A nurse is caring for a terminally ill patient during the 2300 to 0700 shift.
The patient says, "I just can't go to sleep.
I keep thinking about what my family will do when I am gone.”. What response by the nurse would be most appropriate?

"I have talked with your wife and she told me she will be fine.”.

"Oh, don't worry about that now.

"Can I get you the sleeping pill your doctor prescribed, so that you can get some rest?".

"What seems to be concerning you the most?". .

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Telling the patient that their wife will be fine does not address the patient's concerns and may come across as dismissive. It does not encourage further communication about the patient's fears and worries.

Choice B rationale:

Dismissing the patient's concerns and instructing them to sleep does not address the underlying issue. It fails to acknowledge the patient's emotional distress and may make the patient feel unheard and unsupported.

Choice C rationale:

Offering medication without exploring the patient's concerns further does not address the root cause of the patient's anxiety. It is important to assess the patient's emotional state and concerns before resorting to medication.

Choice D rationale:

Asking the patient, "What seems to be concerning you the most?" demonstrates active listening and empathy. It encourages the patient to express their feelings and fears, allowing the nurse to provide appropriate emotional support and interventions. Open-ended questions like this facilitate therapeutic communication and help establish trust between the nurse and the patient.

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Correct Answer is ["C","D"]

Explanation

Choice A rationale:

Asking a patient if their neighbor can visit is not a violation of HIPAA policy as it does not involve sharing sensitive patient information.

Choice B rationale:

Using the facility computer to document patient care is appropriate and not a violation of HIPAA policy, assuming the nurse is following proper security protocols.

Choice C rationale:

Looking at a neighbor's chart to add them to a prayer list at church is a clear violation of HIPAA policy. This action breaches patient confidentiality and compromises their privacy, which is essential under HIPAA regulations.

Choice D rationale:

Failing to log off the computer charting system after documenting patient care is also a violation of HIPAA policy. This can lead to unauthorized access and potential misuse of patient information, putting patient privacy at risk.

Choice E rationale:

Discussing a patient with a coworker in a public place like an elevator violates HIPAA policy. Even though the conversation is with a colleague, it is essential to protect patient information in all circumstances to maintain confidentiality and trust.

A. Weight-bearing activities to stimulate joint relaxation. B. Exercises to strengthen flexor muscles. C. Range of motion exercises to prevent worsening of contractures. D. Frequent position changes to reverse the contractures.

Correct Answer is C

Explanation

Choice A rationale:

Weight-bearing activities are not suitable for a patient with contractures, as they may worsen joint stiffness and discomfort. Engaging in weight-bearing activities could lead to further limitations in joint mobility and exacerbate the contractures.

Choice B rationale:

Exercises to strengthen flexor muscles might be beneficial in other contexts, but for a patient with contractures, the focus should be on improving joint mobility and preventing the contractures from worsening. Strengthening exercises do not directly address the issue of limited joint mobility caused by contractures.

Choice C rationale:

Range of motion exercises are essential for patients with contractures. These exercises involve moving joints through their full range of motion to maintain or improve joint flexibility. Regularly performing range of motion exercises prevents further tightening of muscles and joints, thereby preventing the worsening of contractures.

Choice D rationale:

Frequent position changes are important to prevent pressure ulcers and maintain overall comfort, but they do not specifically address the issue of contractures. While position changes are necessary, they are not the primary intervention for managing contractures.

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A nurse is caring for a terminally ill patient during the 2300 to 0700 shift.The patient says, "I just can't go to sleep.I keep thinking about what my family will do when I am gone.”. What response by the nurse would be most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The director of nursing reprimands the nursing staff for which violations of HIPAA policy? Select all that apply.

Correct Answer is ["C","D"]

Explanation

The newly admitted patient has contractures of both lower extremities.What nursing intervention should be included in this patient's plan of care?

Correct Answer is C

Explanation

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A nurse is caring for a terminally ill patient during the 2300 to 0700 shift.
The patient says, "I just can't go to sleep.
I keep thinking about what my family will do when I am gone.”. What response by the nurse would be most appropriate?