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:

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

Correct Answer: D

Rationale: The correct answer is D: uses short, simple sentences. This is the most appropriate approach because hearing-impaired patients may have difficulty processing complex information. Using short, simple sentences helps improve comprehension. Shouting repeatedly (choice A) can be distressing and ineffective. Speaking directly into the patient's ear (choice B) may be invasive and uncomfortable. Using long, complex sentences (choice C) can overwhelm the patient and lead to confusion. Therefore, option D is the best choice for effective communication with a hearing-impaired patient.

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.

Correct Answer: D

Rationale: The correct answer is D because actively listening to the patient's stories about her past experiences allows for emotional expression, validation, and building trust. It promotes therapeutic communication and helps the patient gain understanding and cope with her diagnosis. Choice A focuses on group support, which may not address the patient's individual needs. Choice B is not appropriate as it may induce unnecessary fear. Choice C assumes the patient has specific spiritual beliefs and may not be welcomed.

Correct Answer: B

Rationale: The correct answer is B: Planning. In the nursing process, planning is a crucial step where the nurse collaborates with the patient, family, and caregivers to develop a comprehensive care plan tailored to the patient's needs and specific disease process. This step involves setting goals, determining interventions, and creating a roadmap for the patient's care. Planning ensures that the care provided is individualized, evidence-based, and addresses the patient's unique circumstances. Evaluation (A) comes after planning to assess the effectiveness of interventions. Implementation (C) involves carrying out the planned interventions. Nursing diagnosis (D) is an earlier step where the nurse identifies the patient's health problems and needs. Planning stands out as the most important step as it guides the entire care process.