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which assessment will the nurse perform?
- A. Assess for Cullen sign
- B. Assess for grey-turner sign
- C. Assess for McBurney sign
- D. Assess for Chvostek sign
Correct Answer: C
Rationale: The correct answer is C: Assess for McBurney sign. The McBurney sign is indicative of appendicitis and involves tenderness at McBurney's point in the right lower quadrant. This assessment is crucial for identifying possible appendicitis in a patient presenting with abdominal pain. Assessing for Cullen sign (A) involves bruising around the umbilicus and is associated with intra-abdominal bleeding, not appendicitis. Grey-Turner sign (B) refers to bruising on the flanks and is also indicative of intra-abdominal bleeding. Chvostek sign (D) is a clinical sign of facial muscle twitching and is associated with hypocalcemia. Therefore, assessing for McBurney sign is the most appropriate choice in this scenario to help diagnose appendicitis.
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When using the telephone to communicate with a primary care provider about a patient, the student nurse should have ready: (Select all that apply.)
- A. current information relative to patient's condition change.
- B. assessment of vital signs.
- C. information on urinary output.
- D. patient's social security number or hospital identification number.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Current information on patient's condition change is crucial for effective communication with the primary care provider.
2. This allows the student nurse to provide accurate and up-to-date information for appropriate decision-making.
3. Assessment of vital signs or information on urinary output may be important, but the question specifically focuses on communication about the patient's condition change.
4. Patient's social security number or hospital identification number is not necessary for communicating about the patient's condition change.
In summary, choice A is correct as it ensures accurate communication, while the other choices are not directly related to communicating patient's condition change.
The characteristic that is representative of the nurse-patient relationship is that this relationship:
- A. focuses on the nurse's ability to build rapport.
- B. continues after discharge.
- C. does not include humor.
- D. focuses on the assessed patient health problems.
Correct Answer: D
Rationale: The correct answer is D because the nurse-patient relationship primarily focuses on addressing the assessed health problems of the patient. This relationship is centered around providing care, support, and assistance related to the patient's health needs. Building rapport (A) is important, but not the primary focus. The relationship does not necessarily continue after discharge (B) as it depends on the circumstances. Humor (C) can be included in the relationship but is not a defining characteristic. Thus, D is the correct choice as it aligns with the fundamental purpose of the nurse-patient relationship.
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.
According to a study by Robinson (2014), three parts of our true presence (how we connect with patients) are found in being:
- A. Friendly, kind, and sweet
- B. Genuine, gifted, and creative
- C. Humorous, partial, and grateful
- D. Genuine, attentive, and immersed
Correct Answer: D
Rationale: The correct answer is D because being genuine shows sincerity and authenticity in interactions with patients. Attentiveness implies active listening and focus on the patient's needs, fostering a strong connection. Immersion signifies being fully engaged and present during patient interactions, enhancing the quality of care provided. In contrast, choices A, B, and C lack the essential components of active listening, authenticity, and full engagement, making them incorrect. Being friendly, kind, and sweet (choice A) may not necessarily reflect genuine presence. Similarly, being humorous, partial, and grateful (choice C) or genuine, gifted, and creative (choice B) do not fully capture the core elements of true presence as outlined in the study by Robinson (2014).
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.