Ch. 8 PrepU

A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue with the interview.

A client is diagnosed with diabetes. The client's adult child offers to serve as an interpreter, because the client does not speak the dominant language. Which is the best action for the nurse to take?

Contact a professional interpreter.

Which nurse would most likely be the best communicator?

A nurse who easily develops a rapport with clients

The nurse is caring for a client who is a victim of sexual assault. Which action would the nurse take to develop a trusting rapport with the client?

Approach the client with empathy and understanding and allow the client to share feelings without being judged.

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

Orientation phase

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:

eliminate as many distractions as possible.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head.

In which situation would the SBAR technique of communication be most appropriate?

A nurse is calling a physician to report a client's new onset of chest pain.

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic?

"Have you ever thought of laser surgery?"

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

"What day of the week is it?"

The nurse observing an interaction between a mother and daughter appropriately identifies the interaction as which communication zone?

Intimate

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response?

Place a chair next to the bed and encourage the parent to hold the client's hand.

The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities?

The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needleless syringe.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.

A nurse touches the client's hand while discussing the client's diagnosis. This action is:

a communication channel.

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:

allow the client to set the pace.

The nurse communicates with a newly admitted client. Which nonverbal behavior will the nurse note?

client's gestures

The nurse is caring for a postoperative client who refuses a blood transfusion due to religious beliefs. The nurse is demonstrating trustworthiness when taking which action in response to the client's treatment wishes?

contacting the interprofessional care team to discuss alternative treatment options

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the client to explain the statement.

When the preoperative client tells the nurse that the client cannot sleep because the client keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is:

"The thought of having surgery is keeping you awake."

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?

The working phase

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse that the client is afraid of waking up during surgery. The best response by the nurse is to:

ask why the client thinks the client will wake up during surgery.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.