Foundations review III

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

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

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

A nurse is caring for a client who sustained a spinal cord injury and has paraplegia. The client is frustrated, crying, and tells the nurse, "I just want to die." What is the nurse's best response to the client?

The nurse says, "I can only imagine how hard this is on you. How can I help you?"

A nurse is performing a wet to dry dressing change on a client's lower abdomen. The nurse should be aware that he or she will be encroaching on which zone?

intimate zone

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

"Let us know if we can answer any further questions after you obtain your second opinion."

The primary care provider is yelling at the nurse in the client's room because the client has not received an intravenous antibiotic. Which statement by the nurse demonstrates assertiveness?

"Let's go to the nurses' station, and I will explain."

A nurse is assessing a client's nutritional intake prior to admission the client has lost 10 lb (4.5 kg) over the last 2 months. Which example best represents therapeutic communication technique?

"Tell me about the type of foods you like to eat."

A client reports to a primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that the client does not want to take the test and would prefer instead to continue taking medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

"Tell me more about how you are feeling."

An older adult client is advised to undergo a 12-lead electrocardiogram (ECG) assessment. The client seems to be anxious because this is the first time undergoing such a procedure. What explanation should the nurse provide to the client?

"The ECG electrodes are painless and will record electrical activity of the heart."

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 pain when it goes in, but I will be by your side throughout and will help you hold your position."

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."

A client with chronic hyperparathyroidism expresses that she is fed up with her diet and can no longer continue with it. What should the nurse's appropriate response to the client be?

"You may be having a difficult time staying on that diet; let's discuss it."

The nurse is completing an admission assessment with a client. The client looked down and became tearful when asked about feeling safe at home. How would the nurse respond to the nonverbal communication displayed by the client?

"You seem upset. You are safe here and can talk to me confidentially."

A nurse is showing an older adult client with severe diabetes the correct method of self-administering an insulin injection. What comment(s) is acceptable if the client continues making mistakes when learning how to self-administer an insulin injection? Select all that apply.

- "First-time learners often have this same concern." - "You have just about figured out how to give yourself an injection." - "Try to angle the syringe a little more this way."

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."

Which statements made by the nurse acknowledge the client as a human being? Select all that apply.

- "Mr. Smith, I will be taking you to x-ray now." - "I have your medications ready for you, Ms. Jackson."

The nurse is caring for a postoperative client who is experiencing hypotension. When contacting the client's health care provider, the nurse will include which statement in the SBAR report? Select all that apply.

- "The client demonstrates additional signs of hypovolemia including slow capillary refill." - "The client has had a sudden drop in blood pressure from 125/90 down to 90/60 mm Hg." - "The client was just admitted to this unit from postanesthesia recovery after having abdominal surgery."

Which are examples of breaches of client confidentiality? Select all that apply.

- A nurse discusses information about a client with a coworker in the elevator. - A nurse shares his or her computer password with another nurse who was unable to log in to the system. - A nurse updates the employer of a client regarding the client's date of return to work.

A nurse needs to complete an assessment and vital signs on a client who has Alzheimer disease. How should the nurse approach this client to gain cooperation? Select all that apply.

- Approach the client from the front. - Use the client's name. - Smile and maintain eye contact.

A nurse is preparing to educate about the importance of contraception and safe-sex practices to a group of college students. Which factors can affect the nurse's teaching strategies? Select all that apply.

- Availability of resources - Learning style preferences of students - Literacy level of target audience

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 chart

The nurse is planning to conduct preoperative teaching for a client and a family member, both of whom speak and understand primarily a nondominant language. What activity(ies) will promote learning for the client and the family? Select all that apply.

- Determine availability of a professional interpreter. - Ensure the room is quiet. - Leave time at the end of the session to answer questions. - Listen to any concerns the client and family may have. - Provide verbal instructions and printed materials in the client's language.

A couple has just learned that their newborn infant has a congenital cardiac anomaly that will require many lifestyle modifications, surgical corrections, and hospital stays. Place the following aspects of the couple's client education in the correct order that nurses should conduct them.

- Determine their emotional readiness to learn. - Draft learning outcomes. - Select educational strategies. - Implement various educational techniques. - Revise the learning plan if needed.

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

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

The nurse is teaching a 6-year-old child prior to cardiac surgery. What activity(ies) does the nurse include to facilitate learning with the child? Select all that apply.

- Involve the parents in the teaching. - Keep explanations short. - Make the teaching sessions brief. - Provide a tour of an empty pediatric ICU client room.

The new nurse works at a hospital that uses paper records. The nurse writes a narrative note about administration of a pain medication, pictured above. Based on documentation guidelines, which suggestions would improve the nurse's charting? Select all that apply.

- Leave no blank space after each entry; draw a line. - Sign each entry. - Provide qualifiers for pain, such as quality and quantity. - Make observations of client behavior, not interpretations.

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. - The client has a clean and dry abdominal dressing. - Pain level is currently a 3 following administration of intravenous morphine.

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

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

- Sight - Observation - Touch - Spoken words

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply.

- The client exhibits agitation and shouts at the nurse. - The client's blood pressure is 135/82 mm Hg. - The client's skin turgor is normal. - The client has redness around the ankles bilaterally. - The client participates in range-of-motion exercises.

The nurse is conducting discharge teaching for a client who has been diagnosed with type 2 diabetes. The nurse is teaching the client how to inject insulin at home. Which cue(s) will alert the nurse that the client has poor health literacy? Select all that apply.

- The client has a history of several missed health appointments. - The client's hospital admission forms were incomplete. - The client has a history of medication nonadherence. - The client did not follow up on when asked to book an appointment with a specialist.

The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his or her charting? Select all that apply.

- The client is crying. - The client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."

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.

The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include? Select all that apply.

- The client's blood pressure trend over the past 24 hours. - The primary reason the client was admitted to the hospital. - Objective and subjective data from the most recent assessment. - An explanation of what is needed to improve the hypotensive state.

The nurse conducts a teaching session for a group of middle-aged women. Which exercise information will the nurse share with this group? Select all that apply.

- The importance of regular exercise to maintain health - The use of exercise to improve the quality of life - The use of ambulation devices to improve exercise - How to perform deep breathing exercises

Which are purposes of documentation in health care records? Select all that apply.

- To facilitate quality - To serve as a financial record - To support decision analysis - To assist with clinical research

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

- any abnormal occurrences with the client during the shift - identifying demographics, including diagnosis - current orders

The client states, "I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today." The client's arms are folded across his chest. His brow is furrowed, and he will not allow morning vital sign measurements. Which entry should be included in the nurse's charting? Select all that apply.

- arms folded across chest and brow is furrowed - states, "I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today" - will not allow morning vital sign measurements

The nurse is discharging several clients from an acute surgical unit on the same day. The nurse will prioritize teaching based on how much time is required for each client. Place the clients in the order, from first to last, in which the nurse will carry out discharge teaching. Use all options.

- client who is learning to draw up and inject insulin for the first time - client who indicates the live-in partner is a registered nurse - client who is being discharged to a long-term care facility - client who is being transferred to another unit in the hospital

What does the nurse recognize as purposes of the electronic health record? Select all that apply.

- documenting continuity of care - qualifying health care providers for government funds - ensuring client safety - facilitating health education and research

A nurse is working as part of a team that has been asked to address the issue of confidentiality and documentation of client health information electronically. Which activity(ies) would the team suggest to help ensure confidentiality? Select all that apply.

- having each person responsible for documenting in the electronic health record not share his or her password - placing computer screens in locations that face away from any public areas such as hallways - ensuring that individuals log off a computer terminal when documentation is completed

The following are prescriptions on a client's chart. Which prescriptions would the nurse question because they are written incorrectly? Select all that apply.

- heparin 5000U subcutaneously every day - metoprolol 25 mg po daily, hold if BP <100 mm Hg - vancomycin 750 mg IV qod

The nurse is conducting a teaching session regarding HIV/AIDS for adult clients in the community. What consideration(s) will the nurse make when teaching this type of session? Select all that apply.

- identifying the length of the session - beginning with basic concepts about HIV/AIDS - providing adequate lighting and comfortable temperature - identifying the time, place, and content for the next teaching session

The nurse is caring for a client who had a stroke with residual affective aphasia. What is an effective method(s) for the nurse to communicate with the client? Select all that apply.

- provide the client with a tablet or whiteboard to attempt communication - patiently await the client's responses after asking questions - have the client point to common phrases or spell with alphabet letters on a laminated form

A nursing student is preparing for an oral class presentation on the types of communication. Which characteristics would the student include as nonverbal communication? Select all that apply.

- silence - tone of voice - facial expression

In the computer, the nurse needs to document the time the client took medication. However, the time is written in the military format, and the computer accepts only the traditional format. How should the nurse enter the time in the computer if the client took his medication at 1530 hours?

03:30 p.m.

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. What statement by the nurse communicates concern and caring about the client?

"I can imagine you have many concerns about your health. Tell me what is on your mind."

The following information appears on a client's medical record:Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area.When documenting this information using the SOAP method, which part would the nurse document as "S"?

"I have a fair amount of pain in my belly near my incision"

The nurse is providing education for a client who will be providing self-care at home. The client states, "I just do not think I can do all of this. It is too much to learn." What is the best response by the nurse?

"I understand that you feel overwhelmed with all of the information. Tell me what I can do to help."

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?

2015

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

The nurse prepares to give the change-of-shift report. The nurse provides the oncoming nurse with the intake and output record of the client for the shift, pictured above. What is the client's fluid balance in milliliters? Record your answer using a whole number.

485

A nurse has administered six units of insulin to the client as per order. What is the safest documentation of this information?

6 units of insulin administered

The nurse is caring for a client with different cultural practices and beliefs regarding health care. In which manner can the nurse ensure health disparities are reduced and the client receives equitable care?

Adapt care to encourage a collaborative, client-centered relationship that ensures safe practice.

A nurse realizes the dosage of hydrocodone/APAP 5-325 administered to the client has been entered incorrectly into the client's eMAR. What would be the first action for the nurse to correct this error?

Add the correct information, making a notation of why the error occurred with the date of correction

Which encounter represents nursing negligence?

Administering a new antibiotic without subsequently reassessing the client.

A nurse is providing care to a client who is diagnosed with a condition, for which surgery is recommended. The client is unsure about whether to have the surgery. Which actions by the nurse best reflect actions the nurse can take to promote advocacy?

Ask the client what concerns the client has about the surgery.

The nurse is caring for a 5-year-old child on the pediatric unit. Which activities would promote the psychomotor skills of this child? Select all that apply.

Assembling blocks Building a house with popsicle sticks Removing the toys from the toy box

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

A nurse enters a client's hospital room to begin a teaching session. When the nurse enters, the client says, "Nurse, I am really cold. Could you get me another blanket? My side is really aching, too, and I'm thirsty." Based on this information, what should the nurse do next?

Attend to the client's needs for warmth, pain relief, and thirst.

The nursing supervisor is giving a performance evaluation to an employee. Which communication technique by the nursing supervisor sends the message of disinterest in the employee?

Avoiding eye contact

Which action(s) will the nurse take when preparing for and conducting a teaching session for clients with visual impairment? Select all that apply.

Avoiding the use of materials printed on glossy paper Using a lamp that shines over the clients' shoulders Ensuring that the clients are wearing prescription eyeglasses

A nurse will be finishing work for the day at 1900. Besides using the health care records, which form of communication should the nurse use to provide client details to the health care team coming on duty at 1900?

Change of shift reports

Alice Jones, a registered nurse, is documenting pain assessment after the administration of pain medication in the client's medical record. How should the nurse document this assessment?

Client rates pain at 2 on a scale of 0-10. A. Jones, RN

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.

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

A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin." Which domains of learning does the nurse identify for this client as having been successfully addressed by education?

Cognitive, affective, and psychomotor

A nurse is documenting information related to a client's condition. When documenting this information in the paper chart, the nurse makes an error documenting vital signs, entering 86/132. What is the best technique for recording the error made in documentation?

Cross out 86/132 with a single line and place the nurse's initials above it.

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

An older adult client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO." Based on this order, what action should the nurse take?

Ensure that the client does not eat or drink anything.

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 experiencing difficulty obtaining the client's cooperation in performing exercises after surgery. Which would be the best method for the nurse to obtain the client's cooperation?

Explain the purpose and benefit of the postsurgical exercises.

The client is an 18-month-old in the pediatric intensive care unit. The client is scheduled to have a subgaleal shunt placed tomorrow, and the client's mother is quite nervous about the procedure. The nurse tells the client's mother, "The surgeon has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?

False reassurance

The nurse is conducting a health interview with an older adult client. During this introductory phase, which action should the nurse take to effectively establish of the nurse-client relationship?

Greet the client by asking by which name he or she prefers to be addressed.

The nurse is educating a group of clients in the community about safe sex practices. When is the best time to evaluate teaching effectiveness?

Immediately after the education session

During a health teaching session, the nurse notes that the client is not attentive and loses concentration easily. Which of the following techniques is most appropriate to grab the attention of the client during the education?

Involve the client in an active way.

The nurse is planning to teach a 75-year-old client about administering medication. How can the nurse enhance the client's ability to learn?

Make the information relevant to the client's condition.

The nurse is caring for a client who is prescribed a pain medication by mouth every 4 to 6 hours. When assessing pain status, the client states not wanting to take any medication right now. Which principle should the nurse consider when documenting interventions regarding medication administration for this client?

Medication that is not administered should be documented along with the reason.

The nurse is teaching a client newly diagnosed with diabetes about the disease, testing, diet, and how to self-administer insulin. The client does not speak the dominant language. What is the appropriate nursing action?

Obtain a medical interpreter.

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

Omitting clients' responses to nursing interventions

The nurse documents that a client does not have pain prior to the administration of pain medication. The client, however, requested medication for increasing postsurgical pain. What is the appropriate action to correct the pain assessment documented in the client's paper medical record?

Place one line through the entry and initial it.

The community health nurse is teaching an 89-year-old community-dwelling client about the care of the client's venous leg ulcer. In light of this client's age, the nurse should make which adaptation to this client's education?

Plan education sessions that are briefer than those intended for younger clients.

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

The client's heart rate is 160 beats per minute. The client is experiencing complications of an excessive heart rate. The primary care provider issues a verbal prescription for intravenous medication to the nurse. Place the steps of taking the verbal prescription in chronological order

Record the prescription in the client's medical record, including date and time. Read back the prescription to the primary care provider who initiated it. Obtain verification from the primary care provider that the prescription is correct. Initiate the prescription and administer the medication. Obtain the signature of the primary care provider who gave the verbal prescription

Which strategy should the nurse use when providing education to the older adult client?

Remain calm and conduct the teaching session in a quiet environment.

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response?

Reteach the length of time to take the prescription.

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

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take?

Revise the plan of care.

The nurse is caring for a client in the intensive care unit who must be administered multiple medications. The client is often unresponsive and cannot offer information during assessment. When administering the medication, which step by the nurse is most important to avoid confusion and ensure safety?

Scan the client's wristband prior to administering medication to verify it is the correct client and correct medication.

The nurse educator is providing a demonstration of the electronic medication administration cart to the student nurses on the clinical unit. Which level of human proxemics would be appropriate for the nurse educator at this time?

Social

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 home care client on how to administer a topical medication. The client is watching television while the nurse is talking. What might be the result of this interaction?

The message will likely be misunderstood.

Which action by the nurse demonstrates respect for the client as an individual?

The nurse is administering medication to a client she addressed as "Mrs. Taylor."

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures.

What situation would permit the nurse to disclose information without the client's approval?

The nurse suspecting that a client is being abused or neglected

A nurse and an older adult client with chronic back pain are in the working phase of the nurse-client relationship. Which activity occurs in the working phase?

The nurse tries to avoid hampering the client's independence.

Which is not a purpose of the client care record?

To serve as a contract with the client

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

A nurse tells a client, "Are you going to get out of bed, or are you just going to sleep all day and night?" This is an example of which barrier to communication?

Using judgmental or belittling language

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult

an audiologist.

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation?

charting by exception

Which type of learner processes information more adequately by listening or reading facts?

cognitive

The nurse is caring for a client. When does the nurse determine that nursing care will be most effective related to nurse-client communication?

common understanding

What ensures continuity of care?

communication

The nurse is providing education to a client recently diagnosed with diabetes. Which action should the nurse take first to address the client's educational needs?

creating a plan with the client based upon needs

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.

A nurse has taught a client with asthma how to administer a daily inhaler. How would the nurse evaluate the teaching-learning process?

directly observing the client using the inhaler

A nurse is teaching the importance of personal hygiene and proper bowel movement to a group of clients using gerogogy. Which client is the nurse addressing?

elderly people

Positive client outcomes are the goal of nurse-client interactions. What is an influential factor directly related to positive client-care outcomes?

health education

A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques?

open-ended question

What is a component of nonverbal communication?

paralanguage

A nurse who has been practicing for three decades has seen significant changes in the roles that clients are expected to perform in the course of their care. What is a role that clients are normally expected to perform while they are receiving care?

participate actively in the planning and execution of their care

A student nurse asks the instructor why so much emphasis is being placed on the importance of client teaching. What benefits would the instructor identify? Select all that apply.

reduced lengths of stay better allocation of resources increased client satisfaction

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis?

the public health department

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan

The child of a client who just died in a hospice unit arrives and asks, "May I please stay and sit at the bedside? I really wanted to be here so my dad would not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

Which statement by the student nurse demonstrates understanding of the appropriate way to document an error in charting?

"If I make an error, I draw a single line through it and put my initials by it."

A client scheduled to have hip replacement surgery states, "I am so scared of the surgery and of the anesthetic." What is the best response by the nurse?

"What questions do you have about the surgery?"

Which abbreviation is correct for use in documentation?

PO

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."

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

The nurse is readmitting a client who was discharged 1 week ago with complications from diabetes mellitus. The client states, "I really did not understand what I was supposed to do to care for myself from those papers that I was sent home with." What question will the nurse ask to promote the client's self-esteem?

"How do you learn best and what can we do to provide you with that information?"

Before clients can learn, they must believe that they need to learn the information. The nurse recognizes that this is an example of which learning principle?

relevance

A nurse has developed strong rapport with the wife of a client who has been receiving rehabilitation following a debilitating stroke. The wife has just been informed that her husband will be unlikely to return home and will require care that can only be provided in a facility with constant nursing care. The client's wife 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?"

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

An unequal sharing of information

The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation?

immediately report the suspected abuse of the client.

A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is:

retrieval of information is more efficient.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data?

subjectivity