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The nurse is performing a well-child assessment on a 15-month-old child. The child's mother and father are present. Which action by the nurse will best determine the health beliefs and values of the parents?
- A. Have the parents independently complete the Myers-Briggs Type Indicator survey.
- B. Read the documented health histories of the child's parents and grandparents.
- C. Actively listen to the parents talk about their lives and health concerns.
- D. Review the traditional health practices of the ethnic group identified by the parents.
Correct Answer: C
Rationale: Rationale:
C is the correct answer because actively listening to the parents talk about their lives and health concerns allows the nurse to understand their perspectives, beliefs, and values. This helps build rapport and trust, providing insight into how they approach healthcare for their child.
A: The Myers-Briggs Type Indicator survey is not relevant to understanding health beliefs and values.
B: Reading documented health histories may provide medical information but does not necessarily reveal beliefs and values.
D: Reviewing traditional health practices may be informative but does not directly assess the parents' personal beliefs and values.
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The primary care provider informs the student nurse that he would like to give a telephone order. The best response by the student is:
- A. document the telephone order on the primary care provider's orders.
- B. ask another student to listen as a witness to the telephone order.
- C. tape record the primary care provider giving the order to the student nurse.
- D. ask the registered nurse to take the telephone order.
Correct Answer: D
Rationale: The correct answer is D because asking the registered nurse to take the telephone order ensures accuracy and accountability. The registered nurse is trained to accurately transcribe orders and can verify the details with the primary care provider if needed. This also follows the chain of command and delegation principles in healthcare.
Choice A is incorrect because the student nurse should not document the order directly without proper verification. Choice B is incorrect as having another student as a witness does not guarantee accuracy or proper documentation. Choice C is incorrect as recording the order could violate patient privacy laws and does not involve a healthcare professional in the transcription process.
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.
The nurse cares for a young adult patient in the emergency room after a sexual assault. Which action by the nurse is appropriate?
- A. Avoid situations in which the patient will be involved with decision making.
- B. Tell the patient to join a local support group for sexual assault victims.
- C. Actively listen to the patient express feelings related to the sexual assault.
- D. Provide detailed information about evidence collection and invasive procedures.
Correct Answer: C
Rationale: The correct answer is C because actively listening to the patient express their feelings related to the sexual assault is essential for providing emotional support and validating their experience. This action shows empathy and helps the patient feel heard and supported. It also allows the nurse to assess the patient's emotional well-being and provide appropriate care.
Avoiding decision-making situations (A) may lead to further distress for the patient. While joining a support group (B) can be beneficial, it may not be appropriate or feasible immediately after a traumatic event. Providing detailed information about evidence collection (D) is important but should be done after addressing the patient's emotional needs.
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 cares for an elderly patient in a long-term care center. Which would be inappropriate for the nurse to share with the client?
- A. Reminisce about birthday celebrations and inquire about the client's traditions.
- B. Use high levels of intimacy to help the client feel more comfortable with the nurse.
- C. Establish a helping relationship based on trust by sharing a personal story with the client.
- D. Share with the client how meditation decreased nausea during chemotherapy treatment.
Correct Answer: B
Rationale: The correct answer is B because using high levels of intimacy with a client, especially in a professional setting like a long-term care center, can violate boundaries and be inappropriate. The nurse should maintain a professional and therapeutic relationship with the client. Reminiscing about birthday celebrations (A) can help establish rapport and show interest in the client's life. Sharing personal stories (C) can build trust and connection. Sharing a relevant experience about meditation (D) can provide valuable information and support. In summary, maintaining appropriate boundaries and professionalism is crucial in a nurse-client relationship.