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The nurse needs to obtain a health history from a Spanish-speaking patient. Which action by the nurse is best?
- A. Ask a bilingual friend of the patient to interpret.
- B. Use nonverbal communication and draw pictures.
- C. Request a Spanish-speaking medical interpreter.
- D. Interview the patient's English-speaking daughter.
Correct Answer: C
Rationale: The correct answer is C because using a professional medical interpreter ensures accurate communication, maintains patient confidentiality, and upholds ethical standards. Step 1: Requesting a Spanish-speaking medical interpreter ensures clear understanding of the patient's health history. Step 2: Using a professional interpreter avoids potential misinterpretations that may arise from using untrained individuals. Step 3: Interviewing the patient's English-speaking daughter may lead to inaccuracies and breaches patient confidentiality. Step 4: Asking a bilingual friend of the patient to interpret lacks professionalism and may result in miscommunication.
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The nurse is caring for a patient who states, "I tossed and turned last night." The nurse responds to the patient, "You feel like you were awake all night?" This is an example of:
- A. open-ended question.
- B. restatement.
- C. reflection.
- D. offering self. Restatement is a
Correct Answer: B
Rationale: The correct answer is B: restatement. Restatement involves repeating the patient's words to confirm understanding. In this scenario, the nurse echoed the patient's statement to show empathy and acknowledge the patient's feelings. This technique helps build rapport and fosters therapeutic communication.
Explanation of why other choices are incorrect:
A: Open-ended question: This involves encouraging the patient to elaborate on their feelings or experiences, not just repeating what the patient said.
C: Reflection: This involves restating the patient's feelings to show understanding, not simply repeating their words.
D: Offering self: This involves offering oneself to the patient for support, which was not demonstrated in the scenario.
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.
Which facial feature, if displayed by the nurse, best conveys warmth?
- A. Small pupils and a fixed gaze
- B. Furrowed brow and a wrinkled forehead
- C. Pursed lips and a forced smile
- D. Relaxed muscles and a concerned expression
Correct Answer: D
Rationale: The correct answer is D because relaxed muscles and a concerned expression convey warmth. Relaxed muscles suggest a sense of ease and approachability, while a concerned expression shows empathy and care. Small pupils and a fixed gaze (A) can indicate tension or distance. Furrowed brow and a wrinkled forehead (B) often signify stress or frustration. Pursed lips and a forced smile (C) may come across as insincere. Overall, D best conveys warmth through a combination of physical relaxation and emotional concern.
The nurse has selected an outcome for the patient to eat all of the food on the breakfast tray each day. Assessing that the patient has eaten all of the breakfast, the nurse would give positive feedback by saying:
- A. "Wow! That breakfast must have been pretty good."
- B. "I like pancakes too. Everyone on the hall seemed to enjoy them."
- C. "I hope you can keep all that breakfast down."
- D. "Hurray! You finished your whole meal! What would you like for tomorrow?" Giving positive feedback increases the likelihood of the desired behavior to be repeated. Commenting on the tastiness of the food or the fact that others liked it is not responding directly to the patient's having eaten the whole meal.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's achievement of finishing the whole meal, provides positive reinforcement, and invites the patient to make choices for the next meal, encouraging continued compliance with the desired outcome. This response directly reinforces the behavior that was targeted, making it more likely for the patient to repeat the behavior in the future. Choices A, B, and C do not specifically address the patient's accomplishment of eating all the food, therefore they do not provide effective positive feedback for reinforcing the desired behavior.
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.