What is NOT important for Myra to do when listening to tape recordings?

Correct Answer: C

Rationale: It is not important for Myra to listen to the tape recordings only when she feels motivated or productive. In a nurse-patient interaction relationship, listening to tape recordings promptly (Choice A) is crucial because it ensures that any important information or cues are not missed or forgotten. Additionally, noting voice tone and inflection (Choice B) and observing pauses (Choice D) are essential for understanding the nuances and emotions conveyed during the interaction, which can be crucial in effective communication. Listening based on motivation may lead to delays and hamper the timely analysis and understanding of the interactions. Hence, it is important for Myra to prioritize active and focused listening to the tape recordings, regardless of her current motivation levels.

Correct Answer: A

Rationale: In delegation, facilitating the professional growth and development of a staff is necessary because it allows team members to gain new skills and experience, leading to overall improved productivity and job satisfaction. This empowers staff and helps them feel more engaged in their work, ultimately benefiting the entire unit. Effective delegation should aim to support individuals in their roles, encourage learning, and build competence, rather than modifying standards of care or only delegating tasks without considering individual growth. Starting delegation from top management to staff-nurse level may not always be practical or efficient, as delegation should be based on competencies and responsibilities. Accountability is indeed a crucial aspect of delegation, as individuals should be held responsible for the tasks they are delegated. However, without providing opportunities for professional growth and development, delegation may not be as effective in achieving organizational goals.

Correct Answer: D

Rationale: In the situation described, where the client experienced a prolonged labor and instrumental delivery, there may be physical and emotional factors impacting breastfeeding success. A lactation consultant is a specialized healthcare provider who can assess the client's breastfeeding difficulties, offer individualized support, and provide guidance on techniques to overcome challenges such as latch issues, positioning problems, and milk supply concerns. Referring the client to a lactation consultant will help ensure that she receives expert assistance tailored to her specific needs, thereby increasing the likelihood of successful breastfeeding. This proactive approach focuses on addressing the root causes of breastfeeding difficulties and supporting the client in achieving her breastfeeding goals.

Correct Answer: D

Rationale: When determining the existence of malpractice, intent is not considered as a factor. Malpractice typically involves unintentional actions or negligence rather than a deliberate intent to cause harm. The key factors that are usually considered in a malpractice case include duty (a legal obligation to provide a certain standard of care), causation (the link between the provider's actions and the patient's injury), and the existence of an injury resulting from the provider's actions or omissions. Intent does not play a direct role in malpractice cases, as they are focused on the standard of care provided by the healthcare professional and the harm caused as a result.

Correct Answer: C

Rationale: If the nurse notices that the patient's arms are not adequately padded while positioning for surgery, the nurse should immediately take action to prevent pressure injuries. Applying soft padding to the patient's arms will help distribute the pressure more evenly, reducing the risk of skin breakdown and potential harm to the patient during the surgical procedure. It is essential to prioritize the patient's safety and comfort in such situations. Simply proceeding with the positioning as planned could lead to complications, so addressing the inadequate padding promptly is the appropriate course of action.

Correct Answer: C

Rationale: When a patient expresses concern about a medication looking different from what they had taken before, it is crucial for the nurse to verify the original prescription to ensure that the correct medication is being administered. Checking the original medication prescription will help the nurse confirm if there have been any changes or errors in the medication orders. This step is essential for patient safety and to prevent any potential medication errors. It is important to prioritize patient safety and well-being in such situations, and verifying the prescription is the appropriate action to take in this case.

Correct Answer: A

Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.

Correct Answer: B

Rationale: Digoxin is a medication commonly used in the treatment of congestive heart failure because it helps to improve cardiac output and reduce heart failure symptoms. One of the desired effects of digoxin is an increase in urinary output. This is because digoxin helps to improve cardiac function, which can lead to better circulation and increased kidney perfusion. As a result, the kidneys are better able to filter and excrete excess fluid, leading to increased urine output. Therefore, an increase in urinary output indicates that the digoxin is having a positive effect in managing the client's congestive heart failure. The other options, such as increased weight, improved appetite, and increased pedal edema, are not indicative of a desired effect of digoxin therapy.

Correct Answer: B

Rationale: The nurse's best approach to address non-compliance with prescribed medications and treatment plans is to actively listen to the patient's reasons for non-compliance. By acknowledging and addressing any barriers or concerns the patient may have, the nurse can work collaboratively with the patient to find effective solutions. This approach promotes open communication, trust, and a patient-centered care plan that takes into consideration the patient's individual needs and circumstances. Dismissing the patient's reasons (choice A), ignoring the non-compliance (choice C), or resorting to a confrontational approach (choice D) are less effective strategies that may lead to further resistance and hinder the patient's willingness to engage in their treatment.