Nokea
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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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.
The nurse instructs the nursing assistant to obtain temperatures on four patients and report abnormal findings immediately. Two hours later the nurse discovers that one of the patients had a fever that was not reported. The nurse is upset with the nursing assistant. Which statement, if made by the nurse, is concrete and specifically explains the nurse's feelings?
- A. "I am not dissatisfied with your performance, because we all make mistakes."
- B. "You must have misunderstood. I wanted to know about any elevated temperatures."
- C. "I am disappointed because you did not follow my directions."
- D. "You have made me so angry. Why did you not report the fever to me?"
Correct Answer: C
Rationale: The correct answer is C: "I am disappointed because you did not follow my directions." This statement is the most concrete and specifically explains the nurse's feelings of disappointment towards the nursing assistant for not reporting the fever as instructed. It directly addresses the issue at hand, which is the failure to follow directions, and conveys the nurse's emotions in a clear and concise manner.
Choice A: "I am not dissatisfied with your performance, because we all make mistakes." This choice does not address the specific issue of the nursing assistant not following instructions, and it seems to downplay the importance of the mistake.
Choice B: "You must have misunderstood. I wanted to know about any elevated temperatures." This choice shifts the blame to the nursing assistant for misunderstanding, rather than holding them accountable for not following instructions.
Choice D: "You have made me so angry. Why did you not report the fever to me?" This choice focuses on the nurse's anger rather than disappointment, and it does not
The nurse chooses to use touch in the nurse-patient relationship because touch:
- A. can convey caring and support when words are difficult.
- B. should be avoided because of problems of cultural misinterpretation.
- C. is appropriate only in special circumstances, such as with young children.
- D. is a nursing intervention of choice in almost all situations.
Correct Answer: A
Rationale: The correct answer is A because touch can convey caring and support when words are difficult, enhancing the nurse-patient relationship. This is supported by research showing the positive impact of touch in providing comfort and building trust. Choice B is incorrect as cultural differences can be addressed through communication and understanding. Choice C is incorrect because touch can be appropriate in various situations beyond just young children. Choice D is incorrect as touch should be used judiciously based on individual preferences and boundaries.
There are 2 hours left before the shift ends. The new UAP tells the team leader that she must leave now because she has a family emergency. What should the team leader do? Select all that apply.
- A. Ask her what tasks and duties are pending for the next 2 hours.
- B. Call a UAP who is scheduled for the next shift to come early.
- C. Allow her to leave but remind her she is still on probation as a new staff member.
- D. Call another unit and see if there is a UAP who could float to the unit.
Correct Answer: A
Rationale: The correct answer is A. The team leader should ask the UAP what tasks and duties are pending for the next 2 hours to assess the workload and determine if it's possible for the UAP to leave immediately. By understanding the pending tasks, the team leader can make an informed decision on whether the UAP leaving will impact patient care or workload. This approach ensures that patient care is not compromised and that the team's responsibilities are managed effectively.
Choices B, C, and D are incorrect because they do not directly address the immediate situation of the UAP needing to leave due to a family emergency. Calling another UAP, reminding the UAP of probation status, or seeking assistance from another unit may not be necessary or relevant if the tasks can be managed effectively without the UAP who needs to leave. These options do not prioritize understanding the pending tasks and duties to make an informed decision.
The nurse cares for a young adult patient in the emergency room after a sexual assault. Which action by the nurse is appropriate?
- A. Avoid situations in which the patient will be involved with decision making.
- B. Tell the patient to join a local support group for sexual assault victims.
- C. Actively listen to the patient express feelings related to the sexual assault.
- D. Provide detailed information about evidence collection and invasive procedures.
Correct Answer: C
Rationale: The correct answer is C because actively listening to the patient express their feelings related to the sexual assault is essential for providing emotional support and validating their experience. This action shows empathy and helps the patient feel heard and supported. It also allows the nurse to assess the patient's emotional well-being and provide appropriate care.
Avoiding decision-making situations (A) may lead to further distress for the patient. While joining a support group (B) can be beneficial, it may not be appropriate or feasible immediately after a traumatic event. Providing detailed information about evidence collection (D) is important but should be done after addressing the patient's emotional needs.