Nokea
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 a therapeutic relationship and understanding their concerns, fears, and challenges. By actively listening, the nurse can address the client's emotional and psychological needs, which are essential in managing a chronic condition like type 1 diabetes. This approach fosters trust, enhances communication, and promotes client engagement in their treatment plan.
Choices A, B, and C are incorrect because ignoring negative statements, avoiding physical contact, and solely focusing on the physical aspects of care can lead to poor client-nurse communication, lack of trust, and ultimately hinder compliance with the therapeutic regimen. Ignoring negative statements may escalate resistance, avoiding physical contact may create distance, and solely focusing on physical care neglects the holistic needs of the client.
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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).
The nurse manager asks the staff nurse to work an extra shift. Which response by the staff nurse is assertive and based on rational beliefs?
- A. "I don't want you upset, so I will work extra.=
- B. "Why do I always have to cover extra shifts?=
- C. "I am not able to work an extra shift.=
- D. "If you can't find anyone else, I will do it.=
Correct Answer: C
Rationale: The correct answer is C: "I am not able to work an extra shift." This response is assertive because it clearly communicates the staff nurse's inability to work the extra shift without making excuses or apologizing. It sets a boundary based on the staff nurse's current capacity and respects their own needs.
Choice A is incorrect because it prioritizes the nurse manager's feelings over the staff nurse's own needs. Choice B is incorrect as it is confrontational and does not provide a clear reason for not being able to work the extra shift. Choice D is incorrect because it implies a willingness to work based on the unavailability of others, rather than the staff nurse's own limitations.
The team leader is reviewing what the HCP has just prescribed for Mr. N (non-Hodgkin lymphoma). What will the team leader question?
- A. Administer filgrastim 5 mcg/kg subcutaneously every day
- B. Catheterize to obtain a urinalysis specimen.
- C. Flush the IV saline lock every shift.
- D. Monitor vital signs every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer filgrastim 5 mcg/kg subcutaneously every day. The rationale for this is that filgrastim is a medication commonly prescribed for patients with non-Hodgkin lymphoma to stimulate the production of white blood cells. Therefore, the team leader should question the dosage, route of administration, and frequency to ensure it aligns with the prescribed treatment plan.
Incorrect choices:
B: Catheterize to obtain a urinalysis specimen - This is not relevant to the prescribed treatment for non-Hodgkin lymphoma.
C: Flush the IV saline lock every shift - Important for maintaining IV access but not directly related to the prescribed medication.
D: Monitor vital signs every 4 hours - Monitoring vital signs is important but not the primary concern when reviewing a prescribed medication for non-Hodgkin lymphoma.
Which assessment finding for Mr. L (tracheostomy and partial laryngectomy) would be of greatest concern?
- A. Pulsation of the tracheostomy tube in synchrony with the heartbeat
- B. Increased secretions in and around the tracheostomy
- C. Increased coughing, with difficulty in expectorating secretions
- D. Presence of food particles in tracheal secretions
Correct Answer: A
Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety.
Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding.
Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding.
Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.
The nurse provides care for a male patient. When the nurse addresses the patient, which would be most appropriate?
- A. Use both first and last name with each encounter.
- B. Ask the patient how he prefers to be addressed.
- C. Call the patient by his first name.
- D. Address the patient by his last name.
Correct Answer: B
Rationale: The correct answer is B because it respects the patient's autonomy and preferences. By asking how the patient prefers to be addressed, the nurse demonstrates respect for the patient's individuality and dignity. This approach promotes a patient-centered care environment.
A: Using both first and last names with each encounter may come off as overly formal and impersonal.
C: Calling the patient by his first name without consent may be perceived as disrespectful and too informal.
D: Addressing the patient by his last name may be too formal and distant, not fostering a therapeutic nurse-patient relationship.