Nokea
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 their feelings related to the sexual assault is essential for providing emotional support and validating their experience. This action shows empathy and helps the patient feel heard and supported. It also allows the nurse to assess the patient's emotional well-being and provide appropriate care.
Avoiding decision-making situations (A) may lead to further distress for the patient. While joining a support group (B) can be beneficial, it may not be appropriate or feasible immediately after a traumatic event. Providing detailed information about evidence collection (D) is important but should be done after addressing the patient's emotional needs.
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The home care nurse is assigned to make the first home visit to a new client who has been discharged from the hospital. After initial introductions, the nurse should take which action to convey respect?
- A. Ask the client to develop a list of needs to discuss at the next visit.
- B. Wear a name badge that clearly identifies the home care agency.
- C. Provide contact information for several other clients who can serve as references.
- D. Tell the client that information obtained will not be shared with others.
Correct Answer: B
Rationale: The correct answer is B because wearing a name badge that clearly identifies the home care agency conveys professionalism and respect. It helps establish trust and credibility with the client. This action also ensures transparency and allows the client to easily identify and verify the nurse's credentials.
Choices A, C, and D are incorrect:
A: Asking the client to develop a list of needs for the next visit is not about conveying respect but rather about gathering information. It does not focus on establishing a professional and respectful relationship.
C: Providing contact information for other clients as references is inappropriate and breaches confidentiality. It does not demonstrate respect for the client's privacy.
D: Assuring the client that information obtained will not be shared with others is expected as part of maintaining confidentiality and privacy. However, it does not specifically address conveying respect during the initial visit.
The nurse cares for a client with hypertension, and a nurse3client 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 because setting realistic and measurable outcomes helps track progress and ensure treatment effectiveness. This promotes accountability and motivation for both the nurse and client. Choice B is incorrect because it is a general practice and not specific to the contract. Choice C is incorrect as the contract doesn't necessarily have to be written and signed, although it is recommended. Choice D is incorrect as confidentiality is a standard practice and not specific to the contract's content.
A patient is attracted to the nurse and attempts to initiate a social relationship. It is most appropriate for the nurse to take which action?
- A. Encourage the client's behavior to develop a trusting nurse3client relationship.
- B. Inform the charge nurse of the situation and ask for a different patient assignment.
- C. Tell the patient that the relationship must remain professional at all times.
- D. Determine if the patient can be transferred to another nursing care unit.
Correct Answer: C
Rationale: The correct answer is C because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.
In which situation(s) would it be appropriate for the nurse to communicate with empathy? (Select all that apply)
- A. An acquaintance who seeks a long-standing social relationship that is superficial.
- B. A patient who is anxious about a change in body image after a mastectomy.
- C. A supervisor who is searching for approval and recognition from staff.
- D. A colleague who expected a promotion but was not awarded the promotion.
Correct Answer: B
Rationale: The correct answer is B because a nurse should communicate with empathy when dealing with a patient who is anxious about a change in body image after a mastectomy. Empathy allows the nurse to connect emotionally with the patient, show understanding, and provide support. In this situation, the patient needs compassionate communication to feel heard and cared for.
Choices A, C, and D are incorrect because empathy is not necessary in those scenarios. For choice A, the acquaintance seeking a superficial social relationship does not require empathetic communication. For choice C, the supervisor seeking approval and recognition would benefit more from professional feedback and recognition of achievements. For choice D, the colleague expecting a promotion needs clear communication and feedback but not necessarily empathy.
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.