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The nurse is interviewing a Native American client. It is most important for the nurse to take which action?
- A. Maintain eye contact to show respect and interest.
- B. Assess whether the client is comfortable with eye contact.
- C. Avoid prolonged eye contact with this client.
- D. Sit next to the patient to avoid any eye contact.
Correct Answer: B
Rationale: The correct answer is B: Assess whether the client is comfortable with eye contact. This is important because different cultures have varying views on eye contact, and it is crucial to respect the client's preferences. By assessing the client's comfort level with eye contact, the nurse can establish rapport and demonstrate cultural sensitivity.
A: Maintaining eye contact may not be culturally appropriate for some Native American clients, so it is important to assess their comfort level first.
C: Avoiding prolonged eye contact assumes all Native American clients have the same preferences, which is not accurate.
D: Sitting next to the patient to avoid eye contact may be perceived as distancing or disrespectful in some cultures.
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During the initial interview of a patient, the nurse should: (Select all that apply.)
- A. assess the language capabilities of the patient.
- B. use open-ended questions.
- C. limit the interview to approximately 30 minutes.
- D. assess comprehension abilities of the patient.
Correct Answer: A
Rationale: The correct answer is A: assess the language capabilities of the patient. This is crucial to ensure effective communication and understanding. By assessing language capabilities, the nurse can tailor communication strategies appropriately. Option B is helpful but not as essential as language assessment. Option C is incorrect as the interview duration should be based on patient needs, not a set time limit. Option D is relevant, but assessing comprehension abilities alone may not be sufficient if language barriers exist.
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
A home health patient with a bleeding ulcer informs the nurse that she ate a bowl of chili with jalapenos. An inappropriate communication block with a judgmental tone by the nurse would be:
- A. "Well, you have had this problem long enough to know what will happen—you certainly can't blame me!"
- B. "I don't think that was a smart thing for you to do considering your ulcer."
- C. "Well, you better watch your stool for evidence of blood so you can notify your primary care provider."
- D. "Oh, poo! A bowl of chili every now and then won't make a lot of difference to your ulcer." Judgmental response is a block to effective communication in which the nurse is judging the patient's action. It implies that the patient must take on the nurse's values and is demeaning to the patient.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates a judgmental tone towards the patient's actions. The nurse is passing a negative judgment on the patient by stating that eating chili with jalapenos was not a smart decision considering the ulcer. This response can make the patient feel guilty or ashamed, hindering effective communication.
Choice A shows frustration and blame towards the patient, which can lead to a defensive response. Choice C is directive and lacks empathy, focusing solely on the medical aspect without considering the patient's feelings. Choice D dismisses the patient's concerns and minimizes the impact of the action, which can be perceived as condescending.
In summary, choice B is the correct answer as it highlights the importance of maintaining a non-judgmental and supportive attitude in patient communication.
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.
While admitting a patient to the medical unit, the nurse should take which action?
- A. Demonstrate human caring by hugging the patient for brief intervals.
- B. Disclose shared intimate details with other healthcare providers.
- C. Maintain a physical distance of at least 3 to 4 feet at all times.
- D. Develop the plan of care and measurable objectives with the patient.
Correct Answer: D
Rationale: The correct answer is D because developing a plan of care and measurable objectives with the patient promotes patient-centered care, encourages collaboration, and ensures the patient's active involvement in their own care. This approach respects the patient's autonomy and preferences, fosters shared decision-making, and enhances treatment adherence.
A: Demonstrating human caring by hugging the patient may not be appropriate as it can violate professional boundaries and personal space.
B: Disclosing shared intimate details with other healthcare providers breaches patient confidentiality and violates privacy rights.
C: Maintaining a physical distance of at least 3 to 4 feet at all times may be necessary for infection control but does not address the core aspect of involving the patient in their care plan.