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 B
Explanation
The correct answer is: B. Determine the acuity and number of casualties arriving at the facility.
Choice A rationale: Assisting in discharging stable clients to home is important but not the primary focus during the immediate response to a mass casualty event.
Choice B rationale: Determining the acuity and number of casualties arriving at the facility is crucial in a mass casualty event. This involves assessing the severity of injuries and prioritizing care based on urgency, ensuring that the most critical patients receive immediate attention.
Choice C rationale: Delegating tasks to emergency health care specialists is typically the responsibility of team leaders or incident command staff, not the medical-surgical unit nurses.
Choice D rationale: Providing informational updates to members of the media is generally managed by hospital administration or public relations staff, not by medical-surgical nurses.
Correct Answer is D
Explanation
Choice A rationale:
Tape the tube to the child's cheek. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.
Choice B rationale:
Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.
Choice C rationale:
Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.
Choice D rationale:
Apply a skin barrier protectant to the site. Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.
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