The nurse cares for a patient who becomes confused and a vest restraint is applied. The nurse should take which action when notifying the patient's family?

Correct Answer: B

Rationale: The correct answer is B because having another nurse who has a good relationship with the family present can help facilitate effective communication and address any concerns or questions the family may have. This approach can help build trust and provide emotional support during a potentially difficult situation. A: Avoiding discussing the treatment plan can lead to confusion and distrust. C: Using medical terms may confuse or intimidate the family and hinder effective communication. D: Assuming the family wants a detailed explanation may not be accurate and can result in information overload.

Correct Answer: A

Rationale: The correct answer is A because it acknowledges the cultural communication norms of Native American individuals, who may take longer pauses during conversations to reflect and respond thoughtfully. By waiting patiently through these pauses, the nurse shows respect for the individual's communication style and allows for effective dialogue. Option B is incorrect because maintaining constant eye contact may be perceived as confrontational or disrespectful in some Native American cultures. Option C is incorrect as it assumes the patient needs permission to speak, which may not align with their cultural norms. Option D is incorrect as it undermines the individual's autonomy and may not accurately represent their perspective.

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 because it is important to acknowledge and praise the student for taking responsibility for the mistake. By doing this, the team leader can encourage a culture of accountability and learning from errors. This approach supports the student's professional growth and self-awareness. Option A is incorrect because the immediate focus should be on addressing the emotional response of the student and providing support rather than assigning blame. Option B is inappropriate as it could undermine the student's confidence and discourage future initiative. Option D is premature as it prioritizes paperwork over supporting the student's learning and emotional well-being.

Correct Answer: A

Rationale: The correct answer is A because documenting the frequency of assessments and interventions for high-risk patients, such as those at risk for falls, is crucial for patient safety and care coordination. By documenting more frequently for high-risk patients, nurses can ensure timely interventions and prevent adverse events. This practice aligns with the principles of patient-centered care and risk management. Choices B, C, and D are incorrect: B: Avoiding labels in documentation is important for professionalism and ethical practice, but it is not directly related to the frequency of documentation for high-risk patients. C: Detailed and specific documentation is required for all patients to ensure comprehensive care, not just for potential malpractice suits. D: While clear and concise documentation is essential, this choice does not specifically address the need for more frequent documentation for high-risk patients.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and respect for the client's autonomy. By stating "I care about you even if you are not following your dietary restrictions," the nurse acknowledges the client's choice while still showing concern for their well-being. This response fosters a supportive and non-judgmental relationship with the client. Choices A, B, and D are incorrect because they either show indifference, use coercion, or imply a comparison between patients based on their dietary choices. These responses do not prioritize the client's feelings, choices, or autonomy, which is essential in providing patient-centered care.

Correct Answer: A

Rationale: Step 1: Understanding the patient's need for information and level of understanding is crucial to providing appropriate care. Step 2: Clear directions are necessary to guide patients, just like clear information is needed to guide their healthcare decisions. Step 3: Assessing the patient's need for information helps tailor education to their level of understanding. Step 4: This choice directly aligns with the analogy of providing clear directions for patients on their healthcare journey. Summary: Choice A is correct as it emphasizes the importance of assessing the patient's need for information and understanding, which is essential for guiding them effectively. Choices B, C, and D are incorrect as they do not directly address the patient's need for information and understanding in the analogy provided.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates a judgmental tone towards the patient's actions. The nurse is passing a negative judgment on the patient by stating that eating chili with jalapenos was not a smart decision considering the ulcer. This response can make the patient feel guilty or ashamed, hindering effective communication. Choice A shows frustration and blame towards the patient, which can lead to a defensive response. Choice C is directive and lacks empathy, focusing solely on the medical aspect without considering the patient's feelings. Choice D dismisses the patient's concerns and minimizes the impact of the action, which can be perceived as condescending. In summary, choice B is the correct answer as it highlights the importance of maintaining a non-judgmental and supportive attitude in patient communication.

Correct Answer: D

Rationale: The correct answer is D: High risk for aspiration because of secretions and removal of epiglottis. This is the priority concern for Mr. L due to the risk of food or liquid entering the airway, leading to aspiration pneumonia and respiratory distress. The tracheostomy and partial laryngectomy compromise the airway protection mechanism, increasing the risk of aspiration. Options A and B are not the priority as infection and poor nutrition can be managed after addressing the risk of aspiration. Option C, while important for communication, is not as immediately life-threatening as the risk of aspiration.