Nokea
The nurse cares for an elderly patient in a long-term care center. Which would be inappropriate for the nurse to share with the client?
- A. Reminisce about birthday celebrations and inquire about the client's traditions.
- B. Use high levels of intimacy to help the client feel more comfortable with the nurse.
- C. Establish a helping relationship based on trust by sharing a personal story with the client.
- D. Share with the client how meditation decreased nausea during chemotherapy treatment.
Correct Answer: B
Rationale: The correct answer is B because using high levels of intimacy with a client, especially in a professional setting like a long-term care center, can violate boundaries and be inappropriate. The nurse should maintain a professional and therapeutic relationship with the client. Reminiscing about birthday celebrations (A) can help establish rapport and show interest in the client's life. Sharing personal stories (C) can build trust and connection. Sharing a relevant experience about meditation (D) can provide valuable information and support. In summary, maintaining appropriate boundaries and professionalism is crucial in a nurse-client relationship.
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The primary care provider informs the student nurse that he would like to give a telephone order. The best response by the student is:
- A. document the telephone order on the primary care provider's orders.
- B. ask another student to listen as a witness to the telephone order.
- C. tape record the primary care provider giving the order to the student nurse.
- D. ask the registered nurse to take the telephone order.
Correct Answer: D
Rationale: The correct answer is D because asking the registered nurse to take the telephone order ensures accuracy and accountability. The registered nurse is trained to accurately transcribe orders and can verify the details with the primary care provider if needed. This also follows the chain of command and delegation principles in healthcare.
Choice A is incorrect because the student nurse should not document the order directly without proper verification. Choice B is incorrect as having another student as a witness does not guarantee accuracy or proper documentation. Choice C is incorrect as recording the order could violate patient privacy laws and does not involve a healthcare professional in the transcription process.
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.
When the patient says, "I don't want to go home," the nurse's best therapeutic verbal response would be:
- A. "I'm sure everything will be fine once you get home."
- B. "You don't want to go home?"
- C. "Doesn't your family want you to come home?"
- D. "I felt like that when I had surgery last year." The use of reflecting encourages the patient to expand on his or her feelings or thoughts.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and empathy by reflecting the patient's statement. It shows the nurse is engaged and seeking to understand the patient's feelings. Choice A dismisses the patient's concerns. Choice C implies the patient is being pressured by their family. Choice D shifts the focus to the nurse's experience, not the patient's feelings.
Which facial feature, if displayed by the nurse, best conveys warmth?
- A. Small pupils and a fixed gaze
- B. Furrowed brow and a wrinkled forehead
- C. Pursed lips and a forced smile
- D. Relaxed muscles and a concerned expression
Correct Answer: D
Rationale: The correct answer is D because relaxed muscles and a concerned expression convey warmth. Relaxed muscles suggest a sense of ease and approachability, while a concerned expression shows empathy and care. Small pupils and a fixed gaze (A) can indicate tension or distance. Furrowed brow and a wrinkled forehead (B) often signify stress or frustration. Pursed lips and a forced smile (C) may come across as insincere. Overall, D best conveys warmth through a combination of physical relaxation and emotional concern.
The nurse prepares to obtain a health history from a hospitalized patient. Which action by the nurse is appropriate?
- A. Set time limits for the interview to reduce cost.
- B. Avoid asking questions that may upset the patient.
- C. Respect the patient's privacy by closing the door.
- D. Stand at the foot of the bed to maintain eye contact.
Correct Answer: C
Rationale: The correct answer is C: Respect the patient's privacy by closing the door. Closing the door ensures confidentiality and privacy during the health history interview, promoting trust between the nurse and patient. This setting allows for open communication and prevents distractions. Options A and D are incorrect because setting time limits for the interview to reduce cost and standing at the foot of the bed to maintain eye contact do not prioritize patient privacy and comfort. Option B is incorrect because avoiding questions that may upset the patient may hinder the nurse's ability to gather important information for proper care.