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When the nurse observes a resident in a long-term facility pounding his fists on his legs and grinding his teeth, the nurse will validate her perception of the patient's nonverbal expression of anger by:
- A. documenting that the patient was agitated and appeared angry.
- B. asking the male nursing assistant if it is his perception that the patient appears angry.
- C. accessing the nursing care plan to ascertain if there is a nursing diagnosis relative to anger.
- D. sitting down near the patient and saying, "You seem upset…can I help?" All perceptions based on the observation of nonverbal behavior should be validated by consulting the patient.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates active listening and empathy towards the patient's nonverbal cues. By sitting down near the patient and acknowledging his emotions, the nurse opens up a channel for communication and offers support. This approach allows the patient to express his feelings and needs, leading to better understanding and potential resolution of the underlying issue.
Other choices are incorrect because:
A: Simply documenting the observation does not address the patient's emotional state or provide any opportunity for direct communication.
B: Asking another staff member for their perception does not involve the patient directly and may not accurately reflect the patient's emotions.
C: Referring to the care plan does not involve the patient in the process and may not address the immediate emotional needs expressed through nonverbal behavior.
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The nurse cares for a client who has several options for cancer treatment. Which document supports the client's right to have access to information about treatment options?
- A. The Standards of Clinical Practice
- B. An Advance Health Care Directive
- C. The Patient's Bill of Rights
- D. A Client's Living Will
Correct Answer: C
Rationale: The correct answer is C: The Patient's Bill of Rights. This document supports the client's right to access information about treatment options as it ensures that clients have the right to make informed decisions about their healthcare. The Patient's Bill of Rights outlines the rights and responsibilities of patients, including the right to receive information about their medical condition, treatment options, risks, and benefits.
The other choices are incorrect because:
A: The Standards of Clinical Practice provide guidelines for healthcare professionals and do not specifically address the client's right to access information.
B: An Advance Health Care Directive is a legal document that specifies a person's wishes regarding medical treatment in the event they are unable to communicate, but it does not necessarily address the right to access treatment information.
D: A Client's Living Will is a legal document that outlines a person's preferences for medical care in certain situations, but it does not specifically address the right to access information about treatment options.
The nurse cares for an elderly patient in a long-term care center. Which would be inappropriate for the nurse to share with the client?
- A. Reminisce about birthday celebrations and inquire about the client's traditions.
- B. Use high levels of intimacy to help the client feel more comfortable with the nurse.
- C. Establish a helping relationship based on trust by sharing a personal story with the client.
- D. Share with the client how meditation decreased nausea during chemotherapy treatment.
Correct Answer: B
Rationale: The correct answer is B because using high levels of intimacy with a client, especially in a professional setting like a long-term care center, can violate boundaries and be inappropriate. The nurse should maintain a professional and therapeutic relationship with the client. Reminiscing about birthday celebrations (A) can help establish rapport and show interest in the client's life. Sharing personal stories (C) can build trust and connection. Sharing a relevant experience about meditation (D) can provide valuable information and support. In summary, maintaining appropriate boundaries and professionalism is crucial in a nurse-client relationship.
Which patient would most likely be uncomfortable with close personal space during an interaction with the nurse?
- A. A 19-year-old white female patient who is standing 2 feet in front of the nurse.
- B. A 40-year-old African-American male patient who is sitting next to the nurse.
- C. A 60-year-old Latin-American female patient who is seated across from the nurse.
- D. An 82-year-old patient from France who is lying in bed with the nurse sitting next to the bed.
Correct Answer: A
Rationale: The correct answer is A because cultural background and individual preferences influence personal space comfort. In this case, the 19-year-old white female patient standing only 2 feet away may feel uncomfortable with close personal space. Different cultures and age groups have varying norms regarding personal space. The other choices are less likely to be uncomfortable based on cultural norms and distance from the nurse. The 40-year-old African-American male patient sitting next to the nurse, the 60-year-old Latin-American female patient seated across, and the 82-year-old patient from France lying in bed with the nurse sitting next to them are all at a comfortable distance, thus less likely to be uncomfortable with personal space.
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.
The nurse cares for a client with hypertension, and a nurse3client contract is developed outlining the activities and responsibilities of each. Which would be appropriate to include in this contract? (Select all that apply)
- A. The outcomes should be realistic and measurable.
- B. Progress should be reviewed at regular intervals.
- C. The contract should be written and signed.
- D. The nurse should keep the information confidential.
Correct Answer: A
Rationale: The correct answer is A because setting realistic and measurable outcomes helps track progress and ensure treatment effectiveness. This promotes accountability and motivation for both the nurse and client. Choice B is incorrect because it is a general practice and not specific to the contract. Choice C is incorrect as the contract doesn't necessarily have to be written and signed, although it is recommended. Choice D is incorrect as confidentiality is a standard practice and not specific to the contract's content.