You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the floor.
What is your first step in the nursing process in this situation?
Leave the patient to get help.
Call the patient’s health-care provider from your cell phone.
Help the patient get up and then document your findings in the chart.
Gather more information by making observations about the patient.
The Correct Answer is D
The first step in the nursing process is assessment, which involves gathering information about the patient’s condition. In this situation, the nurse should make observations about the patient’s physical and mental status, including any signs of injury or distress. This information can then be used to determine the appropriate course of action and provide appropriate care. The other
The other options do not represent the first step in the nursing process and may not be appropriate in this situation.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
These techniques can help a nurse communicate effectively with a patient. Clarifying terms can help ensure that both the nurse and the patient understand each other and are on the same page.
Remaining silent can give the patient space to express themselves and can show that the nurse is actively listening.
Asking open-minded questions can encourage the patient to share their thoughts and feelings and can help the nurse beter understand the patient’s perspective.
Offering false reassurance and discouraging the person from expressing feelings that are unacceptable (e) are not effective communication techniques. False reassurance can undermine trust and discourage honest communication, while discouraging expression of feelings can prevent the patient from fully engaging in the therapeutic process.

Correct Answer is D
Explanation
In this situation, the nurse is recognizing that the woman is distressed and is showing empathy and understanding by offering her a private space to talk. This allows the woman to express herself freely without feeling judged or embarrassed in front of others. It also shows the nurse's respect for the woman's privacy and her cultural beliefs, which may include the need for modesty and privacy during emotional situations.
Option A is not culturally competent because it dismisses the woman's emotional state and implies that her behavior is abnormal.
Option B assumes that medication is the solution to the woman's emotional distress and does not address her cultural needs.
Option C is not culturally competent because it disregards the woman's feelings and emotions and implies that her reaction is inappropriate.
Overall, cultural competence is about being respectful and sensitive to the beliefs, values, and customs of individuals and communities from diverse backgrounds, and providing care that is tailored to their unique needs and preferences.

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