A patient is attracted to the nurse and attempts to initiate a social relationship. It is most appropriate for the nurse to take which action?

Correct Answer: C

Rationale: The correct answer is C because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.

Correct Answer: C

Rationale: The correct answer is C: The Patient's Bill of Rights. This document supports the client's right to access information about treatment options as it ensures that clients have the right to make informed decisions about their healthcare. The Patient's Bill of Rights outlines the rights and responsibilities of patients, including the right to receive information about their medical condition, treatment options, risks, and benefits. The other choices are incorrect because: A: The Standards of Clinical Practice provide guidelines for healthcare professionals and do not specifically address the client's right to access information. B: An Advance Health Care Directive is a legal document that specifies a person's wishes regarding medical treatment in the event they are unable to communicate, but it does not necessarily address the right to access treatment information. D: A Client's Living Will is a legal document that outlines a person's preferences for medical care in certain situations, but it does not specifically address the right to access information about treatment options.

Correct Answer: C

Rationale: The correct answer is C: "I am disappointed because you did not follow my directions." This statement is the most concrete and specifically explains the nurse's feelings of disappointment towards the nursing assistant for not reporting the fever as instructed. It directly addresses the issue at hand, which is the failure to follow directions, and conveys the nurse's emotions in a clear and concise manner. Choice A: "I am not dissatisfied with your performance, because we all make mistakes." This choice does not address the specific issue of the nursing assistant not following instructions, and it seems to downplay the importance of the mistake. Choice B: "You must have misunderstood. I wanted to know about any elevated temperatures." This choice shifts the blame to the nursing assistant for misunderstanding, rather than holding them accountable for not following instructions. Choice D: "You have made me so angry. Why did you not report the fever to me?" This choice focuses on the nurse's anger rather than disappointment, and it does not

Correct Answer: C

Rationale: The correct answer is C because it maintains professional boundaries, prioritizing the patient's well-being. By clearly stating that the relationship must remain professional, the nurse sets clear boundaries and avoids any potential ethical issues. Choice A is incorrect as it can lead to boundary violations and compromise patient care. Choice B is incorrect as it does not address the situation directly and may not be necessary if proper boundaries are set. Choice D is incorrect as transferring the patient may not address the underlying issue and is not a standard response to this situation.

Correct Answer: C

Rationale: The correct answer is C: Assess for McBurney sign. The McBurney sign is indicative of appendicitis and involves tenderness at McBurney's point in the right lower quadrant. This assessment is crucial for identifying possible appendicitis in a patient presenting with abdominal pain. Assessing for Cullen sign (A) involves bruising around the umbilicus and is associated with intra-abdominal bleeding, not appendicitis. Grey-Turner sign (B) refers to bruising on the flanks and is also indicative of intra-abdominal bleeding. Chvostek sign (D) is a clinical sign of facial muscle twitching and is associated with hypocalcemia. Therefore, assessing for McBurney sign is the most appropriate choice in this scenario to help diagnose appendicitis.

Correct Answer: B

Rationale: The correct answer is B because Mr. U is experiencing significant pain related to cancer and pulmonary resection, which typically requires continuous pain management. Around-the-clock fixed doses of opioid analgesics provide consistent pain relief and can be adjusted based on his pain levels. This approach ensures adequate pain control without the need for Mr. U to wait until the pain becomes severe before asking for medication. Option A may lead to undertreatment of pain. Option C delays effective pain relief for Mr. U who is already experiencing significant pain. Option D is incorrect as opioids can be safely administered with proper monitoring, even in patients at high risk for respiratory distress.

Correct Answer: D

Rationale: The correct answer is D because it acknowledges the patient's emotions, shows empathy, and encourages open communication. By stating "You are upset. Can you tell me what's wrong?" the nurse validates the patient's feelings and invites her to express her concerns. This approach fosters trust and allows the nurse to address the underlying issues causing the patient's distress. Choice A is incorrect as it assumes the patient is in pain without confirmation and may come off as dismissive. Choice B is inappropriate as it lacks empathy and demands the patient to stop crying, which can further escalate the situation. Choice C is insensitive as it diminishes the patient's feelings by comparing her situation to a potential worse outcome, which is not helpful in addressing her emotional distress.

Correct Answer: B

Rationale: The correct answer is B because using high levels of intimacy with a client, especially in a professional setting like a long-term care center, can violate boundaries and be inappropriate. The nurse should maintain a professional and therapeutic relationship with the client. Reminiscing about birthday celebrations (A) can help establish rapport and show interest in the client's life. Sharing personal stories (C) can build trust and connection. Sharing a relevant experience about meditation (D) can provide valuable information and support. In summary, maintaining appropriate boundaries and professionalism is crucial in a nurse-client relationship.

Correct Answer: A

Rationale: The correct answer is A because it emphasizes essential components of effective communication: sensitivity, respect, and genuineness. Sensitivity helps in understanding others' emotions, respect fosters a positive relationship, and genuineness promotes trust. Choice B is too simplistic and lacks depth. Choice C is impractical as working as a staff nurse monthly may not be feasible for a manager. Choice D is incorrect as emotional intelligence and empathy are crucial for effective leadership, not being emotionless. Thus, choice A is the best response due to its focus on key communication principles.