The nurse is performing a well-child assessment on a 15-month-old child. The child's mother and father are present. Which action by the nurse will best determine the health beliefs and values of the parents?

Correct Answer: C

Rationale: Rationale: C is the correct answer because actively listening to the parents talk about their lives and health concerns allows the nurse to understand their perspectives, beliefs, and values. This helps build rapport and trust, providing insight into how they approach healthcare for their child. A: The Myers-Briggs Type Indicator survey is not relevant to understanding health beliefs and values. B: Reading documented health histories may provide medical information but does not necessarily reveal beliefs and values. D: Reviewing traditional health practices may be informative but does not directly assess the parents' personal beliefs and values.

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: 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: 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: A

Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety. Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding. Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding. Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.

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.

Correct Answer: B

Rationale: The correct answer is B: Maintaining belief, being with, doing for, and enabling. Swanson's theory of caring includes these four processes along with "knowing." Maintaining belief refers to having faith in the patient's ability to get through the situation. Being with involves being present and showing emotional support. Doing for means providing physical care and assistance. Enabling focuses on empowering the patient to make decisions and take control of their health. Choice A is incorrect because it includes communication, assertiveness, and responsibility, which are not part of Swanson's caring processes. Choice C is incorrect as it includes understanding, action, information, and comfort, which do not align with Swanson's theory. Choice D is incorrect because it includes supporting, which is not one of the caring processes identified by Swanson.

Correct Answer: D

Rationale: The correct answer is D because the nurse-patient relationship primarily focuses on addressing the assessed health problems of the patient. This relationship is centered around providing care, support, and assistance related to the patient's health needs. Building rapport (A) is important, but not the primary focus. The relationship does not necessarily continue after discharge (B) as it depends on the circumstances. Humor (C) can be included in the relationship but is not a defining characteristic. Thus, D is the correct choice as it aligns with the fundamental purpose of the nurse-patient relationship.

Correct Answer: B

Rationale: The correct answer is B because a nurse should communicate with empathy when dealing with a patient who is anxious about a change in body image after a mastectomy. Empathy allows the nurse to connect emotionally with the patient, show understanding, and provide support. In this situation, the patient needs compassionate communication to feel heard and cared for. Choices A, C, and D are incorrect because empathy is not necessary in those scenarios. For choice A, the acquaintance seeking a superficial social relationship does not require empathetic communication. For choice C, the supervisor seeking approval and recognition would benefit more from professional feedback and recognition of achievements. For choice D, the colleague expecting a promotion needs clear communication and feedback but not necessarily empathy.