The patient has a terminal diagnosis and is very near death. When the nurse assesses the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient’s hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating?

Caring touch

Therapeutic touch

Task-oriented touch

Protective touch

Answer and Explanation

The Correct Answer is D

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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A reason: Respirations of 22 and heart rate of 66 suggest arousal or light sleep, not deep NREM sleep, which features slower, regular breathing (12-16 breaths/min) and lower heart rate. This indicates discomfort or instability, not comfortable sleep. Assuming this reflects NREM sleep risks overlooking signs of inadequate rest or stress in ICU patients.

Choice B reason: Mumbling to self indicates partial arousal or REM sleep, not NREM sleep, which is characterized by minimal movement and stable vitals. This suggests discomfort or neurological disturbance. Assuming NREM sleep misidentifies the sleep stage, potentially missing interventions to promote deeper, restorative sleep critical for ICU patient recovery.

Choice C reason: Tossing in bed with respirations of 18 and heart rate of 80 indicates restlessness or light sleep, not deep NREM sleep, which involves calm, slow vitals. This suggests discomfort or pain. Assuming NREM sleep risks neglecting interventions like pain management, critical for ensuring restorative sleep in ICU settings.

Choice D reason: Eyes closed, lying quietly, with respirations of 12 and heart rate of 60 indicate deep NREM sleep, characterized by slow, regular breathing and low heart rate, reflecting parasympathetic dominance. This confirms comfortable, restorative sleep, critical for healing in ICU patients, guiding nurses to maintain conditions supporting this optimal sleep state.

A. Choices: B. Cultural knowledge C. Cultural encounters D. Cultural skills E. Cultural desire F. Cultural transition

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

Explanation

Choice A reason: Cultural knowledge involves understanding diverse cultural beliefs, values, and practices, a core component of Campinha-Bacote’s model. This knowledge enables the nurse to provide informed, sensitive care, reducing misunderstandings and improving outcomes, making it a critical focus for achieving cultural competency.

Choice B reason: Cultural encounters involve direct interactions with diverse patients, fostering experiential learning and reducing stereotypes. In Campinha-Bacote’s model, these encounters build confidence in cross-cultural care, making it an essential area for the nurse to develop competency through real-world application.

Choice C reason: Cultural skills include the ability to assess and communicate effectively with diverse patients, a key element of Campinha-Bacote’s model. Skills like culturally sensitive interviewing ensure tailored care, making this a vital focus for the nurse to achieve competency in delivering equitable healthcare.

Choice D reason: Cultural desire reflects the nurse’s genuine motivation to engage in culturally competent care, a foundational aspect of Campinha-Bacote’s model. This intrinsic drive fuels learning and practice, making it a critical area for the nurse to cultivate to achieve and sustain cultural competency.

Choice E reason: Cultural transition is not part of Campinha-Bacote’s model, which includes knowledge, encounters, skills, desire, and awareness. This term is unrelated to the framework’s components, making it an incorrect focus for the nurse aiming to achieve cultural competency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?

Correct Answer is D

Explanation

A nurse is using Campinha-Bacote’s model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply)

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

Explanation

The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?

A nurse is called into the supervisor’s office regarding deteriorating work performance since the loss of a spouse 2 years ago. The nurse begins sobbing and says, “I’m falling apart at home as well.” Which type of grief is the nurse experiencing?

A severely depressed patient cannot state any positive attributes to life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. Which spiritual concept is the nurse trying to promote?

The patient is admitted with a diagnosis of chronic anxiety. Which action is most appropriate for the nurse to take when providing holistic care?

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient’s medical record?

The patient has a colostomy but has not yet been able to look at it. The nurse teaches the patient how to care for the colostomy. The nurse sits with the patient and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing?