Which example best illustrates the principle of the nurse "knowing" the client? The nurse:
listens as the client describes the day she was diagnosed with breast cancer.
compliments the client when he correctly places an ostomy bag on his stoma.
provides a bed bath with a back rub to help the client relax.
maintains eye contact with the client throughout their conversation.
The Correct Answer is A
A. By actively listening, the nurse shows empathy and a willingness to understand the client's perspective. Understanding significant events like a cancer diagnosis can help the nurse better anticipate the client's emotional and psychological needs.
B. This action shows support and encouragement for the client's achievements in managing their condition. It demonstrates the nurse's awareness of the client's efforts and competence in self-care. While it is positive reinforcement and supportive, it focuses more on the client's physical abilities rather than a deeper understanding of their personal experiences or emotions.
C. This action shows attentiveness to the client's physical comfort and emotional well-being. Offering a back rub during a bed bath can be soothing and comforting, addressing both physical and emotional needs. It demonstrates a caring approach to providing care that considers the client's comfort and relaxation.
D. Eye contact is an important non-verbal communication skill that conveys attentiveness and respect. It helps establish a connection and rapport between the nurse and the client. While maintaining eye contact is important for effective communication and building trust, it alone does not necessarily illustrate knowing the client in terms of understanding their personal experiences or emotions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. A "thready" pulse is weak and difficult to palpate. It feels like a fine thread or string under the fingertips and suggests poor cardiac output or decreased peripheral perfusion. A thready pulse is palpable but weak, indicating inadequate stroke volume with each heartbeat.
A. Hypovolemic refers to a state of decreased blood volume, which can lead to a weak and rapid pulse due to reduced blood flow through the arteries. However, it does not specifically describe the quality of the pulse that is palpable.
B. Bradycardia refers to a slow heart rate, typically below 60 beats per minute in adults. A bradycardic pulse may be slow but can still be strong or weak depending on the underlying cause. It does not specifically describe the quality of a weak but palpable pulse.
C. "Deficient" is not a commonly used term to describe the quality of a pulse. It does not provide specific information about the palpable nature or strength of the pulse.
Correct Answer is B
Explanation
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
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