Foundations of Professional Practice Exam #1

The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When is the most appropriate time to teach the client?

As the client is sitting quietly, reading a book

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

Which is a drawback to the type of documentation known as charting by exception?

Issues related to high-quality care should a negligence claim arise

Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers?

Observing a mother expressing the breast milk

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Submitting a written notice to all clients identifying the uses and disclosures of their health information

A nurse and the facility have been named as defendants in a malpractice lawsuit. In addition to the nurse's attorney, whom else would be appropriate for the nurse to talk with about the case?

The agency's risk manager

When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?

The client's tone of voice

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using:

medical terminology

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.

Nurses are occasionally asked to witness a testator's (person who makes the will) signing of a will. Which guideline is true regarding a nurse's role in witnessing a testator's signature?

Witnesses to a signature do not need to read the will.

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

a communication channel.

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:

aggressive.

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:

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

A client expresses worry about upcoming surgery. Which response by the nurse is a cliché?

"Don't worry, everything will be fine."

A nurse suspects that a client is a prostitute. The nurse documents this suspicion in the medical record and includes it in report to the oncoming shift. The nurse also mentions the suspicion to the nurse's sister saying, "I had a client named Susan in room 126 today who I think is a prostitute." Which violations has this nurse committed? Select all that apply.

-Libel -HIPAA -Slander

The nurse is preparing discharge teaching for a client with diabetes. Which information should the nurse include? Select all that apply.

-Meal planning -Community resources -Appropriate use of a glucometer -Instructions to follow up with the health care provider

A new mother asks the nurse in a pediatric office for information about safety, diet, and immunizations for the baby. What is the best response by the nurse to address the mother's readiness for enhanced coping?

"I have several pamphlets and online parenting videos that are helpful."

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy?

"Just take your time. I am listening."

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."

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

Which scenario is an example of certification?

A nurse who demonstrates advanced expertise in a content area of nursing through special

Which nurse would most likely be the best communicator?

A nurse who easily develops a rapport with clients

A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf?

A surrogate decision maker

A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?

A variance

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing?

Assault

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?

Assertive

The parents of an infant with apnea need to be educated on the apnea monitor and cardiopulmonary resuscitation. What should the nurse assess first regarding the parents?

Baseline knowledge of these concepts

When the newly diagnosed client with insulin-dependent diabetes reports never having received instruction on the administration of injections, an appropriately stated nursing diagnosis for the client is:

Deficient Knowledge of Injection Administration as verbalized by the client, related to the lack of instruction and experience.

The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement?

Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray.

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?

Describe how the walker can improve the client's quality of life.

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?

Document the client's claims and the events surrounding the alleged incident.

The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When should the nurse begin client teaching?

During the admission process

A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address the disrespectful remark.

An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's:

critical thinking.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

A nurse is interviewing a client for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the client's past medical history. In this case, the nurse plays the role in the process of commuication of the:

sender.

The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document?

A living will

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply.

-"I will write, print, or type information legibly." -"I will use only agency-approved abbreviations." -"I will draw a straight line through any blank space."

The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply.

-Sign every entry -Document in chronological order -Identify the day and time for each entry -Acknowledge the client's response to the medication

The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply.

-Spoken words -Sight -Touch -Observation

Which situation is an example of battery that the nurse may witness while performing duties at the health care facility?

Performing a surgical procedure without getting consent

An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis?

Personal perception of health and aging

The nurse is preparing to teach a client about postsurgical care after a laparoscopic cholecystectomy. Which factor should the nurse most consider when determining whether the client is ready and able to learn?

Physical condition

A nurse assisting a new mother in the act of breastfeeding represents which form of learning?

Psychomotor

An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed?

Invasion of privacy

When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed?

Invasion of privacy

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

A client arrives at a crisis center in a state of bipolar mania. The client has a flight of ideas and it is difficult for the nurse to obtain an adequate intake assessment. Which statement or question will elicit the most specific information?

"Are you allergic to any medications?"

The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed?

"Do you have any questions about your cholecystectomy?"

A client who underwent a hysterectomy 4 days ago says to the nurse, "I wonder if I'll still feel like a woman." Which response would most likely encourage the client to expand on this and express concerns in more specific terms?

"Feel like a woman . . ."

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 nurse is assessing a client who has come to the clinic for a follow-up appointment. The client was diagnosed with asthma several months ago and has missed several appointments since that time. The client also has not been following the medication plan and has not kept the appointment for allergy testing. The nurse suspects that the client may be experiencing problems with health literacy. The nurse teaches the client about the condition and prescribed treatment. Which question from the nurse would help to assess the client's health literacy about the condition?

"How are you supposed to take your medication?"

Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn?

"I am having difficulty breathing."

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?

"I cannot give you that information due to client confidentiality."

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing."

A client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which statement by the client suggests that the nurse's teaching has resulted in affective learning?

"I'm starting to see how my lifestyle has caused me to end up here."

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

"Is that a new shirt you're wearing?"

A nurse confides in a nurse friend, "I never report minor incidents. The charge nurse always wants a variance report filled out and they take so much time." Which responses by the friend are indicated? Select all that apply.

"Reporting helps us fix problems that result in danger to clients." "Having documentation might keep you out of trouble someday."

A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response?

"Share with me the advantages and disadvantages of your options as you see them."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse?

"Take it with you. It is recognized universally in the United States."

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?

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

While the nurse is caring for a hearing impaired client, and a family member of the client states, "What do you think is the best way to communicate?" What is the best response by the nurse?

"Use flash cards and writing pads."

The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment?

"We reviewed your plans for your new diet and medications. Do you have any other questions?"

The daughter of an older adult client asks the nurse why a urine specimen was collected from the client earlier that morning. How can the nurse best respond to the daughter's query?

"We want to test the urine to make sure your mother doesn't have a urinary tract infection."

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response?

"When 15 minutes have passed, I will ask your mother to show me how to instill the drops."

Which is an open-ended question?

"Why did the health care provider prescribe this medication for you?"

The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse?

"You have made an amazing recovery."

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

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

A nurse educating a new mother on how to bathe an infant uses the acronym TEACH to maximize the effectiveness of the education plan. Which actions are guidelines based on this acronym? Select all that apply.

-Edit client information. -Act on every teaching moment. -Clarify often.

The nurse is assessing the health literacy of a client and uses the Newest Vital Sign tool. The nurse completes the assessment tool with the following client answers to each question. 1. 1,000 calories 2. 1 cup 3. 24 grams 4. 1% 5. Yes After completing the tool, what assessments about the client's health literacy would the nurse make? Select all that apply.

-The client has difficulty making mathematical calculations. -The client is unable to identify ingredients that could be harmful to oneself. -The client may not understand how to take the medication if prescribed a dose of 2 to 3 times each day.

Which is the proper way to document midnight in a client's record?

0000

Which statement describes the person who is likely the most motivated to learn?

A 70-year-old female who is the client's spouse and is learning the care so the client can come

Which is important to remember when teaching adult learners?

A focus on the immediate application of new material

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 drafts an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication?

Ask the care provider to come and assess the client.

When preparing client teaching materials, how does the nurse best assess a client's preferred learning style?

Ask the client, "Do you learn best by observing, valuing, or doing?"

The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?

Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification

A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client?

Assessing importance

When caring for a client, the nurse gives day-to-day examples to explain certain points of the health education. The nurse also notes the client's concentration level and educates when the client is active. Which aspect related to learning is the nurse targeting in this approach to teaching the client?

Attention and concentration

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching?

Blocking 30 minutes of time for skill teaching

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing?

Certification

A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?

Cognitive

A nurse instructs a client to tell the nurse about the side effects of a medication. What learning domain is the nurse evaluating?

Cognitive

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall?

Cognitive

Which learning domain is the focus for instruction when the nurse educates a new mother about the breast and its role in milk production for feeding the newborn?

Cognitive

Which note includes all elements of a SOAP note?

Client reports nausea, including one episode of nausea yesterday. Also with diarrhea. Mucous membranes are moist, good turgor. Blood pressure of 130/85 mm Hg, heart rate of 92 beats/min. Nausea and vomiting of unknown etiology. Will give an antiemetic and reassess within 1 hour for effectiveness.

A client is scheduled for a colonoscopy. The nurse realizes immediately after administering medications to induce conscious sedation that the client has not signed the informed consent. If the nurse has the client sign the informed consent at this point, which element of informed consent would be violated?

Competence

Which term describes a nurse who is sensitive to the client's feelings, but remains objective enough to help the client achieve positive outcomes?

Empathic

What is the most critical element to document regarding client education?

Evidence that learning has occurred

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase?

Examine goals of the relationship to determine whether they were achieved

A nurse is caring for a client who is visually impaired. Which action is a recommended guideline for communication with this client?

Explain the reason for touching the client before doing so.

Which method of charting did the nurse use to document "Fluid Volume Overload. On assessment client's lower limbs edmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now edema +"?

FOCUS

A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability?

Filling out an occurrence report and notifying the healthcare provider

A nurse caring for an unconscious client knows that communication is important even if the client does not respond. Which nonverbal action by the nurse would communicate caring?

Holding the client's hand while talking

Which strategy might a nurse use to increase compliance with education?

Include the client and family as partners.

The nurse is communicating with a client who begins to cry. The nurse places a hand on the client's arm and sits quietly at the client's beside. What mode of communication is the nurse using to offer caring and comfort for the client?

Kinesthetic

A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce the client's risk for cancer, improve respiratory status, and enhance the quality of life. The nurse also shares a personal story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client?

Motivational

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?

Orientation phase

The nurse makes a contract with the client during which phase of the nurse-client relationship?

Orientation phase

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 home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?

Positive feedback

A client who recently underwent a coronary artery bypass graft is taking furosemide and metoprolol following the procedure. While developing a plan for a heart-healthy diet with the nurse, the client states that diet did not contribute to the heart disease and that the client should be fine just continuing to take the medications. According to the Transtheoretical Model of Change, which stage of change is the client in related to diet?

Precontemplation

During the admission assessment of a client with a suspected mandibular fracture, the client discloses to the nurse that the injury results from the client's spouse hitting the client. Which action should the nurse prioritize when responding to this disclosure?

Reporting the abuse to the appropriate authorities

A new nurse is developing a teaching plan for an assigned client who has just started receiving chemotherapy. The nurse plans to teach the client about symptoms to report after chemotherapy. What is the priority action by the nurse?

Research information available in journal articles and other authoritative sources.

The nurse is leading a discussion with a group of adolescents about what to do "if a friend shows you a gun at school in a backpack." The nurse is encouraging the adolescents to explore consequences of their actions for decisions made. What value transmission is the nurse demonstrating?

Responsible choice

Which diagnosis would best describe a situation in which a parent has a knowledge deficit concerning child safety for a toddler who is currently being treated for burns and was previously treated for a fracture from a fall?

Risk for Injury, related to mother's lack of knowledge about child safety

The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?

Role-playing

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?

Speak directly to the client

A client is reluctant to learn to do finger sticks for home international normalized ratio (INR) monitoring. What is the best statement by the nurse?

Tell me what you know about these tests.

The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill?

The client organizes materials needed and gives return demonstration.

The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education?

The client will be able to perform proper breast self-examination for breast cancer detection and prevention.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?

The nurse ensures that the client's family signs the consent form.

The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. Which expectation should the nurse have when developing the relationship?

The nurse is accountable for the outcome.

The nurse enters a client's room after receiving a morning report. The nurse rapidly assesses the client's airway, breathing, and circulation and greets the client by saying "Good morning." The client makes no reciprocal response to the nurse. How should the nurse best respond to the client's silence?

The nurse should ask appropriate questions to understand the reasons for the client's silence.

Which statement accurately describes the concept of feedback as it pertains to the process of communication?

The sender and the receiver use one another's reactions to produce further messages.

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

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report?

To evaluate the quality of care provided and assess the potential risks for injury to the client

Which documentation by the nurse best supports the PIE charting system?

Vomiting 250 mL undigested food, antiemetic given, no further vomiting

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by:

asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate.

When the nurse informs a client's employer of the client's autoimmune deficiency disease, the nurse is committing the tort of:

invasion of privacy

A home health nurse is visiting a 40-year-old client who has had abdominal surgery. The client is unable to change a dressing because of obesity. The nurse is to instruct the client's spouse on the sterile dressing technique. During the visit, the nurse notes that the spouse has limited abilities due to mental disabilities. One assessment to determine the spouse's literacy would be:

to assess her reading with WRAT.

When communicating with a client, the nurse uses reflection for which purpose?

To have the client elaborate on thoughts and feelings

The nurse has completed teaching. Which client behavior demonstrates understanding within the affective domain?

States, "I feel comfortable using my walker"

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?

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

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?

"I think the client would benefit from intravenous furosemide."

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education?

"I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."

The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply.

-Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. -No new labs have been ordered after surgery. -Pain level is currently a 3 following administration of intravenous morphine. -The client has a clean and dry abdominal dressing.

Which is a characteristic of a person-centered or helping relationship?

An unequal sharing of information

The nurse is assisting a client 55 years of age to understand the anatomy and physiology of the heart following a heart attack. What type of learning is taking place?

Andragogy

Which client would be the best candidate for the nurse to engage in motivational interviewing?

A 28-year-old client with elevated blood glucose for 8 months

What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women?

Lecture/discussion

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?

The client and the nurse are equal participants.

Which observation during the nursing assessment of a client supports the documentation of low health literacy?

The client avoids health care screenings and seeks care in the local emergency department.

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

Therapeutic communication

What is the goal of the nurse in a helping relationship with a client?

To assist the client to identify and achieve goals

What is the primary purpose of FOCUS charting?

To concentrate on the client and client concerns in documentation

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?

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

Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?

"All of the people got themselves out of the car?"

A client is reluctant to undergo surgery and is discussing it with the nurse. Which response by the nurse would reflect an authoritarian approach?

"Surgery is your only option. You need this operation."

A nurse pays a house visit to a client who is on parenteral nutrition. The client reports missing enjoying food with the client's family. What is the most appropriate response by the nurse?

"Tell me more about how it feels to eat with your family."

A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client?

"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"

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?

"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."

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement?

"The rules made by the board of nursing don't reflect my practice."

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?"

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"Why did your physician send you here to be admitted?"

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

A nurse is teaching a 5-year-old boy who was recently diagnosed with type 1 diabetes. The client's mother, who is the primary caregiver, informs the nurse of having a fear of needles. What acttions are appropriate for the nurse to take to ensure a successful education session? Select all that apply.

-Ensuring 20 minutes of uninterrupted teaching time -Using a doll to demonstrate giving an insulin injection -Providing the client's mother with an informational pamphlet about insulin injection

The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing?

"You are hoping to figure out the cause of your extreme fatigue during this hospital stay."

Nurses on a hospital burn unit meet as a group to discuss procedures. Which statements accurately describe effective functioning in a group? Select all that apply.

-Group members elicit mutually respectful relationships. -The leader or other group members confront any member who dominates or thwarts the group process. -Group members support, praise, and critique one another

Which are high-risk errors in documentation? Select all that apply.

-Inadequate admission assessment -Failure to document completely -Charting in advance -Falsifying client records

A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply.

-"Cheer up. Tomorrow is another day." -"Your doctor knows best." -"Don't worry. You will be just fine in another day or two." -"Everything will be all right."

A charge nurse has implemented staff education on nursing values. The nurse would determine that further education is required when which statement(s) are overheard?

-"I can't believe the client is giving that precious baby up for adoption." -"The gonorrhea test was positive. That's what the client gets for sleeping around." -"If that was my mother, I sure wouldn't agree to a no-code."

A nurse and client are working together to help the client make lifestyle changes to promote improved health. The nurse is having the client sign a contractual agreement for the work they will do together. Which statements by the nurse reflect the proper purposes of such agreements? Select all that apply.

-"Our goals are defined, as are ways to meet them." -"With this contract, we show that we are both dedicated to improving your health."

A nurse has been providing care to a client in the home for years. The nurse is asked to witness the client's signature on a will. What factors should cause the nurse to question whether to act as a witness on this document? Select all that apply.

-A relative is telling the client, "You must sign this document now." -The nurse did not watch the client sign the will. -The nurse is included as a beneficiary in the will.

To ensure accurate charting, which actions should the nurse perform? Select all that apply.

-Checks to make sure that the nurse has the correct chart prior to making an entry -Documents interventions as close as possible to the time of execution -Places a label with the client's name and identification number on each page of the client's

According to Rosenstock, which health beliefs are critical for client motivation? Select all that apply.

-Clients view themselves as susceptible to the disease in question. -Clients view the disease as a serious threat. -Clients believe there are actions they can take to reduce the probability of contracting the disease.

The nurse has performed the following activities during the shift. Which activities are violations of client privacy and/or confidentiality? Select all that apply.

-Discussing the client's HIV status over lunch with a friend, a nurse on another team located on the same nursing unit -Answering questions from a client's visitor before verifying the visitor has permission to receive the information -Removing a printed report of a client from the hospital premises to write a case study for a staff meeting -Leaving the mobile computer screen, which contains client information, open when a visitor asked questions

Which actions should the nurse take to ensure that client information remains confidential? Select all that apply.

-Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. -Exit the client's room when called on the hospital-issued cell phone about another client on the team. -Verify the number in the fax machine as correct prior to transmission.

Which are appropriate actions for protecting clients' identities? Select all that apply.

-Document all personnel who have accessed a client's record. -Place light boxes for examining X-rays with the client's name in private areas. -Have conversations about clients in private places where they cannot be overheard.

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply.

-Documenting entries that are up to date and comprehensive -Recording the date and time of all entries -Using approved agency abbreviations

Which actions should the nurse perform to limit casual access to the identity of clients? Select all that apply.

-Obscuring identifiable names of clients and private information about clients on clipboards -Placing fax machines, filing cabinets, and medical records in areas that are off-limits to the public -Keeping record of people who have access to clients' records

The nurse completed education with a client. Which documentation entry represents the most complete teaching plan?

-Printed and verbal information provided on gluten-free diet. -Questions answered. -Verbalizes understanding. -Follow-up scheduled.

The nurse receives a verbal order from a physician during an emergency situation. Which actions should be taken by the nurse? Select all that apply.

-Read back the order. -Mark the date and time of the order. -Include V.O. with the physician name on the order.

Which actions should the nurse take before making an entry in a client's record? Select all that apply.

-Reviewing the agency's list of approved abbreviations -Locating clients' files within an electronic health record system -Identifying the form appropriate to be used for documenting

Which information should the nurse include in a client's plan of care? Select all that apply.

-Routine care, such as the client's bath and mouth care -The client's level of activity and current medical orders -The client's problems, goals, and nursing orders

The nurse is in the process of reporting to the health care provider the changes in the client's status. Which are appropriate ways for the nurse to communicate information about the client to the health care provider? Select all that apply.

-Showing the provider the trends from baseline to present in blood pressure -Informing the provider of the client's present heart rate of 116 beats/min -Faxing the results of blood chemistry levels to the provider's office

A nurse is educating an older adult client with diabetes and family members about the importance of a nutritious diet. What outcomes does the nurse hope to achieve in the process of educating the client and family? Select all that apply.

-The client will achieve optimal health. -The client will cope with alterations in health status.

A client in a mental health unit discusses personal thoughts and feelings with the nurse. The nurse can maintain the circle of confidentiality when reporting this information to which individuals? Select all that apply.

-The client's physician -The nurse from the oncoming shift -The unit's mental health technicians

Which nursing actions would most likely help improve communication with clients and achieve a more effective helping relationship? Select all that apply.

-The nurse controls the tone of voice so that it conveys exactly what is meant. -The nurse makes statements that are as simple as possible, gearing conversation to the client's level. -The nurse takes advantage of any available opportunities to communicate information to clients in routine caregiving situations.

Which are areas of potential liability for the nurse? Select all that apply.

-The nurse fails to document refusal by the client to ambulate following surgery. -The nurse documents that the client's blood pressure has increased from 118/72 to 188/98 mm Hg and decides to retake the blood pressure in an hour.

A nurse is communicating the plan of care for a client who is unconscious. Which nursing actions best facilitate this process? Select all that apply.

-The nurse is careful what is said in the client's presence because hearing is the last sense to go. -The nurse assumes the client can hear and discusses things that would ordinarily be discussed. -The nurse speaks with the client before touching the client.

For which purposes would observing silence be appropriate? Select all that apply.

-To allow the client time to reflect on the client's thoughts -To allow the client time to reflect on communication that has occurred -To allow the client time to formulate an answer after asking the client a question -To allow the client time to compose oneself when the client is upset

A client is requesting to view all medical record information regarding the care received while hospitalized. What rights does the client have regarding accessing the medical record according to HIPAA regulations? Select all that apply.

-To see the health record -To copy the health record -To restrict certain disclosures of the health record

The nurse has completed teaching. Which client behaviors demonstrate understanding within the cognitive domain? Select all that apply.

-Verbalizes key points of a brochure about diabetes that was read -Provides a description of what appropriate wound healing should look like

The nurse enters a client's room and observes that the client is hunched over and appears to be breathing rapidly. What type of question should the nurse first ask the client in this interaction?

A yes or no question

A client states to the nurse, "I understand that I need a mastectomy for the treatment of my breast cancer, but I am fearful of learning about the drains I will need to empty." When responding to the client, the nurse will need to address which type of learning?

Affective

The nurse is providing education to a group of clients with diabetes about the benefits of healthy food choices. What type of learning is the nurse using with this client group?

Affective

A nurse is caring for a client with dementia. Which documentation by the nurse best follows documentation guidelines?

Alert and oriented to self only, hitting staff members with newspaper, did not follow commands to brush teeth

An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action?

Asking the LPN/LVN to teach a new diabetic client how to administer insulin

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

Assess for cultural differences.

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

The nurse uses the acronym TEACH when planning care for clients on a busy hospital ward. Which interventions accurately represent aspects of this acronym? Select all that apply.

A—The nurse acts on every teaching moment. C—The nurse clarifies often. H—The nurse honors the client as a partner in the education process.

Before starting the education process, the nurse should determine the preferred learning style, age and developmental level, capacity to learn, motivation level, readiness to learn, and learning needs of the client. How does this help the nurse in the client's health education?

By implementing effective teaching

The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?

Cognitive learning theory

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan?

Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique.

A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain?

Demonstrating the technique for insulin self-injection

The nurse is performing an admission assessment on a client who was just transferred from the emergency department. The client has an elevated temperature and a wound infection. The client's sensorium is decreased, but the client is responsive. When should the nurse initiate teaching for this client?

During the admission assessment

A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting?

Empathy

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?

Encouraging elaboration

In a helping relationship, the nurse would most likely perform what action?

Establish communication that is continuous and reciprocal.

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request?

Identify and recommend some credible websites appropriate to the spouse's learning needs.

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy?

Identifying with the client's feelings

A client age 42 years recovering from a myocardial infarction (MI) is having difficulty following the care plan to stop smoking and exercise. What is the nurse's best response to this client?

Ignore the behavior and recommend a behavior modification program.

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

Intimate

Which action by the nurse would facilitate the nurse-client relationship during the orientation phase?

Introducing oneself to the client by name

Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged?

Invasion of privacy

When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized?

Include educational strategies that encourage clients to be active participants.

A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients?

Include the child in the education; ask questions of both the mother and the child.

During the health education session at the health care facility, the nurse notes that a client is able to recognize, describe to others, and explain the information learned. What is the final learning stage of the client in this case?

Independent use of new learning

The family of a client in a burn unit ask the nurse for information. The nurse sits with the family and discusses their concerns. What type of communication is this?

Interpersonal

A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments?

Libel

A nurse uses the SBAR method in a hand-off report to communicate to the health care team about the client. Which element should the nurse cover in the "B" section of the SBAR report?

Mental status

A nurse gives a speech on nutrition to a group of pregnant women. Within the model of the communication process, what is the speech itself known as?

Message

Which client characteristic is important to assess when using the health belief model as the framework for education?

Motivation to learn

A client with a body mass index (BMI) of 40.3 kg/m2 states, "I know I need to get rid of this fat. I just don't know how." Which is the best assessment for the nurse to make at this time?

Past interventions for weight loss

A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss?

Preparation

A client 36 years of age is able to understand the health education when given the opportunity to put the education into practice. The nurse helps the client to self-administer the medication dosage before the client is discharged from the health care facility. Which domain correctly identifies the client's learning style?

Psychomotor

When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?

Psychomotor

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?

Return demonstration

The nursing is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out during this phase of the relationship?

Reviewing health changes

A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction?

The client belongs to a different culture.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?

The client describes signs and symptoms of hypoglycemia.

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?

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

At completion of a teaching session with a client, the nurse documents the details of this education encounter in the client's health record. What should another nurse be able to determine from reading this documentation?

The client's response to the health education that was provided

The nurse should consider which client aspect as nonverbal communication?

The client's tone of voice

While at a coworker's house, a nurse discusses with the coworker a client whom the nurse suspects of physically abusing the client's child. The next day, the client is moved to another nursing unit after a surgical procedure and comes under the care of the coworker, who is also a nurse. The coworker confronts the client about the alleged physical abuse. The client is shocked and angered by the accusation and denies it categorically. What would be the charge if the client were to file a suit?

The first nurse could be charged with slander.

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation?

The nurse should ask the physician to come back and write the order.

When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners?

The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.

A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation?

The nurse should call and inform the nursing supervisor of the situation.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner?

Their readiness to learn is often related to a developmental task or social role.

A client is admitted to the health center with chronic diarrhea. When should the nurse begin imparting health teaching about the benefits of proper diet to the client so that the risk of diarrhea is minimized?

When admitting the client

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

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.

In the provision of care and the establishment of the therapeutic relationship, the nurse must first:

be aware of one's own personality.

When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is:

conveying information.

A client shares with the nurse how much the client appreciates understanding the physiology of breastfeeding. The client states, "I felt very comfortable with what you explained to me, and I feel I will be successful at breastfeeding." In affective learning, this represents the nurse:

creating an atmosphere for discussion of feelings.

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.

A nurse is overheard in the hospital cafeteria making false, derogatory comments about a client. The nurse is guilty of:

slander.

The nurse is caring for a client who speaks Chinese, which the nurse does not speak. An appropriate approach to communicating with this client would be:

using a caring voice and repeating messages frequently.