Foundations Exam 2 // CH 8

A registered nurse (RN) is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate for the RN to delegate to the LPN/LVN? Select all that apply. A. Reinforce a postsurgical abdominal dressing B. Insert a nasogastric tube in a client with absent bowel sounds C. Teach a client with diabetes how to administer insulin D. Administer oral aspirin and lisinopril to the client with hypertension E. Perform an initial assessment for a new admission

A. Reinforce a postsurgical abdominal dressing B. Insert a nasogastric tube in a client with absent bowel sounds D. Administer oral aspirin and lisinopril to the client with hypertension Administration of oral medication, insertion of nasogastric tubes, and dressing changes are all within the scope of practice for a LPN/LVN. Patient education and the performance of an initial assessment for a new admission would be outside of the scope of practice for the LPN/LVN and should not be delegated. The RN should make the initial assessment as well as provide education for the client.

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should: A. eliminate as many distractions as possible. B. ask all visitors to leave the room. C. ask the client if she is able to read. D. ask the client's partner to leave the room to allow the client to focus.

A. eliminate as many distractions as possible.

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: A. have group members confront the dominant member to promote the needed team work. B. pick a team leader who is not the dominant member. C. have group members issue a written warning to the dominant member. D. plan a meeting where the dominant person cannot attend.

A. have group members confront the dominant member to promote the needed team work

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse? A. A nurse posts pictures of a client who accomplished a goal of losing 100 lb and later deletes the photo. B. A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's. C. A nurse describes a client on Twitter by giving the client's diagnosis rather than the client's name. D. A nurse describes a client on Twitter by giving the room number rather than the name of the client.

B. A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech? A. Aggressive B. Assertive C. Therapeutic D. Nonassertive

B. Assertive

The nurse is using nonverbal communication when caring for a group of clients. Which situation reflects nonverbal communication? Select all that apply. A. The nurse documents on the SBAR form and sends it to the transferring unit. B. The nurse has a smile when being thanked for caring for a family member. C. The nurse gives a brochure to a client upon discharge. D. The nurse is maintaining eye contact when changing a client's dressing. E. The nurse is using a quiet tone of voice.

B. The nurse has a smile when being thanked for caring for a family member. E. The nurse is using a quiet tone of voice. D. The nurse is maintaining eye contact when changing a client's dressing.

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question? A. "All right, you have four children, is that correct?" B. "Were these term births?" C. "I understand you have four kids; how many times have you actually been pregnant?" D. "How old are your children?"

C. "I understand you have four kids; how many times have you actually been pregnant?"

A nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond? A. "Do you understand that everyone here has your spouse's best interest at heart?" B. "What would help you accept that this is best for both of you?" C. "This must be very difficult for you to hear. How do you feel right now?" D. "Why do you think that the care team has made this recommendation?"

C. "This must be very difficult for you to hear. How do you feel right now?"

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse? A. "Don't worry about labor, I have been through it and it is not so bad." B. "There are many good medications to decrease the pain; it will not be so bad." C. "You're worried about how you will tolerate the pain associated with labor." D. "I would recommend keeping a positive attitude."

C. "You're worried about how you will tolerate the pain associated with labor."

A nurse enters the client's room and states, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." The nurse then gives the client a printed card with this information. In the helping relationship, which phase does this represent? A. Intimate phase B. Working phase C. Orientation phase D. Termination phase

C. Orientation phase

The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurolgoical checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed? A. Situation B. Assessment C. Recommendation D. Background

C. Recommendation

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation? A. The client smiles at the nurse and states, "I cannot wait to go home." B. The client is sitting in a chair and states, "I feel a lot better than I did yesterday. C. The client stares at the floor and states, "I feel fine." D. The client looks at the nurse and states, "I am still not feeling my best."

C. The client stares at the floor and states, "I feel fine."

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: A. use only open-ended questions. B. ask questions as quickly as possible. C. allow the client to set the pace. D. tell the client to rest and allow a family member to answer.

C. allow the client to set the pace.

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should: A. show the child the intravenous catheter and explain how it works. B. ask the child's parents to leave the room while the nurse and child talk. C. involve the child's stuffed animal in the educational session. D. provide both verbal and written information to the child.

C. involve the child's stuffed animal in the educational session.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: A. Staring into the neonate's eyes and smiling. B. softly humming a song near the neonate. C. swaddling the child and gently stroking its head. D. offering the neonate infant formula.

C. swaddling the child and gently stroking its head.

A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic? A. "Why don't you try laser surgery?" B. "My grandfather also benefited from laser surgery." C. "You should try laser surgery." D. "Have you ever thought of laser surgery?"

D. "Have you ever thought of laser surgery?"

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client? A. "You may feel very uncomfortable when the needle goes in, but you should breathe rhythmically." B. "I will be by your side throughout the procedure; the procedure will be painless if you don't move." C. "The procedure may take only 2 minutes, so you might get through it by mentally counting up to 120." D. "The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

D. "The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

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? A. Use facial and hand gestures B. Contact a person skilled in sign language C. Provide paper and pencil for written communication D. Assess how the client would like to communicate

D. Assess how the client would like to communicate

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. A. The nurse communicates in a busy environment to hold the client's attention. B. If there is no response, the nurse does not repeat what is said and takes a break. C. The nurse gives lengthy explanations of the care that will be given. D. The nurse keeps communication simple and concrete. E. The nurse shows patience with the client and gives the client time to respond. F. The nurse maintains eye contact with the client.

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

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply. A. "Does it hurt when I touch you here?" B. "What sorts of things do you do for fun?" C. "Do you smoke cigarettes?" D. "What plans do you have after you are discharged?" E. "Are you ready to get out of bed?" F. "Is there any chance you might be pregnant?"

A. "Does it hurt when I touch you here?" C. "Do you smoke cigarettes?" E. "Are you ready to get out of bed?" F. "Is there any chance you might be pregnant?"

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? A. "I know this is hard for you. Is there any way I can help?" B. "I am so sorry you are going through this. Can we talk?" C. "Sitting in the dark is not going to cure your cancer. Let's open the curtains." " D. Can you please tell me why you are crying?"

A. "I know this is hard for you. Is there any way I can help?"

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information? A. "Did you take any medication when you had the pain?" B. "Could you tell me more about how you are feeling right now?" C. "Have you ever had chest pain prior to this admission?" D. "I have had chest pain before, and it is really scary!"

B. "Could you tell me more about how you are feeling right now?"

Which nurse would most likely be the best communicator? A. A nurse who is proficient in sign language B. A nurse who easily develops a rapport with clients C. A nurse who is bilingual D. An advanced practice nurse

B. A nurse who easily develops a rapport with clients

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using: A. audio-visual material. B. medical terminology. C. written material. D. demonstration.

B. medical terminology.

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: A. look directly at the client and state, "You are afraid of waking up during surgery." B. state "everyone is afraid of that." C. ask why the client thinks the client will wake up during surgery. D. ask the surgeon to come to the bedside to reassure the client.

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

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult: A. an ophthalmologist. B. an optometrist. C. a clinical psychologist. D. an audiologist.

D. an audiologist.

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: A. inform the client that several nurses will be needed to care for this wound. B. ask the charge nurse to change the assignment. C. tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound. D. tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

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

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established? A. Termination phase B. Evaluation phase C. Orientation phase D. Working phase

C. Orientation phase

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? A. "Is today the first day of the month?" B. "What day of the week is it?" C. "Is your name Evelyn?" D. "Are you in a hospital?"

B. "What day of the week is it?"

The nurse makes a contract with the client during which phase of the nurse-client relationship? A. Termination phase B. Intimate phase C. Orientation phase D. Working phase

C. Orientation phase

Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached? A. Empathy B. Commiseration C. Kindness D. Sympathy

A. Empathy

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication? A. "I think there is a better way to handle this." B. "You always act like this." C. "Why are you treating me this way?" D. "What is your problem with me?"

A. "I think there is a better way to handle this."

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation? A. Empathy B. Pity C. Sympathy D. Indifference

A. Empathy

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? A. The working phase B. The termination phase C. The orientation phase D. The introduction phase

A. The working phase

Which is a skill appropriate to use in therapeutic communication? A. void the use of periods of silence. B. Use cliches to enhance a client's understanding of information. C. Control the tone of the voice to avoid hidden messages. D. Be precise and inflexible regarding the intent of the conversation.

C. Control the tone of the voice to avoid hidden messages.