Nokea
Which describes characteristics of mutuality in the nurse3client relationship? (Select all that apply)
- A. Dependency
- B. Collaboration
- C. Paternalism
- D. Acceptance of differences
Correct Answer: B
Rationale: The correct answer is B: Collaboration. Mutuality in the nurse-client relationship involves working together as partners towards shared goals, with both parties contributing equally. Collaboration fosters empowerment, respect, and shared decision-making. Dependency (A) implies an unequal power dynamic, which is not characteristic of mutuality. Paternalism (C) involves a one-sided decision-making process, conflicting with the collaborative nature of mutuality. Acceptance of differences (D) is important but does not solely define mutuality. In summary, collaboration best reflects the principles of mutuality by emphasizing partnership, equality, and shared responsibility.
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When a patient states, "My son hasn't been to see me in months," the nurse's best verbal response is:
- A. "Don't worry; I'm sure your son will visit."
- B. "Your son hasn't been around much lately?"
- C. "My son doesn't come to visit me either."
- D. "How terrible that he doesn't visit you." Restating in different words what the patient said encourages further communication on that topic.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Reflective listening: Restating the patient's statement shows empathy and understanding.
2. Open-ended question: Encourages patient to share more without assumptions.
3. Non-judgmental: Neutral tone promotes trust and openness.
4. Validates patient's feelings: Acknowledges patient's concerns without dismissing them.
Summary:
A: Provides false reassurance, does not address the patient's feelings.
C: Shifts focus to the nurse, not patient-centered.
D: Implies judgment, may shut down communication.
Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?
- A. Carefully monitor the access site during the administration of the medication.
- B. Hold the medication until an implanted port or central line is established.
- C. Ensure that a chemotherapy-certified nurse is assigned to care for the client.
- D. Call the pharmacy to find out if the prescribed medication has vesicant properties.
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer, A:
1. Monitoring the access site during administration allows for early detection of extravasation.
2. Early detection can prevent serious tissue damage and complications.
3. As Mr. L has a tracheostomy and partial laryngectomy, his airway is compromised, making prevention of extravasation crucial.
4. This action is within the nurse's scope of practice and promotes patient safety.
Summary:
- Choice B is incorrect as delaying treatment can impact Mr. L's health.
- Choice C is not directly related to preventing extravasation.
- Choice D, though important, does not directly address preventing extravasation during administration.
The nurse cares for a client who is scheduled for a breast biopsy. Which is the main purpose of the client–nurse relationship?
- A. To develop a mutually satisfying experience for the client and nurse.
- B. To assist the client in achieving and maintaining optimal health.
- C. To provide excellent client service and improve quality of care.
- D. To allow the client to receive important health information.
Correct Answer: B
Rationale: The correct answer is B: To assist the client in achieving and maintaining optimal health. The main purpose of the client-nurse relationship is to promote the client's health and well-being. The nurse's role is to support the client in achieving their health goals and maintaining good health. This goes beyond just providing care during a specific procedure like a breast biopsy. Options A, C, and D are incorrect because while they may be components of the client-nurse relationship, they do not encompass the main purpose of promoting optimal health.
The nurse caring for a patient who is concerned about her 10-pound weight loss relative to her chemotherapy tells the patient, "Lucky you! Every cloud has a silver lining." The nurse's statement is an example of which type of communication block?
- A. Defensive response
- B. Asking probing questions
- C. Using clichés
- D. Changing the subject
Correct Answer: C
Rationale: The correct answer is C: Using clichés. The nurse's statement, "Lucky you! Every cloud has a silver lining," is a cliché that minimizes the patient's concerns about her weight loss and chemotherapy. Clichés are overused phrases that lack originality and can be dismissive or unhelpful in communication. In this case, the nurse's response does not address the patient's emotional or physical needs and fails to provide meaningful support.
Incorrect choices:
A: Defensive response - This choice involves reacting defensively to the patient's concerns, which is not demonstrated in the nurse's statement.
B: Asking probing questions - This choice involves seeking further information from the patient, which is not reflected in the nurse's cliché response.
D: Changing the subject - This choice involves diverting the conversation away from the patient's concerns, which is not explicitly done in the given scenario.
A Hispanic patient approaches the Asian nurse and, standing very close, touches the nurse's shoulder during their conversation. The nurse begins to step back to 18 to 24 inches, while smiling and nodding to the patient. This situation is most likely an example of:
- A. the nurse's need to maintain a professional role rather than a social role.
- B. a patient's attempt to keep the nurse's attention.
- C. a nurse's need to establish a more appropriate location for conversation.
- D. a difference in culturally learned personal space of the nurse and the patient.
Correct Answer: D
Rationale: The correct answer is D: a difference in culturally learned personal space of the nurse and the patient. This is because different cultures have varying norms regarding personal space. In this scenario, the Hispanic patient touching the Asian nurse's shoulder and standing very close suggests a cultural difference in personal space expectations. The nurse stepping back to establish a distance of 18 to 24 inches is a respectful response to accommodate the patient's cultural norm. It demonstrates cultural competence and understanding.
Explanation for why the other choices are incorrect:
A: the nurse's need to maintain a professional role rather than a social role - This choice does not address the cultural aspect of personal space and assumes the nurse's response is solely professional.
B: a patient's attempt to keep the nurse's attention - This choice does not consider the cultural factor influencing the patient's behavior.
C: a nurse's need to establish a more appropriate location for conversation - This choice does not acknowledge the cultural difference in personal space as the primary reason for the nurse