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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After the BCG treatment, the team leader delegates disposal of the fluid contents in Mr. B's (bladder cancer) urinary drainage bag to the UAP. What instructions should be given to the UAP?
- A. "No special handling of the bag or its contents is required."
- B. "Wear a lead apron when you are emptying the drainage container."
- C. "Discard the fluid in the toilet and disinfect the toilet with bleach for 6 hours."
- D. "Wear sterile gloves when you are handling the bag and its contents."
Correct Answer: C
Rationale: The correct answer is C because after BCG treatment, the fluid in the urinary drainage bag is considered hazardous due to the live bacteria used in the treatment. Therefore, instructing the UAP to discard the fluid in the toilet and disinfect it with bleach is crucial to prevent the spread of infection. This step helps to ensure proper disposal and minimize the risk of exposure to others.
Choice A is incorrect because special handling is indeed required due to the nature of the contents. Choice B is incorrect as wearing a lead apron is not necessary for handling the fluid in the urinary drainage bag. Choice D is also incorrect as sterile gloves are not specifically required for this task; instead, proper disinfection of the toilet is essential.
The nurse chooses to use touch in the nurse-patient relationship because touch:
- A. can convey caring and support when words are difficult.
- B. should be avoided because of problems of cultural misinterpretation.
- C. is appropriate only in special circumstances, such as with young children.
- D. is a nursing intervention of choice in almost all situations.
Correct Answer: A
Rationale: The correct answer is A because touch can convey caring and support when words are difficult, enhancing the nurse-patient relationship. This is supported by research showing the positive impact of touch in providing comfort and building trust. Choice B is incorrect as cultural differences can be addressed through communication and understanding. Choice C is incorrect because touch can be appropriate in various situations beyond just young children. Choice D is incorrect as touch should be used judiciously based on individual preferences and boundaries.
The nursing staff are making suggestions about how to help Ms. C (bowel resection) overcome her reluctance to perform colostomy care. Which suggestion will the team leader try first?
- A. Verbally reexplain the procedure and give her written material.
- B. Have a family member come in and do it for her.
- C. Continue to do it for her until she is ready.
- D. Ask her to hold the clamp while the bag is being emptied.
Correct Answer: A
Rationale: The correct answer is A because it involves providing Ms. C with information and resources to help her understand and feel more comfortable with the colostomy care procedure. Verbally reexplaining the procedure and providing written material will empower her with knowledge and autonomy. Choice B undermines her independence and may not address her reluctance. Choice C promotes dependency rather than encouraging her to take ownership of her care. Choice D involves a hands-on approach that may not address her underlying concerns or fears about the procedure. Overall, choice A is the most appropriate initial step to support Ms. C in overcoming her reluctance.
There are 2 hours left before the shift ends. The new UAP tells the team leader that she must leave now because she has a family emergency. What should the team leader do? Select all that apply.
- A. Ask her what tasks and duties are pending for the next 2 hours.
- B. Call a UAP who is scheduled for the next shift to come early.
- C. Allow her to leave but remind her she is still on probation as a new staff member.
- D. Call another unit and see if there is a UAP who could float to the unit.
Correct Answer: A
Rationale: The correct answer is A. The team leader should ask the UAP what tasks and duties are pending for the next 2 hours to assess the workload and determine if it's possible for the UAP to leave immediately. By understanding the pending tasks, the team leader can make an informed decision on whether the UAP leaving will impact patient care or workload. This approach ensures that patient care is not compromised and that the team's responsibilities are managed effectively.
Choices B, C, and D are incorrect because they do not directly address the immediate situation of the UAP needing to leave due to a family emergency. Calling another UAP, reminding the UAP of probation status, or seeking assistance from another unit may not be necessary or relevant if the tasks can be managed effectively without the UAP who needs to leave. These options do not prioritize understanding the pending tasks and duties to make an informed decision.
According to a study by Robinson (2014), three parts of our true presence (how we connect with patients) are found in being:
- A. Friendly, kind, and sweet
- B. Genuine, gifted, and creative
- C. Humorous, partial, and grateful
- D. Genuine, attentive, and immersed
Correct Answer: D
Rationale: The correct answer is D because being genuine shows sincerity and authenticity in interactions with patients. Attentiveness implies active listening and focus on the patient's needs, fostering a strong connection. Immersion signifies being fully engaged and present during patient interactions, enhancing the quality of care provided. In contrast, choices A, B, and C lack the essential components of active listening, authenticity, and full engagement, making them incorrect. Being friendly, kind, and sweet (choice A) may not necessarily reflect genuine presence. Similarly, being humorous, partial, and grateful (choice C) or genuine, gifted, and creative (choice B) do not fully capture the core elements of true presence as outlined in the study by Robinson (2014).