The nurse instructs the nursing assistant to obtain temperatures on four patients and report abnormal findings immediately. Two hours later the nurse discovers that one of the patients had a fever that was not reported. The nurse is upset with the nursing assistant. Which statement, if made by the nurse, is concrete and specifically explains the nurse's feelings?

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: B

Rationale: The correct answer is B because leaning towards the client and making eye contact shows active listening and empathy. This helps the client feel heard and supported. Increasing physical distance (A) may create a barrier. Interrupting the client (C) can be perceived as disrespectful. Initiating a physical assessment (D) is inappropriate as it may seem insensitive and dismissive of the client's concerns.

Correct Answer: C

Rationale: The correct answer is C because it provides constructive feedback and offers a solution to the observed issue. By suggesting the student nurse to closely observe how the nurse displays warmth to patients, it encourages learning through modeling and self-reflection. This approach promotes a positive learning environment and emphasizes the importance of improving communication skills. Choice A is incorrect as it focuses on negative reinforcement and may lead to defensive reactions. Choice B is incorrect as it uses a confrontational approach, which can be demotivating and damaging to the student's self-esteem. Choice D is incorrect as it lacks specificity and guidance on how to improve, making it less effective in addressing the observed behavior.

Correct Answer: C

Rationale: Correct Answer: C - Develop a self-awareness of personal healthcare beliefs. Rationale: 1. Self-awareness is foundational to cultural competence. 2. Understanding one's own biases and beliefs is crucial in providing culturally sensitive care. 3. It helps the nurse recognize potential sources of bias and work towards overcoming them. 4. By knowing personal beliefs, the nurse can better understand and respect the beliefs of diverse clients. Summary of other choices: A: Adopting a transcultural framework is important but should come after self-awareness. B: While important, asking clients about their beliefs doesn't address the nurse's own biases. D: Recognizing ethnocentric beliefs is important but doesn't directly address the nurse's self-awareness.

Correct Answer: D

Rationale: The correct answer is D because listening attentively to the client's perception of having a chronic illness is crucial for building a therapeutic relationship and understanding their concerns, fears, and challenges. By actively listening, the nurse can address the client's emotional and psychological needs, which are essential in managing a chronic condition like type 1 diabetes. This approach fosters trust, enhances communication, and promotes client engagement in their treatment plan. Choices A, B, and C are incorrect because ignoring negative statements, avoiding physical contact, and solely focusing on the physical aspects of care can lead to poor client-nurse communication, lack of trust, and ultimately hinder compliance with the therapeutic regimen. Ignoring negative statements may escalate resistance, avoiding physical contact may create distance, and solely focusing on physical care neglects the holistic needs of the client.

Correct Answer: A

Rationale: The correct answer is A because it involves providing Ms. C with information and resources to help her understand and feel more comfortable with the colostomy care procedure. Verbally reexplaining the procedure and providing written material will empower her with knowledge and autonomy. Choice B undermines her independence and may not address her reluctance. Choice C promotes dependency rather than encouraging her to take ownership of her care. Choice D involves a hands-on approach that may not address her underlying concerns or fears about the procedure. Overall, choice A is the most appropriate initial step to support Ms. C in overcoming her reluctance.

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 because using a professional medical interpreter ensures accurate communication, maintains patient confidentiality, and upholds ethical standards. Step 1: Requesting a Spanish-speaking medical interpreter ensures clear understanding of the patient's health history. Step 2: Using a professional interpreter avoids potential misinterpretations that may arise from using untrained individuals. Step 3: Interviewing the patient's English-speaking daughter may lead to inaccuracies and breaches patient confidentiality. Step 4: Asking a bilingual friend of the patient to interpret lacks professionalism and may result in miscommunication.

Correct Answer: D

Rationale: The correct answer is D because asking the registered nurse to take the telephone order ensures accuracy and accountability. The registered nurse is trained to accurately transcribe orders and can verify the details with the primary care provider if needed. This also follows the chain of command and delegation principles in healthcare. Choice A is incorrect because the student nurse should not document the order directly without proper verification. Choice B is incorrect as having another student as a witness does not guarantee accuracy or proper documentation. Choice C is incorrect as recording the order could violate patient privacy laws and does not involve a healthcare professional in the transcription process.