A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

“You will not be able to eat breakfast until after you are washed.”.

“Please tell me what is worrying you at this time.”.

“I am going to wash you now and then you will take your medications.”.

“Why are you crying again? We haven’t touched you yet.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.

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

Explanation

Choice A rationale
Implementing ventilator-weaning protocols is a crucial intervention in the care plan for a patient on a ventilator to prevent ventilator-associated pneumonia. These protocols aim to minimize the patient’s exposure to mechanical ventilation, which is a significant risk factor for developing ventilator-associated pneumonia. By systematically reducing the level of ventilatory support, these protocols facilitate the earliest possible liberation from mechanical ventilation, thereby reducing the risk of ventilator-associated pneumonia.
Choice B rationale
Providing frequent oral care is another essential intervention in preventing ventilator- associated pneumonia. Oral health can quickly deteriorate in mechanically ventilated patients, leading to an increased risk of ventilator-associated pneumonia. Regular oral care, including the use of antiseptics, can help reduce the number of potential respiratory pathogens in the oral cavity and prevent their aspiration into the lower respiratory tract.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a standard intervention to prevent ventilator-associated pneumonia. Over-suctioning can lead to trauma and inflammation in the airway, potentially increasing the risk of infection. Suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.
Choice D rationale
Positioning the patient in a semi-upright position (30 to 45 degrees), rather than a prone position, is recommended to prevent ventilator-associated pneumonia. This position helps to reduce the risk of aspiration, which is a major risk factor for ventilator-associated pneumonia.
Choice E rationale
Avoiding suctioning the patient is not a recommended strategy for preventing ventilator- associated pneumonia. Suctioning is necessary to clear secretions from the airway, and its omission could potentially increase the risk of infection. However, as mentioned earlier, suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.

A. Ethical conflict. B. Scarcity, safety, and security. C. Competition between groups. D. Cultural differences.

Correct Answer is A

Explanation

Choice A rationale
This situation represents an ethical conflict. The nurse is faced with a dilemma where the children’s wishes for their parent to be a full code contradict the client’s expressed wish in their living will for Do Not Resuscitate (DNR)2. Ethical conflicts often arise in healthcare when there are differing opinions about the right course of action.
Choice B rationale
Scarcity, safety, and security are not the primary sources of conflict in this situation. While these factors can contribute to conflict in certain contexts, they do not directly apply to the ethical dilemma presented in this scenario.
Choice C rationale
Competition between groups is not evident in this situation. The conflict arises from differing views on the appropriate course of action for the client’s care, not from competition.
Choice D rationale
Cultural differences are not the main source of conflict in this scenario. The conflict arises from an ethical issue related to the client’s end-of-life care, not from cultural differences.

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A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of developing a care plan for a patient on a ventilator to prevent ventilator-associated pneumonia, which interventions should be included? Select all that apply.

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

Explanation

Correct Answer is A

Explanation

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