Nokea
Which assessment finding for Mr. L (tracheostomy and partial laryngectomy) would be of greatest concern?
- A. Pulsation of the tracheostomy tube in synchrony with the heartbeat
- B. Increased secretions in and around the tracheostomy
- C. Increased coughing, with difficulty in expectorating secretions
- D. Presence of food particles in tracheal secretions
Correct Answer: A
Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety.
Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding.
Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding.
Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.
You may also like to solve these questions
A nurse manager offers a staff nurse a choice between working 8- or 12-hour shifts. Which statement, if made by the staff nurse, is nonassertive and may result in a frustrated response from the nurse manager?
- A. "I want to decide the shifts for all of the other staff nurses."
- B. "Do whatever you want. It doesn't really matter to me."
- C. "Thank you for offering me a choice. I prefer 12-hour shifts."
- D. "You will never be able to give me what I really want to work."
Correct Answer: A
Rationale: The correct answer is A because it shows an attempt to control others' decisions, which is nonassertive and inappropriate in a professional setting. Assertiveness involves expressing one's own needs and preferences while respecting others' choices. Option A implies a desire for power over others' schedules, leading to potential conflict and frustration. In contrast, options B and D show indifference and negativity, respectively, without clearly stating preferences. Option C is assertive and appreciative of the choice offered, clearly stating a preference for 12-hour shifts without imposing on others.
A nurse manager asks a colleague for advice on strategies to improve communication with staff nurses. Which response by the nurse manager's colleague is best?
- A. "Be sensitive, show respect, and be genuine."
- B. "You need to be consistently nice to the staff nurses."
- C. "Work as a staff nurse every month to develop empathy."
- D. "Staff nurses need a leader who is not emotional."
Correct Answer: A
Rationale: The correct answer is A because it emphasizes essential components of effective communication: sensitivity, respect, and genuineness. Sensitivity helps in understanding others' emotions, respect fosters a positive relationship, and genuineness promotes trust. Choice B is too simplistic and lacks depth. Choice C is impractical as working as a staff nurse monthly may not be feasible for a manager. Choice D is incorrect as emotional intelligence and empathy are crucial for effective leadership, not being emotionless. Thus, choice A is the best response due to its focus on key communication principles.
The charge nurse informs a staff nurse that it is her turn to float to another unit. Which response by the staff nurse is aggressive?
- A. "I had such a bad experience last time. Please send another nurse instead of me."
- B. "I will miss working with you today, but I understand that it is my turn to float."
- C. "I will not survive on the other unit. The staff are always too busy to help me."
- D. "I will float, but you'll be sorry. You cannot handle emergencies without me."
Correct Answer: C
Rationale: The correct answer is C because the response is aggressive and defensive. The staff nurse is making a negative and exaggerated statement about not surviving on the other unit, implying that others are incompetent and not willing to help. This response lacks professionalism and teamwork, showing an unwillingness to adapt and collaborate.
Choice A is not aggressive as it expresses a personal negative experience and suggests sending another nurse. Choice B is not aggressive as it acknowledges the situation and shows understanding. Choice D is assertive but not necessarily aggressive; it implies importance but does not attack or undermine others.
The nurse is caring for a client who is diagnosed with type 1 diabetes mellitus. Which nursing action would most likely improve client compliance with the therapeutic regimen?
- A. Consistently ignore negative statements made by the client.
- B. Avoid touching the client to reduce tension and uneasiness.
- C. Focus on the physical aspects of care such as insulin administration.
- D. Listen attentively to the client's perception of having a chronic illness.
Correct Answer: D
Rationale: The correct answer is D because listening attentively to the client's perception of having a chronic illness is crucial for building a therapeutic relationship and understanding their concerns, fears, and challenges. By actively listening, the nurse can address the client's emotional and psychological needs, which are essential in managing a chronic condition like type 1 diabetes. This approach fosters trust, enhances communication, and promotes client engagement in their treatment plan.
Choices A, B, and C are incorrect because ignoring negative statements, avoiding physical contact, and solely focusing on the physical aspects of care can lead to poor client-nurse communication, lack of trust, and ultimately hinder compliance with the therapeutic regimen. Ignoring negative statements may escalate resistance, avoiding physical contact may create distance, and solely focusing on physical care neglects the holistic needs of the client.
The nurse cares for a patient with urinary incontinence after a stroke. Which response by the nurse is best?
- A. "You seem upset about this. We can work together on a bladder retraining program."
- B. "I don't mind cleaning up your mess. I am used to it because my child does this at night."
- C. "Don't be embarrassed. A lot of patients have this problem after a stroke."
- D. "I will bring you some diapers to wear instead of having you wet the bed all the time."
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy, collaboration, and a patient-centered approach. By acknowledging the patient's feelings and offering to work together on a solution, the nurse shows respect and support. This response promotes patient dignity and autonomy.
Choice B is incorrect as it is unprofessional and may be perceived as insensitive. Choice C, while acknowledging the commonality of the issue, lacks a proactive approach to address the problem. Choice D does not promote independence or address the patient's emotional needs.