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Which assessment finding is the most critical and needs to be addressed first?
- A. Mr. U has tracheal deviation after a pulmonary resection.
- B. Mr. B, with bladder cancer, has decreased urinary output.
- C. Mr. N, with non-Hodgkin lymphoma, is having dysrhythmias.
- D. Ms. C has severe abdominal pain after a bowel resection.
Correct Answer: A
Rationale: The correct answer is A because tracheal deviation after a pulmonary resection indicates a life-threatening condition like tension pneumothorax. This condition requires immediate intervention to prevent respiratory distress and potential cardiovascular collapse. Tracheal deviation is a red flag sign that signals a medical emergency. Options B, C, and D are important but not as urgent as tracheal deviation. Decreased urinary output in a bladder cancer patient could indicate renal dysfunction, dysrhythmias in a patient with non-Hodgkin lymphoma may need further evaluation, and severe abdominal pain post-bowel resection could signal complications but are not as immediately life-threatening as tracheal deviation.
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The nursing supervisor instructs a group of novice nurses about the appropriate use of self-disclosure with patients. The nursing supervisor determines that teaching was successful if the novice nurse makes which statement?
- A. "Self-disclosure provides an opportunity for the patient to understand the nurse."
- B. "It is better to disclose stories about others to maintain professional boundaries."
- C. "Self-disclosure may be used to build a trusting relationship with the patient."
- D. "A fabricated personal experience can be shared if the patient remains the main focus."
Correct Answer: C
Rationale: The correct answer is C. Self-disclosure can be used to build a trusting relationship with the patient. This is because sharing personal information appropriately can help create a connection and foster trust between the nurse and the patient. By being open and genuine, nurses can demonstrate empathy and understanding, leading to better communication and rapport.
Choice A is incorrect because while self-disclosure can help the patient understand the nurse, the primary goal is to build a therapeutic relationship. Choice B is incorrect because disclosing stories about others does not promote genuine connection and may not be relevant to the patient's care. Choice D is incorrect because fabricating personal experiences goes against the principles of honesty and authenticity in therapeutic communication.
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 patient who has had a stroke is unable to speak clearly and has right sided hemiplegia. The nurse will design the approach to the assessment interview by:
- A. asking questions and explaining procedures to the patient's daughter.
- B. speaking slowly and giving the patient time to respond.
- C. telling the patient he will get all necessary information from the daughter.
- D. prompting the answers and finishing the sentences for the patient. Speaking slowly recognizes that the patient may process (if able) information more slowly.
Correct Answer: B
Rationale: The correct answer is B because speaking slowly and giving the patient time to respond allows the patient with speech difficulties due to the stroke to process information and formulate a response. Prompting or finishing sentences can hinder the patient's ability to communicate independently. Asking questions to the patient directly, rather than relying on a family member, ensures accurate information is obtained directly from the patient. Telling the patient that all information will come from the daughter undermines the patient's autonomy and may lead to incomplete or inaccurate information.
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.
A client has high blood pressure and needs to learn about a low-sodium diet. Which question if asked by the client would be an indirect request for information?
- A. "How should I prepare food without adding salt?=
- B. "What will I do to make food taste better?=
- C. "What diet changes are needed to control my blood pressure?=
- D. "What foods should I avoid that are high in sodium?=
Correct Answer: B
Rationale: The correct answer is B because the client is indirectly asking for information on how to make food taste better without explicitly mentioning the need for low-sodium options. By inquiring about making food taste better, the client is seeking alternative ways to enhance flavor without salt, which aligns with the goal of following a low-sodium diet. Choices A, C, and D are more direct in addressing specific aspects of a low-sodium diet, such as food preparation without salt, dietary changes for blood pressure control, and identifying high-sodium foods to avoid, respectively.