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What is the purpose of a nurse providing appropriate feedback?
- A. To give the client good advice
- B. To advise the client on appropriate behaviors
- C. To evaluate the clients behavior
- D. To give the client critical information
Correct Answer: C
Rationale: The purpose of a nurse providing appropriate feedback is to evaluate the client's behavior. This involves assessing the client's actions, understanding their needs, and determining the effectiveness of the care provided. Feedback helps in identifying areas for improvement and guiding the client towards better health outcomes. Choice A is incorrect as feedback is not solely about giving advice. Choice B is incorrect as feedback is not limited to advising on behaviors. Choice D is incorrect as feedback goes beyond just providing critical information to include a holistic evaluation of the client's overall behavior and progress.
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During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.
A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction?
- A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing.
- B. The Nurse Practice Act lists education requirements for licensure and reciprocity.
- C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs).
- D. The Nurse Practice Act lists the general authority and powers of the state board of nursing.
Correct Answer: B
Rationale: The correct answer is B because education requirements for licensure and reciprocity are typically not included in the Nurse Practice Act. The Act primarily focuses on defining the scope of practice, authority of the state board, regulations, and standards for nursing practice. Education requirements are usually outlined in separate regulations or guidelines by the state board of nursing or accrediting bodies. Therefore, if a student statement mentions education requirements as part of the Nurse Practice Act, it indicates a need for further instruction as it is not accurate.
A: This statement is correct as the Nurse Practice Act often includes definitions of important terms to provide clarity and understanding.
C: This statement is correct as the Act does describe the scope of practice for registered nurses to ensure safe and competent care.
D: This statement is correct as the Act typically outlines the general authority and powers of the state board of nursing to regulate and oversee nursing practice.
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, You are incompetent! Which is the nurses best response?
- A. Do you believe that I was the cause of your blood test being canceled?
- B. I see that you are upset, but I feel uncomfortable when you swear at me.
- C. Have you ever thought about ways to express anger appropriately?
- D. Ill give you some space. Let me know if you need anything.
Correct Answer: B
Rationale: The correct answer is B: "I see that you are upset, but I feel uncomfortable when you swear at me." This response acknowledges the client's emotion while setting a boundary against inappropriate behavior. It demonstrates empathy towards the client's feelings without condoning the swearing. It also communicates the nurse's discomfort with the behavior, which can help in de-escalating the situation.
A: Choice A deflects responsibility and may come off as defensive, not addressing the client's emotions directly.
C: Choice C shifts the focus away from the client's immediate distress and may not be well-received in the heat of the moment.
D: Choice D, while giving space, doesn't address the behavior directly and may not effectively address the client's emotions or the impact of their actions on the nurse.
Which should the nurse recognize as an example of the defense mechanism of repression?
- A. A woman whose son was killed in Iraq does not believe the military report.
- B. A man who is unhappily married goes to school to become a marriage counselor.
- C. A woman was raped when she was 12 and no longer remembers the incident.
Correct Answer: C
Rationale: The correct answer is C because repression is a defense mechanism in which traumatic memories are unconsciously blocked from awareness. In this scenario, the woman's inability to remember the rape incident at age 12 is a classic example of repression. She has pushed the memory out of consciousness to avoid the emotional distress associated with it.
Choice A is incorrect as it describes denial, where the woman refuses to accept the truth. Choice B is incorrect as it reflects sublimation, where the man channels his unhappiness into a positive pursuit. Choice D is incomplete, making it impossible to evaluate.
A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate?
- A. Im confident you know whats best for you.
- B. This may not be the best time for you to make such an important decision.
- C. Your children will be terribly disappointed.
- D. Tell me why you want to make this change.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's emotions and gently suggests caution in making a big decision during a vulnerable time. It shows empathy and encourages the client to reconsider the decision later. Choice A lacks exploration of client's feelings, Choice C introduces unnecessary guilt, and Choice D focuses on the change rather than the emotional state.