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Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.
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The nurse is teaching the parent of an infant client about common pediatric conditions. Which statement by the nurse about otitis media is correct?
- A. Otitis media usually occurs before your child experiences a primary bacterial infection.'
- B. Some causes of otitis media can be prevented by administering a vaccine to your child.'
- C. Ear infections are very contagious and can also spread within your child's body.'
- D. If your infant uses a pacifier, it can prevent the development of otitis media.'
Correct Answer: B
Rationale: Otitis media (OM), middle ear infection, is often bacterial (e.g., Streptococcus pneumoniae). The correct statement is B: vaccines like PCV13 prevent some causes by targeting pathogens. A is false; OM typically follows infections. C is wrong; OM isn't highly contagious or systemic. D is incorrect; pacifiers increase OM risk. Rationale: Vaccines reduce OM incidence by immunizing against common bacteria, a key preventive strategy per AAP guidelines, unlike the other statements which misrepresent etiology or prevention.
Myra said 'I saw my dead grandmother here at my bedside a while ago' Budek responded 'Really? That is hard to believe, How do you feel about it?' What technique did Budek used?
- A. Disproving
- B. Disagreeing
- C. Voicing Doubt
- D. Presenting Reality
Correct Answer: C
Rationale: Budek's 'Really? That is hard to believe uses voicing doubt (C), gently questioning Myra's perception (hallucination) while exploring feelings. Disproving (A) or disagreeing (B) outright rejects (e.g., 'That's not true'). Presenting reality (D) corrects (e.g., 'She's not here'). Voicing doubt, per schizophrenia care, balances reality-testing with empathy, making C correct.
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: B
Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion loosen mucus in cystic fibrosis, creating vibrations without pain, a key physiotherapy technique to clear airways. Heel strikes are harsh, frequent repositioning isn't routine, and post-meal percussion risks reflux. Nurses teach this method for effective secretion management, improving breathing and reducing infection risk in this chronic condition.
This is the best patient care model when there are many nurses but few patients.
- A. Functional nursing
- B. Team nursing
- C. Primary nursing
- D. Total patient care
Correct Answer: D
Rationale: Total patient care excels with many nurses and few patients, allowing each nurse to fully address one client's needs e.g., bathing, meds, education. Functional nursing assigns tasks (e.g., one nurse for vitals), team nursing divides labor, and primary nursing focuses continuity, but ample staffing makes total care ideal. For instance, a nurse can devote time to a single ICU patient, optimizing outcomes. This model leverages resources for intensive, individualized attention, enhancing care quality in such scenarios.