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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.
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The nurse plans to use self-disclosure to aid a mother and father in the grieving process after the death of their child. The steps of a helpful self-disclosure appear below. What is the first step?
- A. Succinctly share a personal experience that is a similar grieving experience.
- B. Listen to the parents talk about their child and observe their movements and gestures.
- C. Reflect upon the parent's statements to communicate understanding.
- D. Seek verification that the self-disclosure was helpful to the child's parents.
Correct Answer: B
Rationale: The correct answer is B: Listen to the parents talk about their child and observe their movements and gestures. This is the first step in helpful self-disclosure because it allows the nurse to understand the parents' emotions and experiences before sharing their own. By actively listening and observing, the nurse can establish a connection with the parents and demonstrate empathy. This step sets the foundation for effective communication and builds trust between the nurse and the parents.
Incorrect choices:
A: Succinctly share a personal experience that is a similar grieving experience. This is not the first step because it doesn't consider the parents' feelings and might come across as insensitive or self-centered.
C: Reflect upon the parent's statements to communicate understanding. While reflection is important, it should come after active listening to ensure the nurse fully grasps the parents' emotions.
D: Seek verification that the self-disclosure was helpful to the child's parents. Seeking verification should come at a later stage after the nurse has provided support and guidance through
The author describes the patient journey as driving down a country road and somehow getting lost. At that moment and time, all that is needed is clear directions about how to get to your destination, not about types of entertainment in the area. The same is true for patients. Accordingly, a part of each nursing assessment should include:
- A. Patient's need for information and level of understanding
- B. Detailed overview of disease process
- C. Specific examples from other patients with same disease
- D. Nurse's feelings about newest treatment modality
Correct Answer: A
Rationale: Step 1: Understanding the patient's need for information and level of understanding is crucial to providing appropriate care.
Step 2: Clear directions are necessary to guide patients, just like clear information is needed to guide their healthcare decisions.
Step 3: Assessing the patient's need for information helps tailor education to their level of understanding.
Step 4: This choice directly aligns with the analogy of providing clear directions for patients on their healthcare journey.
Summary: Choice A is correct as it emphasizes the importance of assessing the patient's need for information and understanding, which is essential for guiding them effectively. Choices B, C, and D are incorrect as they do not directly address the patient's need for information and understanding in the analogy provided.
According to Swanson's theory, there are five caring processes, one of which is "being with.= Which of the responses by the nurse portrays an understanding of the concept of "being with= a client?
- A. The nurse charting in the room to spend more time with the client
- B. The nurse wearing locator badge so you can quickly respond any time patient would call front desk and ask to page you
- C. The nurse requesting one-on-one nurse staffing
- D. The nurse being emotionally present to the client
Correct Answer: D
Rationale: Step 1: Swanson's theory emphasizes the importance of "being with" a client, which involves being emotionally present and fully engaged.
Step 2: Choice D reflects the concept of "being with" as it highlights the nurse's emotional presence and connection with the client.
Step 3: The nurse actively engages with the client on an emotional level, demonstrating empathy and understanding.
Step 4: Choices A, B, and C do not capture the essence of "being with" as they focus more on physical presence or logistical aspects rather than emotional connection.
Summary: Choice D is correct because it aligns with the core principle of "being with" by emphasizing emotional presence, while the other choices lack this critical component.
Mr. U (pulmonary resection) has developed a tension pneumothorax. He is currently receiving high-flow oxygen via nonrebreather mask but continues to experience respiratory distress. What is the priority action?
- A. Remove the occlusive dressing around the chest wound.
- B. Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
- C. Initiate cardiopulmonary resuscitation (CPR).
- D. Call for the crash cart and intubation equipment.
Correct Answer: B
Rationale: The correct answer is B: Perform a needle thoracotomy with a 14- to 16-gauge catheter needle.
Rationale:
1. Tension pneumothorax is a life-threatening emergency where air accumulates in the pleural space, causing lung collapse and increased pressure in the chest.
2. The standard treatment for tension pneumothorax is needle thoracostomy, which involves inserting a large-bore needle into the chest to release the trapped air.
3. In this scenario, Mr. U is in respiratory distress despite receiving high-flow oxygen, indicating a significant problem with ventilation that requires immediate intervention.
4. Performing a needle thoracotomy will rapidly decompress the tension pneumothorax, relieving pressure on the heart and lungs, and improving respiratory function.
5. This action takes precedence over other options such as removing the occlusive dressing, initiating CPR, or calling for intubation equipment, as immediate decompression is crucial in managing tension pneumoth
The nurse is caring for a client who is diagnosed with type 1 diabetes mellitus. Which nursing action would most likely improve client compliance with the therapeutic regimen?
- A. Consistently ignore negative statements made by the client.
- B. Avoid touching the client to reduce tension and uneasiness.
- C. Focus on the physical aspects of care such as insulin administration.
- D. Listen attentively to the client's perception of having a chronic illness.
Correct Answer: D
Rationale: The correct answer is D because listening attentively to the client's perception of having a chronic illness is crucial for building trust, understanding their concerns, and fostering a therapeutic relationship. By actively listening, the nurse can address any misconceptions, provide education tailored to the client's needs, and involve the client in decision-making, ultimately improving compliance.
Choice A is incorrect as ignoring negative statements can lead to feelings of neglect and hinder communication. Choice B is incorrect as avoiding touching the client may create a barrier to building rapport. Choice C is incorrect as focusing only on physical care neglects the psychological and emotional aspects of managing a chronic condition like diabetes.