Nokea
Which situation denotes a nontherapeutic nurse-patient-family relationship?
- A. The nurse is planning to read a favorite fairy tale to a patient
- B. During shift report, the nurse is criticizing parents for not visiting their child
- C. The nurse is discussing with a fellow nurse the emotional draw to a certain patient
- D. The nurse is working with a family to find ways to decrease the family's dependence on health care providers
Correct Answer: B
Rationale: Criticizing parents or making negative comments about their involvement is nontherapeutic and can damage the nurse-patient-family relationship.
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The nurse is caring for an adolescent who is overweight. Which of the following psychological effects of being overweight during adolescence will the nurse consider when planning care for the adolescent?
- A. Poor body image
- B. Sexual promiscuity
- C. Feelings of contempt for thin peers
- D. Lack of independence
Correct Answer: A
Rationale: Adolescents who are overweight often struggle with poor body image, which can lead to low self-esteem and mental health issues. Addressing body image concerns and promoting healthy lifestyle changes are important aspects of care. Choices B, C, and D are incorrect. Sexual promiscuity is not a direct psychological effect of being overweight; feelings of contempt for thin peers are not a common or recommended psychological response; lack of independence is a broad term that does not specifically relate to the psychological effects of being overweight.
At what stage can infants raise their heads and gain control of their trunks before walking due to which directional pattern of development?
- A. Cephalocaudal
- B. Anterior to posterior
- C. Proximodistal
- D. Normal growth curve charts
Correct Answer: A
Rationale: The correct answer is A: Cephalocaudal. The cephalocaudal pattern of development means that growth and motor control proceed from the head downward through the body. This explains why infants can raise their heads before they can sit and gain control of their trunks before walking. Choices B, C, and D are incorrect. Anterior to posterior refers to development from the front to the back, while proximodistal refers to development from the center of the body outward. Normal growth curve charts are used to track physical growth over time and are not directly related to the directional pattern of development in infants.
A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, "I want to go back to work, but I don't want Eric to suffer because I'll have less time with him." Which is the nurse's most appropriate answer?
- A. "I'm sure he'll be fine if you get a good babysitter."
- B. "You will need to stay home until Eric starts school."
- C. "Let's talk about the childcare options that will be best for Eric."
- D. "You should go back to work so Eric will get used to being with others."
Correct Answer: C
Rationale: The best approach is to discuss childcare options that would suit Eric's needs, allowing the mother to make an informed decision without guilt or pressure.
Which disease would require strict isolation of the patient?
- A. Mumps
- B. Chickenpox
- C. Exanthema subitum (roseola)
- D. Erythema infectiosum (fifth disease)
Correct Answer: B
Rationale: The correct answer is B: Chickenpox. Chickenpox is highly infectious and is transmitted through direct contact, droplet spread, and contaminated objects. Due to its high communicability, strict isolation of the patient is necessary to prevent the spread of the disease. Mumps is primarily transmitted through direct contact with the infected person's saliva, with peak contagiousness before the onset of swelling. Exanthema subitum (roseola) has an unknown transmission source. Erythema infectiosum (fifth disease) is contagious before the appearance of symptoms. Therefore, these diseases do not require the same level of strict isolation as chickenpox.
Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)
- A. All below
- B. Considering alternative actions
- C. Using formal and informal thinking to gather data
- D. Giving deliberate thought to a patient's problem
Correct Answer: A
Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.