue of functional ability for self-care.
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.
When communicating with an adolescent, the nurse should be very sensitive to avoid:
- A. asking embarrassing questions.
- B. offering advice.
- C. interrupting frequently.
- D. using active listening. An adolescent needs time to talk. The nurse should use active listening, avoid interrupting, and show acceptance. The nurse should try not to give advice.
Correct Answer: B
Rationale: The correct answer is B because offering advice can come off as dismissive to adolescents who value autonomy and independence. Adolescents prefer to feel heard and understood rather than being told what to do. Providing unsolicited advice can hinder trust and communication. Asking embarrassing questions (A) can be inappropriate but can still be necessary for assessment. Interrupting frequently (C) disrupts the flow of communication. Using active listening (D) is important but does not directly relate to avoiding sensitive topics with adolescents.
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.