A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day.
The nurse interrupts the bath and obtains a healthy meal for the client.
This action by the nurse is an example of which of the following?
Countertransference.
Promoting trust.
Boundary crossing.
Veracity.
The Correct Answer is B
Choice A rationale: Countertransference is not the appropriate concept in this scenario. Countertransference refers to the nurse's emotional response to the client, which may be based on the nurse's unresolved issues and can negatively affect the therapeutic relationship. In this case, the nurse's actions are not driven by unresolved issues but by a desire to meet the client's basic needs.
Choice B rationale: Promoting trust is the most suitable explanation for the nurse's actions. By interrupting the bath and providing a healthy meal to a newly admitted client who hasn't eaten all day, the nurse is demonstrating empathy, compassion, and a commitment to meeting the client's physiological needs. This action helps build trust between the nurse and the client, as the client can see that their well-being is a priority.
Choice C rationale: Boundary crossing refers to actions that may blur or violate professional boundaries between a nurse and a client. While the nurse is going beyond the routine bath to provide a meal, this action is justified by the client's immediate need and doesn't constitute an inappropriate boundary crossing. The nurse is still maintaining professionalism in caring for the client.
Choice D rationale: Veracity is the principle of truth-telling and honesty in healthcare. It doesn't directly apply to this situation since the nurse's actions are not about providing information or disclosing something to the client. Instead, the nurse's primary concern is the client's nutritional well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. "We need to check the client's urine output every hour."
Choice A rationale:
Monitoring urine output every hour is crucial for assessing kidney function and ensuring the urostomy is functioning properly, especially in the immediate postoperative period.
Choice B rationale:
A pale stoma is not an expected finding. A healthy stoma should be pink to red. A pale stoma could indicate inadequate blood supply and needs immediate evaluation.
Choice C rationale:
While some blood or small clots in the urine might be expected shortly after surgery, this is not a standard instruction to give. Any significant or persistent bleeding should be reported and assessed promptly.
Choice D rationale:
Restricting fluid intake is generally not recommended after surgery unless specifically ordered. Adequate hydration is important for recovery and maintaining urinary output.
Correct Answer is D
Explanation
Choice A rationale:
The nurse should not recommend placing the diaper over the strap of the Pavlik harness. Placing the diaper over the strap can cause discomfort and may interfere with the proper function of the harness, which is designed to maintain hip joint alignment in infants with developmental hip dysplasia.
Choice B rationale:
The Pavlik harness is typically worn continuously, including during sleep. It should not be removed for sleeping each night because consistent use is essential for its effectiveness in promoting hip joint development.
Choice C rationale:
Applying lotion under the straps of the harness is not recommended. Lotions or creams can create friction and moisture, which may lead to skin irritation or discomfort for the infant. It's best to follow the healthcare provider's instructions regarding the care and maintenance of the harness.
Choice D rationale:
The correct choice is D. The nurse should include the statement that "The harness can promote hip joint development" in the teaching. This is because the Pavlik harness is used to treat developmental hip dysplasia by maintaining the hip joint in a stable position, allowing for proper development. It is important for parents to understand the purpose and benefits of the harness in order to ensure compliance and effectiveness of the treatment.
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