Which action by the nurse demonstrates the concept of nurse autonomy?
The nurse braids the patient’s long hair to prevent tangles.
The nurse checks the policy manual before changing the central line dressing.
The nurse counts the patient’s pulse before administering digoxin.
The nurse directs the nursing assistant to obtain the patient's weight.
The Correct Answer is B
Choice A reason: This is an incorrect choice because the nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.
Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.
Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.
Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because sleep-wake pattern is not the most important assessment to determine if a patient is receiving sufficient sleep. Sleep-wake pattern is the cycle of sleeping and waking that follows a circadian rhythm. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep-wake patterns that suit their needs and preferences.
Choice B reason: This is an incorrect choice because hours of sleep each night is not the most important assessment to determine if a patient is receiving sufficient sleep. Hours of sleep each night is the duration of sleep that a person gets in a 24-hour period. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep needs and requirements that vary according to age, lifestyle, health, and other factors.
Choice C reason: This is the correct choice because whether the patient feels rested is the most important assessment to determine if a patient is receiving sufficient sleep. Feeling rested is the subjective perception of the patient about their sleep quality and quantity. It is a reliable indicator of sleep sufficiency, as it reflects the patient's satisfaction and well-being after sleeping.
Choice D reason: This is an incorrect choice because frequency of nocturia is not the most important assessment to determine if a patient is receiving sufficient sleep. Frequency of nocturia is the number of times that a person has to urinate at night. However, it is not a reliable indicator of sleep quality or quantity, as it may be influenced by other factors such as fluid intake, medication, or medical conditions.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because suggesting having warm milk with a shot of whisky before going to bed is not an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Warm milk may have some soothing effects on the patient, but adding whisky to it may counteract the benefits and worsen the insomnia. Alcohol is a depressant that can make the patient feel sleepy at first, but it can also disrupt the sleep cycle and cause frequent awakenings, nightmares, or hangovers.
Choice B reason: This is an incorrect choice because obtaining a prescription for zolpidem to be taken at bedtime is not an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Zolpidem is a hypnotic drug that can induce sleep and improve the sleep quality and quantity of the patient, but it can also have many side effects and interactions, and cause dependence, tolerance, or withdrawal. Zolpidem should be used only as a short-term treatment for insomnia, and only under the supervision of a physician.
Choice C reason: This is an incorrect choice because recommending the use of sleep aids such as triazolam is not an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Triazolam is a benzodiazepine drug that can enhance the activity of GABA, a neurotransmitter that inhibits brain activity and promotes sleep. However, it can also have many side effects and interactions, and cause dependence, tolerance, or withdrawal. Triazolam should be used only as a short-term treatment for insomnia, and only under the supervision of a physician.
Choice D reason: This is the correct choice because encouraging the patient to practice peaceful meditation before bedtime is an appropriate intervention to treat ongoing insomnia for a middle-aged adult with a busy career. Meditation is a relaxation technique that can reduce stress, anxiety, and negative emotions, and promote calmness, mindfulness, and well-being. Meditation can help the patient to fall asleep faster and sleep better, and it does not have any adverse effects or risks. The nurse should teach the patient how to meditate and encourage the patient to practice it regularly.
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