A nurse is teaching a newly licensed nurse about the benefits of atraumatic care.
Which of the following statements by the newly licensed nurse indicates that the teaching was effective?
Atraumatic care reduces client and caregiver stress, fear, and anxiety.
Atraumatic care removes control from the client and caregivers, thereby reducing stress.
Atraumatic care reduces anxiety while enabling faster healing.
Atraumatic care minimizes the time nurses need to spend with the client and caregivers.
Correct Answer : A,C
Choice A rationale
Atraumatic care focuses on minimizing physical and psychological distress for both the client and their caregivers. By employing strategies such as therapeutic play, age-appropriate explanations, and parental involvement, it reduces fear, anxiety, and stress responses, which can negatively impact physiological outcomes and coping mechanisms. This approach promotes a sense of security and control.
Choice B rationale
Atraumatic care aims to *enhance* client and caregiver control, not remove it. Empowering clients and families by providing information, involving them in decision-making, and respecting their preferences is a core principle. This approach fosters a sense of partnership and autonomy, which inherently reduces feelings of helplessness and stress, improving overall well-being.
Choice C rationale
By minimizing emotional and physical distress, atraumatic care helps to reduce the physiological stress response, including the release of cortisol and catecholamines. This reduction in stress mediators can improve immune function and reduce inflammation, thereby promoting a more conducive environment for healing and recovery, leading to potentially faster resolution of illness or injury.
Choice D rationale
Atraumatic care often requires *more* time initially from nurses to establish rapport, provide thorough explanations, engage in therapeutic play, and involve families in care. While it can lead to improved long-term outcomes and potentially fewer complications, its immediate implementation involves an investment of time to ensure comfort and understanding, not a reduction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Calling in additional staff from home involves complex decision-making regarding staffing needs, skill mix, and regulatory requirements, which falls outside the scope of practice for unlicensed assistive personnel. This task requires a registered nurse's clinical judgment and professional accountability to ensure appropriate patient care staffing levels.
Choice B rationale
Assisting medics with inter-facility transport involves patient assessment, monitoring, and potentially administering medications or interventions during transit. These activities require specialized training, licensure, and clinical judgment possessed by paramedics or registered nurses, not within the UAP's scope of practice.
Choice C rationale
Updating vital signs is a fundamental skill within the UAP's scope of practice, as it involves routine data collection and documentation. Recognizing and reporting changes in vital signs to the charge nurse aligns with the UAP's role in assisting with patient monitoring and contributing to the nursing assessment process.
Choice D rationale
Disclosing patient information to family members, even in an emergency, requires adherence to patient confidentiality regulations (e.g., HIPAA) and the nurse's clinical judgment to accurately convey complex medical information. This is a responsibility of a licensed nurse, not a UAP, to ensure ethical and legal compliance.
Correct Answer is C
Explanation
Choice A rationale
While obtaining a magnesium level is important for monitoring therapeutic range (typically 4-7 mEq/L), the client's current signs of respiratory depression (8/min) and absent deep tendon reflexes indicate severe magnesium toxicity, a life-threatening emergency. Immediate intervention is required to prevent respiratory arrest and cardiac complications.
Choice B rationale
Administering calcium gluconate is the antidote for magnesium sulfate toxicity because calcium ions competitively antagonize the effects of magnesium at the neuromuscular junction, reversing respiratory depression and cardiac effects. However, the priority action is to stop the causative agent first before administering the antidote.
Choice C rationale
Stopping the magnesium sulfate infusion is the most immediate and critical action to prevent further escalation of magnesium toxicity. The respiratory rate of 8/min is indicative of significant respiratory depression, a severe complication. Halting the infusion prevents additional magnesium from entering the bloodstream, allowing the body to excrete the excess.
Choice D rationale
Taking the client's blood pressure is part of a complete assessment; however, it is not the most immediate priority when the client is exhibiting severe signs of respiratory depression and absent deep tendon reflexes. These signs suggest impending respiratory arrest, which requires immediate intervention to preserve life.
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