The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:
a. Administer the FACT test.
b. Ask him to describe his first job.
c. Give him the Four Unrelated Words Test.
d. Ask him to describe what television show he was watching before coming to the clinic.
ANS: C
Ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person's ability to lay down new memories and is a highly sensitive and valid memory test.
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An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale
The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurse's best response? A) "Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes." B) "We need to provide pain medications because it is the law, and we must always follow the law." C) "Unless there is strong evidence to the contrary, we should take the patient's report at face value.'" D) "It's not unusual for patients to misreport pain to get our attention when we are busy."
While providing morning care, the nurse begins to talk with a client about attending church the previous evening. The client is quiet and does not respond to the nurse's dialogue. What should the nurse do in this situation?
a. Realize the conversation may be making the client uncomfortable and change the subject. b. Analyze the client's silences as possible spiritual distress. c. Ask the client if they usually go to church. d. Call the hospital chaplain because the client may need counseling.
While inserting a rectal thermometer, the nurse encounters resistance. What action should the nurse take?
a. Remove the thermometer immediately. b. Ask the patient to take a few deep breaths. c. Apply mild pressure to advance the ther-mometer. d. Remove the thermometer and reinsert gently.
A manager is educating a group of nurses on the importance of cultural competence. The manager knows that the teaching has been effective when one of the nurse's states:
a. "Cultural competence does not impact pa-tient care.". b. "Cultural competence is not important in health care.". c. "Lack of cultural competence leads to suboptimal patient outcomes.". d. "Lack of cultural competence does not cause active harm to the patient.".