Nokea
What is the most appropriate action when a parent crosses their arms and legs during an interview?
- A. Just changing positions
- B. More comfortable in this position
- C. Tired and needs a break
- D. Uncomfortable talking about his son's treatment
Correct Answer: D
Rationale: The correct answer is D because crossing arms and legs can indicate defensiveness or discomfort, which may suggest the parent is uneasy discussing their son's treatment. This nonverbal cue could signal a need for empathy and sensitivity in communication. Choice A is incorrect as it overlooks the significance of body language. Choice B assumes comfort without considering the context. Choice C assumes tiredness without considering other possibilities. Understanding body language cues can help in building rapport and addressing concerns effectively.
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What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Monitor serum glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.
What should be the nurse's first action when caring for a client who has a suspected stroke?
- A. Assess the client's airway
- B. Administer oxygen
- C. Administer aspirin
- D. Perform a CT scan
Correct Answer: A
Rationale: The correct answer is A: Assess the client's airway. This is the first action because airway patency is the top priority in any emergency situation, including a suspected stroke. Ensuring the client can breathe effectively is crucial to prevent hypoxia and further complications. Administering oxygen (choice B) may be necessary after assessing the airway. Administering aspirin (choice C) should be done after a definitive diagnosis of an ischemic stroke. Performing a CT scan (choice D) is important for diagnosis but is not the first action to take in a suspected stroke scenario.
Which nursing intervention should be prioritized for a client with congestive heart failure (CHF)?
- A. Administer diuretics
- B. Limit fluid intake
- C. Promote activity
- D. Maintain fluid balance
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life.
Summary of Incorrect Choices:
A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity.
B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation.
D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.
Critique the following statement made by the nurse: "I know it may be hard, but you should do what the doctor ordered because he/she is the expert in this field.'
- A. This statement is inappropriate because it shows the nurse's bias.
- B. This statement is appropriate because members of the health care team are experts in the area of patient care.
- C. This type of statement creates dependency and inferiority in the patient and is best avoided in an interview situation.
- D. At times, it is necessary to use authority statements when dealing with patients, especially when they are undecided about an issue.
Correct Answer: C
Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making.
The other choices are incorrect because:
A: This choice focuses on bias, which is not the main issue at hand in this scenario.
B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience.
D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.
The nurse is caring for a patient who is a recent immigrant and has limited English proficiency. Which of the following is the best action the nurse should take?
- A. Use medical jargon to explain the procedure to ensure the patient understands.
- B. Speak loudly and slowly to make sure the patient understands.
- C. Use a professional interpreter or translation services to communicate effectively.
- D. Ask the patient's family to translate for the nurse.
Correct Answer: C
Rationale: The correct answer is C: Use a professional interpreter or translation services to communicate effectively. This is the best action because it ensures accurate communication and understanding between the nurse and the patient. Professional interpreters are trained to accurately convey information while respecting cultural nuances.
Explanation for why the other choices are incorrect:
A: Using medical jargon can confuse the patient further and hinder effective communication.
B: Speaking loudly and slowly can come across as patronizing and does not address the language barrier.
D: Relying on the patient's family for translation can lead to miscommunication or breaches of patient confidentiality.