The home care nurse visits a mother and her newborn 2 days after discharge from the hospital. The mother states, "My baby cries all the time. I must not be a very good mother.= Which response by the nurse is nontherapeutic?

Correct Answer: C

Rationale: The correct answer is C because it dismisses the mother's feelings and suggests a temporary distraction instead of addressing her concerns. Choice A validates the mother's feelings and promotes open communication. Choice B demonstrates empathy and physical support. Choice D encourages the mother to express her emotions further for better understanding. Overall, choice C is nontherapeutic as it does not address the underlying issue of the mother's feelings of inadequacy and instead offers a superficial solution.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates a proactive approach to ensuring the client receives adequate pain relief. By waiting until the medication change occurs and then monitoring the client's response, the healthcare provider can assess the effectiveness of the new medication and make any necessary adjustments promptly. This approach prioritizes the client's well-being by addressing their pain management needs in a timely and thorough manner. Choices B, C, and D are not as effective as they do not involve actively monitoring the client's response to the medication change, which is crucial in ensuring optimal pain relief for the client.

Correct Answer: B

Rationale: The correct answer is B: Perform a needle thoracotomy with a 14- to 16-gauge catheter needle. Rationale: 1. Tension pneumothorax is a life-threatening emergency where air accumulates in the pleural space, causing lung collapse and increased pressure in the chest. 2. The standard treatment for tension pneumothorax is needle thoracostomy, which involves inserting a large-bore needle into the chest to release the trapped air. 3. In this scenario, Mr. U is in respiratory distress despite receiving high-flow oxygen, indicating a significant problem with ventilation that requires immediate intervention. 4. Performing a needle thoracotomy will rapidly decompress the tension pneumothorax, relieving pressure on the heart and lungs, and improving respiratory function. 5. This action takes precedence over other options such as removing the occlusive dressing, initiating CPR, or calling for intubation equipment, as immediate decompression is crucial in managing tension pneumoth

Correct Answer: A

Rationale: The correct answer is A: assess the language capabilities of the patient. This is crucial to ensure effective communication and understanding. By assessing language capabilities, the nurse can tailor communication strategies appropriately. Option B is helpful but not as essential as language assessment. Option C is incorrect as the interview duration should be based on patient needs, not a set time limit. Option D is relevant, but assessing comprehension abilities alone may not be sufficient if language barriers exist.

Correct Answer: B

Rationale: The correct answer is B because it promotes mutual respect and collaboration in the nurse-client relationship. By involving the client in decision-making about self-care, the nurse empowers the client to take ownership of their health and fosters a sense of partnership. This approach enhances the client's autonomy and self-efficacy, leading to better adherence to the diabetes management plan. Choice A is incorrect as it implies a power dynamic where the nurse controls the relationship, which can hinder trust and collaboration. Choice C is incorrect because while expert knowledge is valuable, it does not necessarily build mutuality unless shared in a collaborative manner. Choice D is incorrect as solving problems for the client may undermine their ability to develop problem-solving skills and independence in managing their condition.

Correct Answer: D

Rationale: The correct answer is D because developing a plan of care and measurable objectives with the patient promotes patient-centered care, encourages collaboration, and ensures the patient's active involvement in their own care. This approach respects the patient's autonomy and preferences, fosters shared decision-making, and enhances treatment adherence. A: Demonstrating human caring by hugging the patient may not be appropriate as it can violate professional boundaries and personal space. B: Disclosing shared intimate details with other healthcare providers breaches patient confidentiality and violates privacy rights. C: Maintaining a physical distance of at least 3 to 4 feet at all times may be necessary for infection control but does not address the core aspect of involving the patient in their care plan.

Correct Answer: C

Rationale: The correct answer is C: obtaining feedback from the patient that indicates accurate comprehension. This is the best way to ensure effective communication because it directly involves the patient in the communication process, allowing for clarification if needed. By receiving feedback from the patient, the nurse can confirm whether the information has been understood correctly. This approach promotes active listening and engagement from the patient, enhancing the likelihood of accurate communication. Incorrect choices: A: Speaking slowly and clearly in the patient's native language may help, but it does not guarantee comprehension. B: Asking family members may not accurately reflect the patient's understanding and could lead to miscommunication. D: Checking for signs of hearing loss or aphasia is important, but it does not directly assess the patient's understanding of the communication.

Correct Answer: C

Rationale: The correct answer is C. This response provides constructive feedback by suggesting a specific action for improvement. Here's a step-by-step rationale: 1. Option A is incorrect because it is negative and does not offer guidance for improvement. 2. Option B is incorrect because it is judgmental and may be discouraging to the student nurse. 3. Option D is incorrect because it is vague and lacks specificity on how to change behavior. 4. Option C is the best choice as it offers a positive solution by providing guidance on how to improve through observation and learning from the nurse's warmth towards patients.

Correct Answer: C

Rationale: The correct answer is C because it dismisses the mother's feelings and suggests a temporary distraction instead of addressing her concerns. Choice A validates the mother's feelings and promotes open communication. Choice B demonstrates empathy and physical support. Choice D encourages the mother to express her emotions further for better understanding. Overall, choice C is nontherapeutic as it does not address the underlying issue of the mother's feelings of inadequacy and instead offers a superficial solution.