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 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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While admitting a patient to the medical unit, the nurse should take which action?
- A. Demonstrate human caring by hugging the patient for brief intervals.
- B. Disclose shared intimate details with other healthcare providers.
- C. Maintain a physical distance of at least 3 to 4 feet at all times.
- D. Develop the plan of care and measurable objectives with the patient.
Correct Answer: D
Rationale: The correct answer is D because developing a plan of care and measurable objectives with the patient promotes patient-centered care, encourages collaboration, and ensures the patient's active involvement in their own care. This approach respects the patient's autonomy and preferences, fosters shared decision-making, and enhances treatment adherence.
A: Demonstrating human caring by hugging the patient may not be appropriate as it can violate professional boundaries and personal space.
B: Disclosing shared intimate details with other healthcare providers breaches patient confidentiality and violates privacy rights.
C: Maintaining a physical distance of at least 3 to 4 feet at all times may be necessary for infection control but does not address the core aspect of involving the patient in their care plan.
The nurse cares for a client with hypertension, and a nurse–client 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: The outcomes should be realistic and measurable. This is appropriate to include in the nurse-client contract because setting realistic and measurable outcomes helps in monitoring progress and evaluating the effectiveness of interventions in managing hypertension. It allows for clear communication between the nurse and the client regarding the goals of treatment.
Incorrect choices:
B: Progress should be reviewed at regular intervals - While this is important in the management of hypertension, it is a process rather than a specific component of a contract.
C: The contract should be written and signed - This is important for legal purposes but not specifically related to setting goals and outcomes.
D: The nurse should keep the information confidential - This is a standard ethical practice but not a specific component of a contract outlining activities and responsibilities.
The nurse explains that the therapeutic nurse-patient relationship differs from the social relationship because:
- A. a social relationship does not have goals or needs to be met.
- B. the nurse-patient relationship ends when the patient is discharged.
- C. the focus is mainly on the nurse in the nurse-patient relationship.
- D. a social relationship does not require trust or sharing of life experiences. The nurse-patient relationship is limited to the patient's stay in the facility and is focused on the patient. A social relationship may have goals or needs and does require trust and sharing of life experiences.
Correct Answer: C
Rationale: The correct answer is C because in a therapeutic nurse-patient relationship, the focus is mainly on the nurse being therapeutically beneficial to the patient. This relationship is professional, goal-oriented, and centered on the patient's needs and well-being. The nurse's primary role is to provide care, support, and help the patient achieve their health goals. Unlike a social relationship, where the focus is mutual and not solely on the nurse, the therapeutic relationship is asymmetrical, with the nurse taking on a more authoritative and guiding role. This ensures that the patient receives the necessary care and support during their healthcare journey.
Choices A, B, and D are incorrect because a social relationship can have goals or needs to be met, the nurse-patient relationship extends beyond the patient's discharge, and trust and sharing of life experiences are essential components of the nurse-patient relationship.
An experienced nurse is supervising a student nurse in an acute care setting. Which statement, if made by the experienced nurse, would be most appropriate to help the student nurse establish credibility with other nurses on the unit?
- A. "It is impossible to be credible when you are a student because you lack experience.=
- B. "Try to hide your feelings of inadequacy and portray a sense of confidence.=
- C. "Be honest with the nurses about your strengths and about areas that need improvement.=
- D. "It would help if you bring special treats for the nurses so that they will like you.=
Correct Answer: C
Rationale: The correct answer is C: "Be honest with the nurses about your strengths and about areas that need improvement." This statement promotes transparency, self-awareness, and humility, which are important traits in gaining credibility. Being honest about strengths shows confidence, while acknowledging areas for improvement demonstrates a willingness to learn and grow. This approach fosters trust and respect among colleagues.
Choice A is incorrect as it undermines the student nurse's potential for credibility based on experience. Choice B suggests masking feelings of inadequacy, which can lead to inauthentic interactions. Choice D is inappropriate as it implies trying to buy favor with treats rather than earning credibility through professional conduct.
The nurse manager asks the staff nurse to work an extra shift. Which response by the staff nurse is assertive and based on rational beliefs?
- A. "I don't want you upset, so I will work extra."
- B. "Why do I always have to cover extra shifts?"
- C. "I am not able to work an extra shift."
- D. "If you can't find anyone else, I will do it."
Correct Answer: C
Rationale: The correct answer is C because it directly and assertively communicates the staff nurse's inability to work an extra shift. This response sets clear boundaries and respects the nurse's own limitations and well-being. It is based on rational beliefs as it acknowledges personal capacity without guilt or unnecessary explanations.
Explanation of other choices:
A: This choice is not assertive as it prioritizes avoiding upsetting the nurse manager over the nurse's own needs and boundaries.
B: This response is confrontational and does not address the request directly, focusing instead on questioning past occurrences.
D: While this response offers to work the extra shift as a last resort, it does not assert the nurse's own limitations clearly, leaving room for potential guilt or manipulation.