Nokea
The nurse cares for an adult client who is diagnosed with active tuberculosis. Which action, if performed by the nurse during introductions, shows respect for the client? (Select all that apply)
- A. Maintain eye contact by looking at the client.
- B. Avoid touch to reduce transmission of the disease.
- C. Stay at least 4 to 6 feet away from the client.
- D. Briefly converse about the weather to break the ice.
Correct Answer: A
Rationale: The correct answer is A. Maintaining eye contact by looking at the client during introductions shows respect by acknowledging the client as an individual and demonstrating active listening. This helps establish trust and rapport.
Incorrect choices:
B: Avoiding touch may be necessary for infection control, but it does not necessarily show respect for the client.
C: Staying 4 to 6 feet away may be necessary for infection control, but it does not demonstrate respect or engagement with the client.
D: Briefly conversing about the weather is a social nicety but may not convey the same level of respect and attentiveness as making eye contact.
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which assessment will the nurse perform?
- A. Assess for Cullen sign
- B. Assess for grey-turner sign
- C. Assess for McBurney sign
- D. Assess for Chvostek sign
Correct Answer: C
Rationale: The correct answer is C: Assess for McBurney sign. The McBurney sign is indicative of appendicitis and involves tenderness at McBurney's point in the right lower quadrant. This assessment is crucial for identifying possible appendicitis in a patient presenting with abdominal pain. Assessing for Cullen sign (A) involves bruising around the umbilicus and is associated with intra-abdominal bleeding, not appendicitis. Grey-Turner sign (B) refers to bruising on the flanks and is also indicative of intra-abdominal bleeding. Chvostek sign (D) is a clinical sign of facial muscle twitching and is associated with hypocalcemia. Therefore, assessing for McBurney sign is the most appropriate choice in this scenario to help diagnose appendicitis.
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.
The nurse has selected an outcome for the patient to eat all of the food on the breakfast tray each day. Assessing that the patient has eaten all of the breakfast, the nurse would give positive feedback by saying:
- A. "Wow! That breakfast must have been pretty good."
- B. "I like pancakes too. Everyone on the hall seemed to enjoy them."
- C. "I hope you can keep all that breakfast down."
- D. "Hurray! You finished your whole meal! What would you like for tomorrow?" Giving positive feedback increases the likelihood of the desired behavior to be repeated. Commenting on the tastiness of the food or the fact that others liked it is not responding directly to the patient's having eaten the whole meal.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's achievement of finishing the whole meal, provides positive reinforcement, and invites the patient to make choices for the next meal, encouraging continued compliance with the desired outcome. This response directly reinforces the behavior that was targeted, making it more likely for the patient to repeat the behavior in the future. Choices A, B, and C do not specifically address the patient's accomplishment of eating all the food, therefore they do not provide effective positive feedback for reinforcing the desired behavior.
The characteristic that is representative of the nurse-patient relationship is that this relationship:
- A. focuses on the nurse's ability to build rapport.
- B. continues after discharge.
- C. does not include humor.
- D. focuses on the assessed patient health problems.
Correct Answer: D
Rationale: The correct answer is D because the nurse-patient relationship primarily focuses on addressing the assessed health problems of the patient. This relationship is centered around providing care, support, and assistance related to the patient's health needs. Building rapport (A) is important, but not the primary focus. The relationship does not necessarily continue after discharge (B) as it depends on the circumstances. Humor (C) can be included in the relationship but is not a defining characteristic. Thus, D is the correct choice as it aligns with the fundamental purpose of the nurse-patient relationship.
The nurse is performing a well-child assessment on a 15-month-old child. The child's mother and father are present. Which action by the nurse will best determine the health beliefs and values of the parents?
- A. Have the parents independently complete the Myers-Briggs Type Indicator survey.
- B. Read the documented health histories of the child's parents and grandparents.
- C. Actively listen to the parents talk about their lives and health concerns.
- D. Review the traditional health practices of the ethnic group identified by the parents.
Correct Answer: C
Rationale: Rationale:
C is the correct answer because actively listening to the parents talk about their lives and health concerns allows the nurse to understand their perspectives, beliefs, and values. This helps build rapport and trust, providing insight into how they approach healthcare for their child.
A: The Myers-Briggs Type Indicator survey is not relevant to understanding health beliefs and values.
B: Reading documented health histories may provide medical information but does not necessarily reveal beliefs and values.
D: Reviewing traditional health practices may be informative but does not directly assess the parents' personal beliefs and values.