Nokea
The nursing staff are making suggestions about how to help Ms. C (bowel resection) overcome her reluctance to perform colostomy care. Which suggestion will the team leader try first?
- A. Verbally reexplain the procedure and give her written material.
- B. Have a family member come in and do it for her.
- C. Continue to do it for her until she is ready.
- D. Ask her to hold the clamp while the bag is being emptied.
Correct Answer: A
Rationale: The correct answer is A because it involves providing Ms. C with information and resources to help her understand and feel more comfortable with the colostomy care procedure. Verbally reexplaining the procedure and providing written material will empower her with knowledge and autonomy. Choice B undermines her independence and may not address her reluctance. Choice C promotes dependency rather than encouraging her to take ownership of her care. Choice D involves a hands-on approach that may not address her underlying concerns or fears about the procedure. Overall, choice A is the most appropriate initial step to support Ms. C in overcoming her reluctance.
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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 characteristic that is representative of the nurse-patient relationship is that this relationship:
- A. focuses on the nurse's ability to build rapport.
- B. continues after discharge.
- C. does not include humor.
- D. focuses on the assessed patient health problems.
Correct Answer: D
Rationale: The correct answer is D because the nurse-patient relationship primarily focuses on addressing the assessed health problems of the patient. This relationship is centered around providing care, support, and assistance related to the patient's health needs. Building rapport (A) is important, but not the primary focus. The relationship does not necessarily continue after discharge (B) as it depends on the circumstances. Humor (C) can be included in the relationship but is not a defining characteristic. Thus, D is the correct choice as it aligns with the fundamental purpose of the nurse-patient relationship.
A 36-year-old woman who is in traction for a fractured femur that she received in an auto accident is found crying quietly. The nurse can best address this situation by saying:
- A. "What's the matter? Why are you crying? Are you in pain?"
- B. "Stop crying and tell me what your problem is."
- C. "This could have been much worse. You're lucky no one was killed."
- D. "You are upset. Can you tell me what's wrong?"
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's emotions, shows empathy, and encourages open communication. By stating "You are upset. Can you tell me what's wrong?" the nurse validates the patient's feelings and invites her to express her concerns. This approach fosters trust and allows the nurse to address the underlying issues causing the patient's distress.
Choice A is incorrect as it assumes the patient is in pain without confirmation and may come off as dismissive. Choice B is inappropriate as it lacks empathy and demands the patient to stop crying, which can further escalate the situation. Choice C is insensitive as it diminishes the patient's feelings by comparing her situation to a potential worse outcome, which is not helpful in addressing her emotional distress.
There are 2 hours left before the shift ends. The new UAP tells the team leader that she must leave now because she has a family emergency. What should the team leader do? Select all that apply.
- A. Ask her what tasks and duties are pending for the next 2 hours.
- B. Call a UAP who is scheduled for the next shift to come early.
- C. Allow her to leave but remind her she is still on probation as a new staff member.
- D. Call another unit and see if there is a UAP who could float to the unit.
Correct Answer: A
Rationale: The correct answer is A. The team leader should ask the UAP what tasks and duties are pending for the next 2 hours to assess the workload and determine if it's possible for the UAP to leave immediately. By understanding the pending tasks, the team leader can make an informed decision on whether the UAP leaving will impact patient care or workload. This approach ensures that patient care is not compromised and that the team's responsibilities are managed effectively.
Choices B, C, and D are incorrect because they do not directly address the immediate situation of the UAP needing to leave due to a family emergency. Calling another UAP, reminding the UAP of probation status, or seeking assistance from another unit may not be necessary or relevant if the tasks can be managed effectively without the UAP who needs to leave. These options do not prioritize understanding the pending tasks and duties to make an informed decision.
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.