Therapeutics Chapter 3
The nurse cares for a patient with urinary incontinence after a stroke. Which response by the nurse is best? A. "You seem upset about this. We can work together on a bladder retraining program." B. "I don't mind cleaning up your mess. I am used to it because my child does this at night." C. "Don't be embarrassed. A lot of patients have this problem after a stroke." D. "I will bring you some diapers to wear instead of having you wet the bed all the time."
ANS: A The nurse must consider the client's self-esteem and preserve the client's dignity. Clients want to preserve or manage their image of self or "face." How the nurse handles a situation can influence the client's willingness to problem-solve.
The nurse cares for a client with hypertension, and a nurse-client contract is developed outlining the activities and responsibilities of each. Which would be appropriate to include in this contract? (Select all that apply) A. The outcomes should be realistic and measurable. B. Progress should be reviewed at regular intervals. C. The contract should be written and signed. D. The nurse should keep the information confidential. E. The nurse and client should mutually evaluate progress.
ANS: A, B, E The contract should be realistic and spell out measurable behaviors. The nurse and client should mutually evaluate outcome achievement at regular intervals. The contract may be either verbal or written. The nurse should not promise to keep information confidential; nurses must share information that is important to the well-being of the client or others (e.g., plans to harm self or others).
The home health nurse visits a client with heart failure who has increased dyspnea and peripheral edema and weight gain. The nurse suspects the client is not restricting fluids as prescribed. Which action by the nurse is most appropriate? A. Teach the client about the consequences of not following the fluid restrictions. B. Ask the client to report the amount of fluid intake for the past 24 hours. C. Provide the client with sugarless candy or gum to decrease the thirst sensation. D. Consult with the healthcare provider about increasing the dose of the diuretic.
ANS: B Client validation of the assessment data leads to mutual problem solving with the nurse. Incorporating validation keeps nurses focused on the rights and obligations of clients to make their own decisions about their health. Validation means consciously seeking out the client's opinions and feelings, unearthing questions or concerns related to plans for their healthcare, and securing an understanding and willingness to proceed to the next step. Incorporating validation into problem solving ensures that the nurse obtains complete agreement and commitment from the client about the nursing care plan.
The nurse cares for an adult client diagnosed with type 1 diabetes mellitus. Which is essential in building mutuality in the nurse-client relationship? A. The nurse controls the relationship by retaining the power to make judgments about diabetes education. B. The nurse teaches diabetes management by involving the client in making decisions about self care. C. The nurse has expert knowledge of diabetes and formulates appropriate learning outcomes for the client. D. The nurse demonstrates trust and respect by solving problems for the client when issues occur with self-management.
ANS: B Mutuality is an essential element in building relationships with the client and is characterized by empathy, collaboration, equality, and interdependency. Mutuality is a sharing of collective knowledge and decision making.
The nurse makes a home visit to a client with chronic kidney disease. The client asks the nurse to make the decision about whether or not to start dialysis. Which action by the nurse is most appropriate? A. Encourage the client to appoint a durable power of attorney. B. Invite the client to make a decision after reviewing options. C. Direct the client to have the physician make a decision. D. Have the client visit with an individual receiving dialysis.
ANS: B Nurses should encourage clients to be active, responsible partners in their care; the nurse encourages a mutual problem-solving process by inviting or requesting the full participation of clients. A durable power of attorney can be authorized to make healthcare decisions if clients are no longer able to speak for themselves. Having the physician make decisions for the client places the client in a passive role. The client may visit with another person receiving dialysis, but the decision should be made by the client.
Which describes characteristics of mutuality in the nurse-client relationship? (Select all that apply) A. Dependency B. Collaboration C. Paternalism D. Acceptance of differences E. Empathy
ANS: B, D, E Mutuality is characterized by empathy, collaboration, and equality (i.e., acceptance of differences). Mutuality is characterized by interdependency, not dependency. Paternalism is the practice of managing or governing other individuals; shared decision making is a characteristic of mutuality.
According to the ANA's Standards of Clinical Nursing Practice, there are several steps within the nursing process that surround patient care. However, one of the most important steps is the one in which the nurse partners with the patient, family, and other caregivers to create an acceptable path that meets the patient's needs and is specific to the disease process. This important step is identified as: A. Evaluation B. Planning C. Implementation D. Nursing diagnosis
ANS: BThe standards set forth in Standards of Clinical Nursing Practice by the American Nurses Association (2010)—assessment, diagnosis, outcome identification, planning, implementation, and evaluation—provide support for a mutual problem-solving approach with clients. During planning, the registered nurse develops an individualized plan in partnership with the person, family, and others considering the person's characteristics (2010, p. 36).
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
ANS: C The Patient's Bill of Rights (presented by the American Hospital Association) describes the expectations for respect, knowledge, privacy and confidentiality, and access to any information essential for adequate treatment. The Standards of Clinical Practice (by the American Nurses Association) provide standards for quality of care, diagnosis, outcomeidentification, planning, implementation, and evaluation. A Client's Living Will is a document that identifies healthcare preferences (related to care intended to sustain life) if the client is incapacitated. An Advance Health Care Directive is a legal document that indicates a client's wishes about healthcare.
The nurse cares for a patient who is scheduled for abdominal surgery. Which action, if taken by the nurse, is most appropriate? A. Mandate the use of a complementary therapy such as guided imagery. B. Administer opioids for pain rated more than 3 (on a 0 to 10 pain scale). C. Ask the patient about expectations for postoperative pain management. D. Provide pain management based on a standardized nursing care plan.
ANS: C The nurse in collaboration with the patient should set priorities and determine expected and desired outcomes related to management of pain after surgery. Interventions to manage postoperative pain should be discussed with the patient. The patient and nurse should collaborate and determine appropriate pain management interventions. In addition, the pain management interventions should be individualized for each patient.
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.
ANS: C The nurse should exhibit polite behaviors when interacting with patients who are fearful, embarrassed, or angry. Polite behaviors lessen the threat of intimate or invasive nursing actions (e.g., questions about behavior, physical assessment, and treatments). Active listening is an example of polite behavior. When discussing a potentially embarrassing situation, the nurse should be careful about the language used and ask questions gently. Nurses may tactfully encourage the patient's participation in decision making and problem solving. Nurses should avoid a direct order (e.g., joining a support group) because it is considered impolite and inappropriate.
The nurse discusses smoking cessation with a client. Which action, if taken by the nurse, would most likely result in a behavior change? A. The nurse should advise the client to contact the national telephone quitline. B. The nurse should recommend nicotine replacement and behavioral interventions. C. The nurse should collaborate with the client to develop an individualized plan of action. D. The nurse should implement a strategy that has been validated by research.
ANS: C The nurse should include validation in the nursing process; validation and collaboration with the client increase the probability of a successful change in behavior (e.g., smoking cessation). Specific interventions that are evidence based are appropriate, but the nurse should include the client in the nursing process or the problem-solving process.