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The nurse cares for a young adult patient in the emergency room after a sexual assault. Which action by the nurse is appropriate?
- A. Avoid situations in which the patient will be involved with decision making.
- B. Tell the patient to join a local support group for sexual assault victims.
- C. Actively listen to the patient express feelings related to the sexual assault.
- D. Provide detailed information about evidence collection and invasive procedures.
Correct Answer: C
Rationale: The correct answer is C because actively listening to the patient express feelings related to the sexual assault is crucial for providing emotional support and establishing trust. This action demonstrates empathy and validates the patient's experience. It allows the patient to process their emotions and facilitates a therapeutic relationship.
Avoiding decision-making situations (A) is inappropriate as it disregards the patient's autonomy. Suggesting joining a support group (B) may be helpful but should not be the immediate priority over addressing the patient's current emotional needs. Providing detailed information about evidence collection and procedures (D) is important but should come after addressing the patient's emotional well-being.
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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- B. A 32-year-old patient who is withdrawn and refuses nursing care.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.
The nurse is interviewing a Native American client. It is most important for the nurse to take which action?
- A. Maintain eye contact to show respect and interest.
- B. Assess whether the client is comfortable with eye contact.
- C. Avoid prolonged eye contact with this client.
- D. Sit next to the patient to avoid any eye contact.
Correct Answer: B
Rationale: The correct answer is B: Assess whether the client is comfortable with eye contact. This is important because different cultures have varying views on eye contact, and it is crucial to respect the client's preferences. By assessing the client's comfort level with eye contact, the nurse can establish rapport and demonstrate cultural sensitivity.
A: Maintaining eye contact may not be culturally appropriate for some Native American clients, so it is important to assess their comfort level first.
C: Avoiding prolonged eye contact assumes all Native American clients have the same preferences, which is not accurate.
D: Sitting next to the patient to avoid eye contact may be perceived as distancing or disrespectful in some cultures.
A non-Hispanic white nurse provides care to mostly Hispanic patients. It would be most important for the nurse to take which action?
- A. Discover cultural influences on healthcare perceptions and behaviors.
- B. Assist the patients to adapt to American culture and health beliefs.
- C. Avoid confrontation of underlying issues of discrimination.
- D. Improve communication by learning how to speak Spanish.
Correct Answer: A
Rationale: Step 1: Understanding cultural influences is crucial for providing effective care to diverse patients.
Step 2: By discovering healthcare perceptions and behaviors, the nurse can tailor care to meet the patients' needs.
Step 3: This approach promotes cultural competence and improves patient outcomes.
Step 4: Other choices are incorrect as they do not address the core issue of cultural understanding and sensitivity.
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.
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.