A nurse prepares to assess a new patient who moved to the United States from Central America 3 years ago. After introductions, what is the nurse's next comment?

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Question 1 of 5

A nurse prepares to assess a new patient who moved to the United States from Central America 3 years ago. After introductions, what is the nurse's next comment?

Correct Answer: D

Rationale: The correct next comment for the nurse is D: "Are you comfortable conversing in English, or would you prefer to have a translator present?" This is the best choice because it directly addresses the patient's language preference and ensures effective communication. By asking this question, the nurse demonstrates cultural sensitivity and respect for the patient's linguistic needs. It also shows a willingness to accommodate the patient's communication preferences, promoting trust and understanding in the healthcare setting. Choice A is incorrect as it focuses on the patient's journey to the U.S., which is unrelated to the immediate healthcare assessment. Choice B assumes the patient needs help from a family member without first assessing the patient's language proficiency. Choice C, while offering an interpreter, does not directly inquire about the patient's language preference, potentially overlooking the patient's comfort level with English.

Question 2 of 5

A patient is being treated for prostate cancer; his prognosis is very poor. The patient has a strong faith, and he has been active in his church for many years. He is concerned about his health and the challenges he faces as his cancer progresses. Which comment by the nurse reflects the most appropriate spiritual nursing intervention for the patient?

Correct Answer: D

Rationale: The correct answer is D, "We can pray together if you'd like." This is the most appropriate spiritual nursing intervention because it acknowledges and respects the patient's faith, offers emotional support, and fosters a connection between the nurse and the patient. It shows empathy and understanding of the patient's spiritual needs during a challenging time. Explanation for why the other choices are incorrect: A: Taking the patient to visit the nurse's church may not align with the patient's faith and may not be comfortable for the patient. B: Requiring the patient to belong to the same church as the nurse to go to heaven is imposing the nurse's beliefs on the patient, which is inappropriate. C: Offering guided imagery may be helpful for relaxation, but it does not directly address the patient's spiritual needs or provide the emotional support that praying together can offer.

Question 3 of 5

The nurse is determining the success of a patient's plan of care by evaluating outcome indicators. The nurse understands that these indicators are usually determined initially at which time?

Correct Answer: B

Rationale: The correct answer is B: During the assessment process. This is because outcome indicators are used to measure the effectiveness of the care plan and are typically established during the assessment phase to provide a baseline for comparison. By evaluating outcome indicators during the assessment process, the nurse can track progress, adjust interventions if needed, and ensure the patient's goals are being met. A: On the day of discharge - This is incorrect because outcome indicators are typically determined before discharge to assess the overall success of the care plan. C: At the initial interview - This is incorrect as outcome indicators are more closely related to the assessment process and ongoing evaluation. D: With goal-setting process - This is incorrect because while outcome indicators are used to measure goal achievement, they are typically determined during the assessment to establish a starting point.

Question 4 of 5

During a group session, one of the members states, 'Let's keep this discussion going so that everyone can participate, but let's keep the time each person speaks to about 3 minutes.' The leader interprets this member as acting in which role?

Correct Answer: B

Rationale: The correct answer is B: Gatekeeper. The member is facilitating the group by ensuring equal participation and time management. Gatekeepers help maintain communication flow and ensure everyone has a chance to speak. They focus on group dynamics and encourage participation without dominating the conversation. Group observer (A) mainly watches and records group interactions. Encouragers (C) provide support and positive feedback. Energizers (D) motivate and stimulate group energy but may not necessarily focus on time management.

Question 5 of 5

The nurse is preparing to care for a patient under severe stress resulting from caring for her elderly aunt diagnosed with leukemia. When assessing the patient's psychological domain, which question would the nurse ask first?

Correct Answer: A

Rationale: The correct answer is A because it encourages the patient to express their feelings without assuming or directing their response. This open-ended question allows the patient to share their emotional state freely, providing valuable insight into their psychological well-being. Choice B focuses specifically on depressed moods, which may limit the patient's response. Choice C is more focused on the patient's caregiving duration rather than their current emotional state. Choice D assumes the patient is feeling overwhelmed and may not capture the full range of emotions the patient is experiencing. Overall, choice A promotes effective communication and comprehensive assessment of the patient's psychological domain.

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