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What would be an appropriate nursing response when a mother reports that her 16-month-old toddler has an earache?
- A. Maybe the toddler is just teething.
- B. I will check her ear for an ear infection.
- C. Are you sure the toddler is really in pain?
- D. Please describe what the toddler is doing to indicate she is in pain.
Correct Answer: B
Rationale: The appropriate nursing response would be to assess the toddler's ear to determine if there is indeed an ear infection causing the earache. It is crucial to provide timely and suitable care for the child's pain and discomfort. Checking for an ear infection is a necessary step in evaluating the source of the toddler's earache. Choice A is incorrect as it assumes the earache is due to teething without proper assessment. Choice C questions the mother's report rather than focusing on the child's condition. Choice D is not as direct and focused as directly examining the ear for a possible infection.
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During an interview, the nurse states, 'You mentioned shortness of breath. Tell me more about that.' Which verbal skill is used with this statement?
- A. Reflection
- B. Facilitation
- C. Direct question
- D. Open-ended question
Correct Answer: D
Rationale: The nurse's statement, 'Tell me more about that,' is an example of an open-ended question. Open-ended questions encourage the interviewee to provide detailed information and expand on their responses. This type of question is useful for gathering narrative information and allows the interviewee to express themselves freely. Reflection involves restating or paraphrasing the client's words, facilitation encourages the client to say more, and direct questions typically elicit specific, close-ended responses, unlike open-ended questions.
When communicating with a patient who has a hearing impairment, what technique would be most beneficial?
- A. Determine the communication method he prefers.
- B. Avoid using facial and hand gestures as they can be degrading to most hearing-impaired individuals.
- C. Request a sign language interpreter before meeting to facilitate communication.
- D. Speak loudly and with exaggerated facial movement, as this helps with lip reading.
Correct Answer: A
Rationale: When communicating with a patient who has a hearing impairment, it is crucial to determine the preferred communication method, whether it involves signing, lip reading, or writing. By directly asking the patient for their preferred method of communication, the healthcare provider can ensure effective and respectful interaction tailored to the individual's specific needs and preferences. Option B is incorrect because using facial and hand gestures can actually aid in communication for some individuals with hearing impairments. Option C is not always necessary and may not be the preferred method for all patients. Option D is incorrect because speaking loudly and with exaggerated facial movements is not necessary and may not be preferred by the patient.
Among many Asians there is a belief in the yin\yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief?
- A. A person is able to work and produce.
- B. A person is happy, stable, and feels good.
- C. All aspects of the person are in perfect balance.
- D. A person is able to care for others and function socially. - C) All aspects of the person are in perfect balance. Page: 21 Many Asians believe in the yin\yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory.
Correct Answer: C
Rationale: In Asian belief systems like the yin\yang theory rooted in Tao philosophy, health is seen as existing when all aspects of a person are in perfect balance. This means that physical, mental, emotional, and spiritual elements need to be harmonized for an individual to be considered healthy. The other statements do not encapsulate this holistic perspective on health.
An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would:
- A. contact the hospital administrator about the best course of action.
- B. automatically get a curandero for her because it is not culturally appropriate for her to request one.
- C. further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires.
- D. ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.
Correct Answer: C
Rationale: When caring for a patient with traditional beliefs, especially one belonging to a culture like Mexican-American where folk or religious healers are important, a culturally-sensitive nurse should assess the patient's beliefs and preferences. By offering assistance in contacting a curandero or priest, the nurse acknowledges and respects the patient's cultural practices and provides holistic care that aligns with the patient's values. This approach helps build trust and ensures the patient receives care that is culturally appropriate and respectful. Choice A is incorrect as contacting the hospital administrator may not directly address the patient's cultural needs. Choice B is inappropriate as assuming the patient needs a curandero without assessment disregards individual preferences. Choice D is incorrect because while family involvement is valued in Mexican-American culture, the primary focus should be on the patient's individual preferences and autonomy.
When evaluating the reliability of a patient's responses, which of these statements would be correct? The patient:
- A. has a history of drug abuse and therefore is not reliable.
- B. provided consistent information and therefore is reliable.
- C. smiled throughout the interview and therefore is assumed reliable.
- D. would not answer questions concerning stress and therefore is not reliable.
Correct Answer: B
Rationale: In evaluating the reliability of a patient's responses, consistency in the information provided by the patient is crucial. When a patient provides consistent information, it indicates that their responses are trustworthy and reliable. In this scenario, the nurse can consider the patient as reliable based on the consistency of the information provided. Other factors such as a history of drug abuse, smiling behavior, or refusal to answer certain questions may not necessarily determine the reliability of the patient's responses. Therefore, the correct choice is B as consistency in responses is a more reliable indicator of trustworthiness than other factors mentioned in the choices.