The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a “Do not disturb” sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient’s care attempting to enter the room. Which response by the nurse is most appropriate?
Scold the surgeon for not obeying the sign and respecting the patient’s wishes.
Firmly explain that the patient does not wish to have visitors at this time.
Allow the surgeon to enter.
Call for security to remove the surgeon.
The Correct Answer is B
Choice A reason: Scolding the surgeon is unprofessional and escalates the situation unnecessarily. It fails to respect the colleague’s role while disregarding therapeutic communication. A firm, respectful explanation upholds the patient’s wishes without confrontation, making this an inappropriate response that could harm professional relationships.
Choice B reason: Firmly explaining that the patient does not wish to have visitors respects the patient’s autonomy and the agreed-upon “Do not disturb” sign. This response is professional, assertive, and protects the patient’s need for rest, reducing agitation while maintaining collegiality, making it the most appropriate action.
Choice C reason: Allowing the surgeon to enter disregards the patient’s expressed need for privacy and the “Do not disturb” sign. This undermines trust and exacerbates the patient’s agitation, contradicting the nurse’s role as an advocate. This action fails to prioritize the patient’s well-being, making it incorrect.
Choice D reason: Calling security is an extreme measure, inappropriate for a non-threatening situation. It escalates a manageable interaction and risks damaging professional relationships. A firm explanation is sufficient to enforce the patient’s wishes, making this an overreactive and unnecessary response to the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The ego defense model, rooted in psychoanalytic theory, describes psychological mechanisms (e.g., denial) to cope with stress, not a normal line of defense for health. It focuses on mental protection, not holistic wellness, making it unrelated to the nursing theory described with a line of defense.
Choice B reason: The immunity model is not a recognized nursing theory. While immunity relates to biological defense, it does not encompass a “normal line of defense” for person, family, or community health. This choice is incorrect, as it lacks the holistic framework described in the question.
Choice C reason: Pender’s Health Promotion Model focuses on behaviors to enhance health but does not use the concept of a normal line of defense. It emphasizes individual motivation and barriers, not systemic protection against stressors, making it an incorrect match for the described nursing theory.
Choice D reason: The Neuman Systems Model views individuals, families, or communities as systems with a normal line of defense, a protective barrier against stressors. This holistic theory emphasizes maintaining stability through primary, secondary, and tertiary prevention, aligning with the described concept, making it the correct theory.
Correct Answer is D
Explanation
Choice A reason: Caring touch involves physical contact to convey empathy, like holding a hand. The nurse leaves the room without touching the patient or family, overwhelmed by grief. This action does not involve physical contact or comfort, making it unrelated to caring touch in this scenario.
Choice B reason: Therapeutic touch is a healing technique using energy fields, not applicable here. The nurse’s departure due to emotional overwhelm does not involve physical or energetic interaction with the family or patient, focusing instead on self-preservation, making this an incorrect type of touch.
Choice C reason: Task-oriented touch involves physical contact for procedures, like taking a pulse. The nurse’s action of leaving the room is not task-related or physical. It reflects an emotional response to grief, not a clinical task, making this an incorrect description of the nurse’s behavior.
Choice D reason: Protective touch describes actions to shield oneself or others from emotional distress, like withdrawing from overwhelming situations. The nurse, overwhelmed by the family’s grief, leaves the room to cope, demonstrating protective touch by prioritizing emotional self-preservation, making this the correct description.
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