Nokea
The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?
- A. Insist that family members provide most of the patient's personal care.
- B. Maintain a personal space of at least 2 feet when assessing the patient.
- C. Ask permission before touching a patient during the physical assessment.
- D. Consider the patient's ethnicity as an important factor in planning care.
Correct Answer: C
Rationale: Culturally appropriate nursing care requires sensitivity to the beliefs and practices of diverse cultural groups. Asking permission before touching a patient during a physical assessment is a universally respectful practice, as many cultures consider it disrespectful to touch a person without consent. This approach demonstrates respect for the patient's autonomy and cultural preferences. Maintaining a personal space of at least 2 feet can be a good practice for infection control or personal comfort but may not be culturally significant for all patients. Insisting that family members provide most of the patient's personal care may not align with the patient's cultural norms or preferences. Considering a patient's ethnicity as the most important factor in care planning overlooks the individuality of the patient and may lead to stereotyping or assumptions that are not accurate or helpful in providing tailored care.
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What psychodynamic process is suggested by a client calling the emergency department during a suicide attempt?
- A. A cry for help
- B. A need for attention
- C. Ambivalence about dying
- D. An inability to stick to a decision
Correct Answer: C
Rationale: The correct answer is 'Ambivalence about dying.' When a client calls the emergency department during a suicide attempt, it suggests conflicting feelings about living and dying. This act can indicate an unconscious desire to be stopped from dying, showing ambivalence between the wish to die and the wish to live. It is not primarily a cry for attention or a need to punish others. The client's intention of suicide alongside seeking help demonstrates the struggle between life and death, making ambivalence the key psychodynamic process at play.
A toddler is 26 months old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the toddler in?
- A. Trust vs. mistrust
- B. Initiative vs. guilt
- C. Autonomy vs. shame and doubt
- D. Intimacy vs. isolation
Correct Answer: C
Rationale: The correct stage for a toddler who is 26 months old, according to Erik Erikson's stages of psychosocial development, is Autonomy vs. shame and doubt. This stage occurs between 18 months to 3 years of age. During this stage, children are focused on developing a greater sense of control and independence. Choice A, Trust vs. mistrust, is the first stage occurring from birth to 18 months, where infants learn to trust or mistrust their caregivers based on their care. Choice B, Initiative vs. guilt, is the third stage occurring from 3 to 5 years, where children start to assert themselves more. Choice D, Intimacy vs. isolation, is a stage occurring in adulthood, not relevant to a toddler's development.
A client decides to have hospice care rather than undergo an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?
- A. Justice
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: C
Rationale: The correct answer is 'Autonomy.' Autonomy refers to an individual's right to make decisions about their own care. In this scenario, the client is choosing hospice care over surgery, demonstrating their autonomy in making healthcare choices. Justice involves fairness and equality in the distribution of resources and services, which is not the primary ethical principle illustrated in this case. Veracity pertains to truthfulness and honesty, which is not directly related to the client's decision-making process. Beneficence refers to the duty to do good and act in the best interest of the patient, which is not the central ethical principle demonstrated by the client's decision for hospice care.
A client who is at 28 weeks' gestation and in active labor is crying. She says, 'I just know that this baby is going to die. What's the use of doing all this to save it?' Which explanation would interpret the client's statements?
- A. She is depressed and needs gentle, positive support during labor.
- B. She is experiencing anticipatory grief and withdrawing from bonding.
- C. She is in need of emotional support to help her cope with the impending birth.
- D. She is struggling to cope with the birth by using the word 'it.'
Correct Answer: B
Rationale: The client's statement indicates anticipatory grief, where she is preparing for a potential loss. This grief is not necessarily about the literal death of the baby but about the loss of the anticipated healthy full-term baby. The client may not be ready to bond with the reality of a preterm baby. Providing gentle, positive support is essential to help her cope with her feelings, as firm support may come across as dismissive. Sedation is not appropriate as it could hinder the client's emotional processing. Allowing the client to express her emotions and work through anticipatory grieving is crucial. The use of the word 'it' reflects the client's emotional struggle and is not the primary issue at hand.
When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
- A. Interview a family member instead.
- B. Wait for the patient to answer the questions.
- C. Remind the patient that you have other patients who need care.
- D. Give the patient an assessment form listing the questions and a pen.
Correct Answer: B
Rationale: When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.