Nokea
The nurse cares for elderly clients in an assisted living center. Which action by the nurse would best show respect for these clients?
- A. Patronize clients who share ideas or voice concerns.
- B. Identify healthcare needs by listening to the clients.
- C. Address the clients formally by their last names.
- D. Limit the clients' opportunities to express opinions.
Correct Answer: B
Rationale: The correct answer is B because listening to the elderly clients to identify their healthcare needs demonstrates respect by valuing their input and autonomy. This approach fosters a collaborative and client-centered care environment. Choice A is incorrect as patronizing clients undermines their dignity. Choice C may be seen as impersonal and distant. Choice D is disrespectful as it restricts clients' autonomy and diminishes their voice. Listening and considering clients' needs is crucial in providing respectful care to the elderly population.
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Ms. C (bowel resection and colostomy) is receiving epoetin alfa. Which laboratory test will the nurse check to see if the medication should be discontinued?
- A. Hemoglobin
- B. White cell count
- C. Potassium level
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin. Epoetin alfa is a medication that stimulates red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of the medication. If hemoglobin levels rise too high, it can lead to complications like blood clots. Checking hemoglobin levels helps determine if the dose of epoetin alfa should be adjusted or discontinued.
Summary:
B: White cell count - Monitoring white cell count is not directly related to epoetin alfa therapy.
C: Potassium level - Monitoring potassium level is important for other medications like diuretics or ACE inhibitors, not specifically for epoetin alfa.
D: Blood glucose level - Monitoring blood glucose level is important for diabetic patients but not directly related to epoetin alfa therapy.
A patient asks the nurse to make a decision for her about whether or not to continue taking hormone replacement therapy (estrogen). Which response by the nurse is most appropriate?
- A. "You should check with a doctor; I cannot give you advice about drugs."
- B. "My friend has taken estrogen for more than 5 years without any problems."
- C. "I can answer any questions you have but it is up to you to make this decision."
- D. "Herbal supplements were much better for me than prescription-strength estrogen."
Correct Answer: C
Rationale: The correct answer is C because it emphasizes patient autonomy and informed decision-making, aligning with ethical principles. The nurse should not make decisions for the patient but should provide information and support. Choice A deflects responsibility and does not empower the patient. Choice B is anecdotal and not a reliable source of information. Choice D is not relevant to the patient's question and could potentially lead to misinformation. Ultimately, choice C encourages the patient to take an active role in their healthcare decisions, which promotes patient-centered care.
A patient is irritable and complains to the nurse about difficulty sleeping last night. Which response by the nurse is most appropriate?
- A. "I know you will sleep better tonight.=
- B. "Tell me more about what happened last night.=
- C. "Did you drink too much caffeine yesterday?=
- D. "No one sleeps well in the hospital.=
Correct Answer: B
Rationale: The correct response is B. Asking the patient to elaborate on what happened last night allows the nurse to gather more information about the situation, which is crucial for assessing the patient's sleep difficulties accurately. It shows active listening and empathy, building rapport and trust with the patient. Options A, C, and D are incorrect because they do not address the patient's concerns effectively or gather relevant information to provide appropriate care. Option A makes an assumption without understanding the root cause of the sleep issue. Option C assumes the cause of sleep difficulty without exploring further. Option D dismisses the patient's concerns without providing support or understanding.
Let me know how you're doing and whether you need any help."
- A. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed."
- B. "Take the vital signs on all the patients in the lounge and tell me whether there are problems." The clarity and brevity of the direction makes the delegated task clear and leaves the responsibility of assessment to the nurse.
Correct Answer: B
Rationale: The correct answer is B because it provides clear instructions to take vital signs on all patients in the lounge and report any problems. This ensures comprehensive assessment and communication. Choice A is incorrect because it lacks specificity and may lead to overlooking important tasks. Choice C and D are incorrect as they are blank. Providing clear and concise directions is crucial in delegation to ensure tasks are completed accurately and efficiently.
The nurse cares for a female patient who is trying to gain understanding of her life and her diagnosis of metastatic breast cancer. Which approach by the nurse would best meet this patient's needs?
- A. Suggest the patient join a breast cancer support group.
- B. Provide the patient with reading material on death and dying.
- C. Contact the patient's spiritual leader to request daily visits.
- D. Listen to the patient's stories about her past experiences.
Correct Answer: D
Rationale: The correct answer is D because actively listening to the patient's stories about her past experiences allows for emotional expression, validation, and building trust. It promotes therapeutic communication and helps the patient gain understanding and cope with her diagnosis. Choice A focuses on group support, which may not address the patient's individual needs. Choice B is not appropriate as it may induce unnecessary fear. Choice C assumes the patient has specific spiritual beliefs and may not be welcomed.