When a patient begins crying during a conversation with the nurse about the patient's upcoming surgery for possible malignancy, the nurse's most therapeutic response would be:
- A. "Your surgeon is excellent, and I know he'll do a great job."
- B. "Oh, dear, your gown is way too big, let me get you another one."
- C. "Don't cry; think about something else and you'll feel better."
- D. "Here is a tissue. I'd like to sit here for a while if you want to talk."
Correct Answer: D
Rationale: The correct answer is D. This response acknowledges the patient's emotions, offers support, and provides an opportunity for the patient to express their feelings. Offering a tissue shows empathy and readiness to listen. Sitting with the patient shows availability and willingness to engage further. This response validates the patient's emotions and fosters a therapeutic nurse-patient relationship.
Choice A is incorrect because it dismisses the patient's emotions and focuses on the surgeon rather than the patient. Choice B is incorrect as it ignores the patient's emotional distress and focuses on a non-essential issue. Choice C is incorrect as it invalidates the patient's feelings and suggests avoidance rather than addressing the emotions directly.
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The home health nurse visits a client with heart failure who has increased dyspnea and peripheral edema and weight gain. The nurse suspects the client is not restricting fluids as prescribed. Which action by the nurse is most appropriate?
- A. Teach the client about the consequences of not following the fluid restrictions.
- B. Ask the client to report the amount of fluid intake for the past 24 hours.
- C. Provide the client with sugarless candy or gum to decrease the thirst sensation.
- D. Consult with the healthcare provider about increasing the dose of the diuretic.
Correct Answer: B
Rationale: The most appropriate action for the nurse is to ask the client to report the amount of fluid intake for the past 24 hours. This is the correct answer because it directly addresses the issue of non-compliance with fluid restrictions. By assessing the actual fluid intake, the nurse can identify the extent of the problem and provide targeted interventions.
Option A is not the best choice as teaching about consequences may not address the immediate issue. Option C does not address the root cause of the problem but only provides a temporary solution. Option D is not appropriate as increasing the diuretic dose should be done in collaboration with the healthcare provider after assessing the client's current condition.
According to the ANA's Standards of Clinical Nursing Practice, there are several steps within the nursing process that surround patient care. However, one of the most important steps is the one in which the nurse partners with the patient, family, and other caregivers to create an acceptable path that meets the patient's needs and is specific to the disease process. This important step is identified as:
- A. Evaluation
- B. Planning
- C. Implementation
- D. Nursing diagnosis
Correct Answer: B
Rationale: The correct answer is B: Planning. In the nursing process, planning is a crucial step where the nurse collaborates with the patient, family, and caregivers to develop a comprehensive care plan tailored to the patient's needs and specific disease process. This step involves setting goals, determining interventions, and creating a roadmap for the patient's care. Planning ensures that the care provided is individualized, evidence-based, and addresses the patient's unique circumstances. Evaluation (A) comes after planning to assess the effectiveness of interventions. Implementation (C) involves carrying out the planned interventions. Nursing diagnosis (D) is an earlier step where the nurse identifies the patient's health problems and needs. Planning stands out as the most important step as it guides the entire care process.
According to the Workplace Bullying Institute, nurses are also exposed to this type of behavior within their professional environment. In teaching the possibility to an incoming graduate nurse, you know that the nurse understands when he or she includes which of the following as abusive conduct? (Select all that apply)
- A. Threats
- B. Humiliation
- C. Intimidation
- D. Physical abuse
Correct Answer: A
Rationale: The correct answer is A: Threats. Threats are considered abusive conduct in the context of workplace bullying. Nurses may be subjected to threats that create a hostile work environment. Threats can instill fear and distress in the victim, affecting their well-being and performance.
Summary of why other choices are incorrect:
B: Humiliation - While humiliation is a form of abuse, the question specifically asks about abusive conduct in the context of workplace bullying for nurses.
C: Intimidation - Intimidation is another form of abusive behavior, but the question focuses on identifying abusive conduct in the workplace environment for nurses.
D: Physical abuse - While physical abuse is a serious issue, the question pertains to identifying abusive conduct within the professional environment for nurses, where physical abuse may not be as common as other forms of bullying behavior.
A nurse preceptor is assigned to help several graduate nurses assess their ability to convey warmth to patients. Which activity, if selected by the nurse preceptor, is best?
- A. Set up sessions for the graduate nurses to practice various nonverbal gestures.
- B. Ask the graduate nurses to record the behaviors of experienced nurses on the unit.
- C. Provide the graduate nurses with a list of nonverbal behaviors that convey warmth.
- D. Have the graduate nurses evaluate each other during simulated patient interviews.
Correct Answer: A
Rationale: The correct answer is A because setting up sessions for the graduate nurses to practice various nonverbal gestures allows for active skill development. By practicing these gestures, they can receive immediate feedback from the preceptor and improve their ability to convey warmth effectively.
Choice B is incorrect because simply observing behaviors of experienced nurses may not actively engage the graduate nurses in practicing and developing their own skills.
Choice C is incorrect because providing a list of nonverbal behaviors may not be as effective as hands-on practice in improving the graduate nurses' ability to convey warmth.
Choice D is incorrect because having the graduate nurses evaluate each other during simulated interviews may not provide structured guidance and feedback from the preceptor to help them improve their nonverbal communication skills effectively.
The first-semester nursing student tells the team leader that her clinical assignment for the day is to take vital signs and obtain a client history that will take about 1 or 2 hours to complete. Which clients would the leader recommend that she approach to fulfill her assignment? (Select all that apply.)
- A. Mr. N (non-Hodgkin lymphoma)
- B. Mr. L (tracheostomy and partial laryngectomy)
- C. Mr. B (bladder cancer)
- D. Ms. C (bowel resection and colostomy)
Correct Answer: B
Rationale: The correct answer is B because Mr. L, who has a tracheostomy and partial laryngectomy, will likely require vital signs monitoring and a detailed client history due to his complex respiratory and communication needs. This assignment will provide the student with valuable experience in caring for clients with specialized needs.
Incorrect choices:
A: Mr. N (non-Hodgkin lymphoma) - While Mr. N may require vital signs monitoring, his condition does not necessarily involve complex care needs that would warrant a 1-2 hour history-taking session.
C: Mr. B (bladder cancer) - Vital signs monitoring and history-taking for a client with bladder cancer may not require as much time as the scenario suggests, as the care needs may not be as complex as those of a client with a tracheostomy and laryngectomy.
D: Ms. C (bowel resection and colostomy) - While Ms. C may require vital signs monitoring and history-taking
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