Fundamentals of Nursing, Communication, Care 1: Communications

The nurse plans to administer a 3-mL intramusclar injection. The nurse understands that LEAST desirable muscle for the administration of this medicine is: 1. Deltoid 2. Dorsogluteal 3. Ventrogluteal 4. Vastus Lateralis

1. The deltoid, on the lateral aspect of the upper arm, is a small muscle that is incapable of absorbing a large medication volume. The site is more appropriate for 1mL of solution.

The nurse understands that human responses can be classified as objective or subjective. Identify those that are subjective: SELECT ALL THAT APPLY 1. Nausea 2. Jaundice 3. Dizziness 4. Diaphoresis 5. Hypotension

1, 3

Which route is unrelated to the parenteral administration of medications? 1. Buccal 2. Z-Track 3. IV 4. Intradermal

1. A parenteral medication is one that does not use the GI tract. A medicine administered in the buccal area is in the mouth, which is part of the GI tract.

The nurse plans to administer a bolus dose of a medication via a currently running IV infusion. The nurse should first: 1. Ensure that it is compatible with the IV solution being infused. 2. Pinch the tubing above the the infusion port while instilling the bolus. 3. Instill it into a 50 mL bag of NS and infuse it via a secondary line. 4. Administer it via a volume-control infusion set with microdrip tubing.

1. An incompatible solution can increase, decrease or neutralize the effects of medications.

The nurse is administering an intradermal injection. The nurse inserts the needle at a: 1. 15 degree angle 2. 30 degree angle 3. 45 degree angle 4. 90 degree angle

1. An intradermal injection is administered by inserting a needle at a 10 to 15 degree angle through the skin with the bevel facing upwards in the skin.

During which of the 5 steps in the nursing process does the nurse analyze the data critically? 1. Diagnosis 2. Clustering 3. Collection 4. Assessment

1. During the diagnosis step of the Nursing Process data are critically analyzed and interpreted, significance of the data is determined, inferences are made and validated, sues and clusters of cues are compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing diagnoses are identified and prioritized.

What is being communicated when the nurse leans forward during a patient's interview?

1. Leaning forward is a nonverbal behavior that conveys involvement. It is a form of physical attending, which is being present to another.

The physician orders a rectal suppository for an adult patient. When administering the rectal suppository, the nurse should: 1. Lubricate the medication before insertion 2. Warm the medication to body temperature 3. Insert the medication at least two inches into the rectum. 4. Place the patient in the prone position to administer the medication.

1. Lubrication ease insertion by reducing friction which limits tissue trauma and discomfort.

The planning step of the nursing process is influenced most directly by the: 1. Related factors 2. Diagnostic label 3. Secondary factors 4. Medical diagnosis

1. Related factors (etiology, contributing factors) contribute to the problem statement of the nursing diagnosis and directly impact on the planning step of the NP.

The nurse understands that the appropriateness of a Nursing diagnosis is supported by: 1. Defining characteristics 2. Planned interventions 3. Diagnostic statement 4. Related risk factors

1. The defining characteristics are the major and minor cues that form a cluster that support or validate a nursing diagnosis. At least one major defining characteristic must be present for a nursing diagnosis to be considered appropriate for that patient.

The nurse understands that evaluation most directly relates to which aspect of the nursing process? 1. Goal 2. Problem 3. Etiology 4. Implementation

1. The evaluate the effectiveness of a nursing action, the nurse needs to compare the actual patient outcome with the expected patient outcome. The expected outcomes are measurable data that reflect goal achievement, while the actual outcomes are what really happened.

An essential concept related to understanding the Nursing Process is that it: 1. Is dynamic rather than static 2. Focuses on the role of the nurse 3. Moves from simple to the complex 4. Is based on the patient's medical problem

1. The nursing process is dynamic process that is designed to diagnose and treat human responses to health problems. The nurse moves among the steps as necessary to meet the needs of the patient.

A patient verbally communicates with the nurse while exhibiting nonverbal behavior. To confirm the meaning of the nonverbal behavior, the nurse should: 1. Look for similarity in meaning between the patient's verbal and nonverbal behavior. 2. Ask family members to help interpret the patient's behavior. 3. Validate inferences by asking patient questions. 4. Recognize that what the patient says is most important.

1. The patient is the primary source of information. When nonverbal communication reinforces the verbal message, the message reflects the true feelings of the patient because non verbal behavior is under less conscious control than verbal statements.

The stage of the interview that establishes the relationship between the nurse and the patient is the: 1. Opening stage 2. Working stage 3. Surrogate state 4. Examining state

1. The purposes of the opening stage of an interview are to establish rapport and orient the interviewee. A relationship is established through a process of creating goodwill and trust. The orientation focuses on explaining the purpose and nature of the interview and what is expected of the patient.

The nurse uses reflective technique when communicating with an anxious patient. The nurse uses reflective technique in this situation because it focuses on: 1. Feelings 2. Content themes 3. Clarification of information 4. Summarization of the topics discussed

1. The reflective technique requires active listening to identify the underlying emotional concerns or feelings contained in a patient's messages. These feelings are then referred back to the patients to promote a clearer understanding of what they have said.

The nurse understands that the statement that is most accurate about communication is: 1. Communication is inevitable 2. Behavior clearly reflects feelings. 3. Hands are the most expressive part of the body. 4. Verbal communication is essential for human relationships.

1. Theory indicates that all behavior has meaning, people are always behaving, and we cannot stop behaving or communicating, therefore communication is inevitable.

The nursing action that best reflects the concept of therapeutic communication is: 1. Using interviewing skills to discuss the patients concerns 2. Letting the patient control the focus of the conversation 3. Setting time aside to talk with the patient 4. Agreeing with the patient's statements.

1. Therapeutic communication is patient-centered and goal-directed. It facilitates the exploration of the patient's thoughts and feelings and helps to establish a constructive relationship between the nurse and patient.

Which interviewing skill is being used when the nurse says, "You mentioned before that you are having a problem with your colostomy?": 1. Focusing 2. Clarifying 3. Paraphrasing 4. Acknowledging

1. This example of focusing helps the patient explore a topic of importance. The nurse selects one topic for further discussion from among several topics presented by the patient.

The nurse is collecting data for an admission nursing history. Which question by the nurse is best to open the discussion? 1. What brought you to the hospital? 2. Would it help to discuss your feelings? 3. Do you want to talk about your concerns? 4. Would you like to talk about why you are here?

1. This is a focused open-ended statement that invites the patient to communicate while centering on the reason for seeking health care.

A patient who is to receive nothing by mouth (NPO) in preparation for a bronchoscopy says,"I am worried about the test and I can't even have a drink of water." What is the best response by the nurse? 1. "Lets talk about your concerns regarding this test." 2. "I'll see if the doctor will let you have some ice chips" 3. "The doctor will review the results of the test as soon as possible." 4. As soon as the test is over I'll get you whatever you would like to drink."

1. This response encourages the patient to explore concerns. Verbalization of concerns, validating of feelings, and patient teaching may help reduce anxiety.

An agitated 80 year old patient states, "I'm having trouble with my bowels." Which response by the nurse incorporates the interviewing skill of reflection? 1. "You seem distressed about your bowels." 2. "You're having trouble with your bowels?" 3. "It's common to have problems with the bowels at your age." 4. "When did you first notice having trouble with your bowels."

1. This response recognizes the and reflects back the underlying feeling in the patients message (reflective technique). When people consider themselves in trouble, they usually feel threatened or stressed.

The nurse is preparing the draw up medication from a vial. What should the nurse do first? 1. Ensure the needle is firmly attached to the syringe. 2. Rub vigorously back and forth over the rubber cap of the medication vial with an alcohol swab. 3. Inject air into the vial with the needle bevel below the surface of the medication. 4. Draw up slightly more air that the volume of the medication to be withdrawn from the vial

1. This will ensure a tight seal and a closed system.

The nurse identifies that the patient statement that provides subjective data is: 1. I am not sure that I am going to be able to manage at home by myself 2. I can call a home-care agency if I feel I need help at home. 3. What should I do if I have uncontrollable pain at home? 4. Will a home health aide help me with my care at home?

1.This is subjective information because it is the patient's perception and can only be verified by the patient

Nurses use the Nursing Process to provide nursing care. These statements reflect nursing care being provided to a variety of patients. Place the statements in order as the nurse progresses through the NP starting with assessment and ending with evaluation: 1. "I am going to give you an enema" 2. What brought you to the hospital today? 3. The patients adaptations indicate that he is dehydrated 4. The patient will have a bowel movement in the morning 5. Did you sleep last night after I gave you the sleeping medication?

2,3,4,1,5

The nurse understands that subjective data has been obtained when the patient states: 1. "I just went in the urinal and it needs to be emptied" 2. "My pain feels like a 5 on a scale of 1 to 5." 3. "The doctor said I can go home today." 4. " I only ate half my breakfast."

2. A patient's perception about pain level is subjective information. It is a feeling only the patient can confirm.

Which human response identified by the nurse is an example of objective data? 1. Pain of 5 on 1 to 10 pain scale. 2. Irregualr rapid pulse of 50 bpm 3. Shortness of breath 4. Dizziness

2. A radial pulse is objective, not subjective, data. Objective data is measurable and checkable.

The main purpose of the working phase of a therapeutic nurse-patient relationship is to: 1. Establish a formal or informal contract that addresses the patients problems 2. Implement nursing interventions designed to achieve expected patient outcomes. 3. Develop rapport and trust so the patient feels protected and an initial care plan can be identified 4. Clearly identify the role of the nurse and establish parameters of the professional relationship.

2. During the working phase of the therapeutic relationship, nursing interventions have a two fold purpose: assisting patients to explore and understand their thoughts and feelings and supporting patient decisions and actions.

During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved? 1. Implementation 2. Evaluation 3. Diagnosis 4. Planning

2. Evaluation occurs when actual outcomes are compared with expected out comes that reflect goal achievement. If a goal is achieved, the patient's needs are met.

The nurse is changing a patient's dressing over an abdominal wound. What level of space around the patient is entered during the dressing change? 1. Personal 2. Intimate 3. Social 4. Public

2. Physically caring for a patient involves inspection and touch that invades the instinctual, protective distance immediately surrounding an individual. Intimate space (less than 1.5 feet) is characterized by body contact and visual exposure.

Which nursing action reflects an activity associated with diagnosis step of the Nursing Process? 1. Formulating a plan of care. 2. Identifying the patient's potential risks 3. Designing ways to minimize a patients stressors 4. Making decisions about the effectiveness of patient care.

2. Potential risk factors are identified during the diagnosis step of the nursing process.

The patient appears tearful and is quiet and withdrawn. The nurse says, "You seem very sad today." What interviewing approach did the nurse use? 1.Examining 2.Reflecting 3.Clarifying 4.Orienting

2. Reflective technique refers to feelings implied in the content of verbal communication or in exhibited nonverbal behaviors. Patients who are crying, quiet and withdrawn are often sad.

The nurse understands that the primary goal of the assessment phase of the Nursing Process is to: 1. Build trust and rapport 2. Collect and cluster data 3. Establish goals and outcomes 4. Identify and validate the medical diagnosis.

2. The primary purpose of assessment in the NP is to collect data from various sources using a variety of approaches. After data is collected, it should be clustered into meaningful categories.

Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the patient holistically? 1. Teacher 2. Advocate 3. Surrogate 4. Counselor

2. When the nurse supports, protects, and defends a patient from a holistic view point, the nurse functions as an advocate.

The nurse must conduct a focused interview to complete an admission history. Which interviewing technique should the nurse use? 1. Probing 2. Clarification 3. Direct questions 4. Paraphrasing

3. A focused interview explores a particular topic or obtains specific information. Direct questions meet these objectives and avoid extraneous information.

The physician orders a medication that must be administered transdermally. The nurse understands that a drug administered transdermally is: 1. Inhaled into the respiratory tract. 2. Dissolved under the tongue 3. Absorbed through the skin 4. Inserted into the rectum

3. A medicated patch or disk can be applied directly to the skin where the medication is released and absorbed over time.

The nurse instructs a patient to close his/her eyes after the administration of eye drops. The nurse understands this is done to: 1. Limit corneal irritation. 2. Squeeze the excess medication from the eyes. 3. Disperse the medication over eyeballs 4. Prevent medication from entering the lacrimal duct.

3. Closing the eyes moves the medication over the conjunctiva and eyeball and helps ensure even distribution of medication.

During the evaluation step of the Nursing Process, the nurse must: 1. Establish outcomes 2. Determine priorities 3. Take corrective action 4. Set the time frames for goals

3. Corrective action takes place in the evaluation step of the NP. If during an evaluation is it determined that a goal was not met, the reasons for failure must be identified and the plan modified.

When providing nursing care, humor should be used to: 1. Diminish feelings of anger 2. Refocus the patients attention 3. Maintain a balanced perspective 4. Delay dealing with the inevitable

3. Humor is an interpersonal tool and it is a healing strategy. It releases physical and psychic energy, enhances well-being, reduces anxiety, increases pain tolerance, and places experiences within the context of life.

The nurse teaches the patient about taking sublingual nitroglycerin tablets. The nurse evaluates that the patient understands when the patient states "I should place it..." 1.On my skin 2. Inside my cheek 3. Under my tongue 4. In the lower lid of my eye

3. Sublingual medication is placed under the tongue. It is absorbed quickly through the mucous membranes into the systemic circulation.

The nurse collects objective data when a hospitalized patient states: 1. "I am hungry" 2. "I feel very warm" 3. "I ate half my lunch" 4. I have the urge to urinate"

3. The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed.

When placing cream into a patient's vaginal canal, the nurse should use: 1. A finger 2. A gauze pad 3. An applicator 4. An irrigation kit

3. The consistency of a cream requires that an applicator be used to ensure that the medication is deposited along the full length of the canal.

When considering the Nursing process, the nurse understands that the word "observe" is to "assess" as the word "determine" is to: 1. Plan 2. Analyze 3. Diagnose 4. Implement

3. The definitions of the words "observe" and "assess" are similar as are the definitions of "determine" and "diagnose".

A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is most directly related to this concept? 1. Defining characteristics 2. Outcome criteria 3. Etiology 4. Goal

3. The etiology (also known as contributing factors) are the conditions, situations, or circumstances that add to the development of the human response identified in the problem statement of the nursing diagnoses.

The nurse is attempting to develop a helping relationship with a patient who was recently diagnosed with cancer. The nurse understands that a factor that is unique to this helping relationship is that it is: 1. Characterized by allowing the patient to take the dominant role. 2. Distinguished by an equal sharing of information. 3. Specific to a person while guided by a purpose 4. Based on the needs of both participants.

3. The helping relationship (interpersonal relationship, therapeutic relationship) is a personal, client-focused, goal oriented process whereby the nurse assists a person to problem solve and meet needs.

The nurse understands that the word most closely associated with scientific principles is: 1. Data 2. Problem 3. Rationale 4. Evaluation

3. The word rationale is closely related to the term "scientific principles". Scientific principles are based on rationales.

A young man who had a leg amputated because of trauma says " No one will ever choose to love a person with one leg." What is the best response by the nurse? 1. You are a good looking young man, and you will have no trouble meeting someone who cares. 2. You may feel that way now, but you will feel differently as time passes. 3. Do you feel that no one will marry you because you have one leg? 4. How do you see our situation at this point?

3. This is an example of paraphrasing, which restates the patients message in similar words. It promotes communication.

The nurse evaluates that therapeutic communication is effective when: 1.Verbal and nonverbal communication is congruent. 2. Interaction is conducted in a professional manner. 3. Common understanding is achieved. 4. Thoughts can be put into words.

3. Understanding is the foundation of therapeutic communication. When the nurse comprehends, appreciates and empathizes with the patient, therapeutic communication is achieved.

The nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information? 1. Observing 2. Inspection 3. Auscultation 4. Interviewing

4 Interviewing a patient is the most effective data collection method when collecting subjective data associated with a patient's anxiety. The patient is the primary source for information about perceptions, feelings, fears, concerns, beliefs and values.

The nurse collects data about the patient. Next the nurse should? 1. Write a patient centered goal 2. Formulate a nursing diagnosis 3. Design a plan of nursing interventions 4. Determine the significance of the information.

4. After data are collected, they are clustered to determine significance.

The nurse comes to the conclusion that a patient's elevated temperature, pulse, and respiration are significant. What step of the Nursing Process is being used when the nurse comes to this conclusion? 1. Implementation 2. Assessment 3. Evaluation 4. Diagnosis

4. During the diagnosis step of the Nursing Process data are critically analyzed and interpreted, significance of the data is determined, inferences are made and validated, sues and clusters of cues are compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing diagnoses are identified and prioritized.

The nurse plans to foster a therapeutic relationship with a patient. It is most important that the nurse: 1. Works on establishing a friendship with the patient. 2. Use humor to defuse emotionally charged topics of discussion. 3. Sympathize with the patient when the patient shares sad feelings. 4. Demonstrate respect when discussing emotionally charged topics.

4. Emotionally charged topics should be approached with respectful, sincere, interactions that are accepting and non-judgmental, which will promote further verbalization.

A patient has multiple diagnostic tests performed. Where in the patient's chart can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reported? 1. Physician's History and Physical 2. Social Service Record 3. Admission Sheet 4. Progress Notes

4. Generally the Progress Notes contain the documentation by all members of the health team. After a patient is admitted and diagnostic tests are completed, the patient's medical diagnosis may change. The ingoing changes are documented in the progress notes.

The nurse is preparing the administer a subcut injection of insulin. The nurse knows that the best site to use to promote it's absorption in: 1. Upper lateral arms 2. Anterior thighs 3. Upper chest 4. Abdomen

4. The abdomen is the preferred site for administration of insulin because is a large area that promotes a systematic rotation of injections and it has the fastest rate of absorption.

A mother whose daughter has died of leukemia is crying, and is unable to talk about her feelings. What is the best response by the nurse? 1. "Everyone will remember he because she was so cute, she was one of our favorites." 2. "As hard as this is, it is probably for the best because she was in a lot of pain." 3. She put up a good fight but now she is out of pain and in heaven." 4. I feel so sad. It can be hard to deal with such a precious loss.

4. The first sentence communicates empathy. The second sentence focuses on the feeling surrounding loss and provides and opportunity for the patient to verbalize.Both of these are therapeutic responses to the situation.

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?: 1. Reassess the patient 2. Examine the "related to" factors 3. Analyze the "secondary to" factors 4. Review the defining characteristics

4. The first thing the nurse should do to differentiate between two closely related nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the diagnoses being considered.

Determine what nursing actions will be employed occurs during which step of the nursing process? 1.Implementation 2. Assessment 3. Diagnosis 4. Planning

4. The identification of nursing actions designed to help a patient achieve a goal occurs during the planning step of the NP.

The patient states " I think that I am dying" The nurse responds, "You feel as though you are dying?". What interview approach did the nurse use? 1.Focusing 2. Reflecting 3.Validating 4. Paraphrasing

4. The nurses response is an example of paraphrasing because it uses similar words to restate the patients message.

The goals of therapeutic communication mainly should depend on: 1. Environment in which communication takes place. 2. Role of the nurse in that particular setting 3. Skill level of the nurse in the situation. 4. Concerns of the patient.

4. The patient and significant others and their needs are always the focus of nursing interventions, including the goals of communication.

The patient states "My wife is going to be very upset that my prostate surgery probably is going to leave me impotent." What is the best response by the nurse? 1.I'm sure your wife will be willing to make the sacrifice in exchange for your well-being 2.The doctors are getting great results with nerve-sparing surgery today. 3.Your wife may not put as much emphasis on sex as you think. 4.Let's talk about how you feel about this surgery.

4. The patient may be using projection to cope with the potential for impotence. This response indicates that it is acceptable to talk about sexuality and invites the patient to verbalize concerns.

The instructions on a medication states to use the Z-track technique when administering the injection. Therefore the nurse should: 1. Pinch the site throughout injection 2. Massage the site after needle is removed 3. Remove the needle immediately after the medication is injected. 4. Change the needle after the medication is drawn into the syringe.

4. This ensures that medication is not on the outside of the needle, which prevents tracking of medication into subcutaneous tissue during needle insertion.

The nurse is caring for a male patient with a urinary elimination problem. Which is the most accurately stated goal? "The patient will...": 1. Be taught how to use the urinal when on bed rest 2. Experience fewer incontinence episodes at night 3. Be assisted to the toilet every two hours and whenever necessary 4. Transfer independently and safely to a commode before discharge.

4. This is a correctly worded goal. Goals must be patient centered, measurable, realistic and include a time frame.

The nurse is caring for a patient with a fever. Which is a well designed goal for this patient? "The patient will..." 1. Have a lower temperature 2. Be given aspirin every eight hours p.r.n 3. Be taught how to take an accurate temperature 4. Maintain fluid intake sufficient to prevent dehydration.

4. This is a well written goal. Goals must be patient centered, measurable, realistic and include a time frame.

The nurse teaches a patient to use visualization to cope with chronic pain. This action reflects which step of the nursing process? 1. Planning 2. Diagnosis 3. Evaluation 4. Implementation

4. This is an example of implementation during the NP. During the implementation step, planned nursing care is delivered.

The patient is exhibiting anxious behavior and states, "I just found out that I have cancer everywhere and I don't have long to live. My life is over." What is the best response by the nurse? 1. It might be good if your wife were here right now. Shall I call her? 2. What might be the best way to approach this terrible news? 3. That is so sad, you must feel like crying. 4. It sounds like you feel hopeless.

4. This is an example of reflective technique. When no solutions to a problem are evident, a person becomes hopeless.

When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to: 1. Plan 2. Evaluate 3. Diagnose 4. Implement

4. This is the correct analogy. The words identify and recognize have the same definition. The words do and implement also have the same definition.

The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: 1. Diagnose if the patient is at risk for falls 2. Ensure that the patient's skin is intact 3. Establish a therapeutic relationship 4. Identify important data

4. This is the primary purpose of a nursing admission assessment. Data must be collected and then analyzed to determine significance, and grouped in meaningful clusters before a nursing diagnosis can be made.

The patient states "I can't believe I couldn't even eat half my breakfast." Which statement by the nurses uses the interviewing skill of reflection? 1. Let's talk about your inability to eat. 2. What part of your breakfast were you able to eat? 3. How long have you been unable to eat most of your breakfast? 4. You seem surprised that you weren't able to eat all of our breakfast.

4. This question is an example of reflective technique because it focuses on the feeling of surprise.

A patient says, "I don't know if I'll make it through this surgery." Which response by the nurse may block further communication by the patient? 1."You sound scared" 2."You think you will die" 3."Surgery can be frightening" 4."Everything will be alright"

4. This response is false reassurance. It denies the patient's concerns about survival and does not invite the patient to elaborate.

The patient is upset and crying and mentions something about her job and the nurse cannot understand. The nurse's best response is: 1. It's natural to be worried about your job. 2. Your job must be very important to you. 3. Calm down so that I can understand what you are saying. 4. I am not quite sure I heard what you were saying about your work.

4. This response requests additional information in an attempt to clarify an unclear message.

The patient says, "I'm really nervous about having a spinal tap tomorrow." The best response by the nurse is: 1. "I'll ask the doctor for a little medication to help you relax." 2."Patients who have had a spinal tap say it's not that uncomfortable." 3. " The doctor is excellent and is very careful when spinal taps are done." 4. " It's alright to be nervous, and I don't remember anyone who wasn't."

4. This statement is therapeutic. It recognizes the patient's feelings, gives the patient permission to feel nervous and reassures the patient that one's behavior is not unusual. This statement sets the groundwork for the next statement, such as "Let's talk a little about the spinal tap and the concerns you may have."

The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?"

A. "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having."

Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.

A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking.

Identify behaviors that foster the development of trust. (Select all that apply.) A. Answer the call light promptly. B. Call the patient by first name unless requested otherwise. C. Do all the care as quickly as possible and leave the room so the patient can rest. D. Answer questions honestly. E. Demonstrate competence when doing treatments.

A. Answer the call light promptly. D. Answer questions honestly. E. Demonstrate competence when doing treatments.

Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals

A. Taking vital signs of clients on the nursing unit Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP.

The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift

A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status.

A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation

A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.

The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply. A. Client and Family B. Other nursing staff on the unit C. Security department D. Hospital administration E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

A. Client and Family B. Other nursing staff on the unit Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.

The nurse would make which of the following inferences after performing the appropriate client assessment? A. Client is hypotensive B. Respiratory rate of 20 breaths per minute C. Oxygen saturation of 95% D. Client relays anxiety about blood work

A. Client is hypotensive Rationale: An inference is the nurse's judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences.

When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones

A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement.

The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. A. Hopelessness B. Powerlessness C. Interrupted sleep pattern D. Disturbed self esteem E. Self care deficit

A. Hopelessness B. Powerlessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).

The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete data B. Generalize from experience C. Identifying with the client D. Lack of clinical experience

A. Incomplete data Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented.

During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation

A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview.

After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods? A. Return demonstration B. Explanation C. Achievement of 90 on written test D. Have client explain produce to the family

A. Return demonstration Rationale: Interpersonal skills are the sum of the activities the nurse uses when communicating with others. Technical/psychomotor skills are "hands-on" skills, which are often procedures and are evaluated by return demonstration. Cognitive skills are the intellectual skills of analysis and problem-solving and are evaluated by tests.

The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source

A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source?

Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

A. The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse? A. Discomfort B. Deficit C. Feeding D. Fractured wrists

D. Fractured Wrists Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the client's feeding problem.

You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, "Why don't you figure it out?" What would be the best response? A. Say nothing and walk away. Find a different nurse to help you. B. "When you brush me off like that, it takes me even longer to do my job." C. "Why do you always put me down like that?" D. "I guess I just enjoy having you make fun of me."

B. "When you brush me off like that, it takes me even longer to do my job."

Which of the following statements would be most likely to block communication? A. "You look kind of tired today." B. "Why do you always put so much salt on your food?" C. "It sounds like this has been a hard time for you." D. "If you use your oxygen when you walk, you may be able to walk farther."

B. "Why do you always put so much salt on your food?"

The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" C. "Were you aware I've has this same type of surgery?" D. "What would you like to talk about?"

B. "You are really excited about the plastic surgery, aren't you?" Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning.

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop client goals

B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours

B. Anxiety Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.

The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly

B. Call the prescriber to discuss the order and the nurse's concern Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe.

The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique? A. Providing information B. Clarifying C. Focusing D. Paraphrasing

B. Clarifying

The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply. A. Client has an actual health problem B. Client has a wellness diagnosis C. Collaborative health problem needs to be written D. Possible nursing diagnosis exists E. Specific questions about the diet should be asked next

B. Client has a wellness diagnosis E. Specific questions about the diet should be asked next Rationale: The description indicates a healthy pattern of nutrition for the client. A wellness diagnosis might be stated as: "Potential for enhanced nutrition." An actual health problem is a client problem that is currently present. The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature.

Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? A. Provide her the opportunity to practice drawing up insulin B. Coach her to give herself positive messages about her ability to do this C. Bring her written material that clearly describes the steps of insulin administration D. Use therapeutic communication to help her express her feeling about giving herself an injection

B. Coach her to give herself positive messages about her ability to do this

The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abnormal assessment C. Administer an anti-nausea medication D. Notify the physician

B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment.

The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should: A. Formulate post-discharge nursing diagnoses B. Draw conclusion about resolution of current client problems C. Assess the client for baseline data to be used at the LTC facility D. Plan the care that is needed in the LTC facility

B. Draw conclusion about resolution of current client problems Rationale: Terminal evaluation is done to determine the client's condition at the time of discharge. This evaluation is best reflected in option 2 because it focuses on which goals were achieved and which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, such as twice a week. Items related to care post-discharge (options 2, 3, and 4) should be done on admission to the LTC facility.

The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain

B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.

The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background-Assessment-Recommendation) to help with the communication. What does the nurse first address? A. The respiratory rate is 28. B. The patient has a history of lung cancer. C. The patient is short of breath. D. He or she requests an order for a breathing treatment.

C. The patient is short of breath.

The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4).

Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) A. Turning on the television to her favorite show B. Pulling the curtain to provide privacy C. Offering to discuss information about her condition D. Asking her why she is crying E. Sitting quietly by her bed and hold her hand

B. Pulling the curtain to provide privacy C. Offering to discuss information about her condition E. Sitting quietly by her bed and hold her hand

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief

B. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation.

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis

B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

B. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention.

When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication

B. Suggesting the medication can be diluted in a beverage Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication.

Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes

B. The client will lose 4 lbs. within next 2 weeks Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed.

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."

B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.

When the nurse takes the patient's nursing history, he or she sits: A. Next to the patient. B. 4 to 12 feet from the patient. C. 18 inches to 4 feet from the patient. D. 12 inches to 3 feet from the patient.

C. 18 inches to 4 feet from the patient.

Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers

C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk.

Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse

C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.

Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond? A. Use therapeutic communication to assess for increased anxiety B. Sit down and position yourself closer so you are at eye level C. Deflect your eyes downward to show respect D. Continue to maintain eye contact

C. Deflect your eyes downward to show respect

A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview? A. Help the client to get settled and do the interview the next morning when the client is rested B. Do the interview immediately, directing the majority of the questions to the client's spouse C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns Rationale: To collect data accurately, the client must participate. Attending to the client's immediate personal needs before expecting the client to focus on the interview will maximize the accuracy of the data collected. Data should be collected shortly after admission. The best source of data is the client. The management of the client's anxiety is the responsibility of the nurse conducting the interview and initiating the relationship.

A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation B. Goal met: Client cited numbness and tingling as sign of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation D. Goal not met: Client unable to describe signs of impaired circulation

C. Goal not met: Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal.

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation.

In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens

C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan.

The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question? A. Close-ended question B. Open-ended question C. Leading question D. Neutral question

C. Leading question Rationale: A leading question is asked in a way that suggests the type of answer that is expected. This can result in inaccurate data collection. A closed-ended question generally requires only a "yes" or "no" or short factual answer. Open-ended questions encourage clients to elaborate on their thoughts and feelings. Neutral questions do not influence the client's answer.

You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? A. Leave the room quietly since she evidently does not want to be bothered right now B. Repeat the question in a loud voice, speaking very slowly C. Move to her bedside, get her attention, and repeat the question while facing her D. Bring her a communication board so she can express her needs

C. Move to her bedside, get her attention, and repeat the question while facing her

A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? A. Uses a dictionary to give directions for medication administration B. Explains the directions to the patient's 14-year-old daughter C. Obtains an interpreter to facilitate communication of medication information D. Uses a picture board and visual aids to communicate medication administration information

C. Obtains an interpreter to facilitate communication of medication information

The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness

C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions.

When working with an older adult, the nurse remembers to avoid: A. Touching the patient. B. Allowing the patient to reminisce. C. Shifting quickly from subject to subject. D. Asking the patient how he or she feels.

C. Shifting quickly from subject to subject.

The nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. B. A weight of 185 lbs. is recorded in the chart C. The client reported an infected toe D. The client's blood pressure is 124/70. It was 118/68 yesterday.

C. The client reported an infected tow Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement.

Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase.

Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated

D. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm.

A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed, possibly suicidal B. Client reports being tired of being ill and wants to die C. Client does not want to live any longer and is tired of being ill D. Client states, "I'm tired of being sick. I wish I could end it all."

D. Client states, "I'm tired of being sick. I wish I could end it all." Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal

D. Client voided 250 mL of urine 2 hours after the urinary catheter removal Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report.

The nurse would write which of the following outcome statements for a client starting an exercise program? A. Client will walk quickly three times a day B. Client will be able to walk a mile C. Client will have no alteration in breathing during the walk D. Client will progress to walking a 20-minute mile in one month

D. Client will progress to walking a 20-minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.

The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan B. Recopy the care plan without the resolve diagnosis C. Write a nursing process not indicating that the outcome goals have been achieved D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members.

Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation

D. Evaluation Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions.

The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? A. Referent B. Channel C. Environment D. Feedback

D. Feedback

What phase of the therapeutic relationship is characterized by finding healthy ways to conclude a relationship?

Phase 4 - Termination phase

The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals

D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings.

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

D. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs

D. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions.

You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? A. Summarize what you have talked about in the previous sessions B. Review his medical record and talk to other nurses about how he is reacting C. Explore his feelings about losing his leg D. Talk with him about his favorite hobbies

D. Talk with him about his favorite hobbies

The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time

D. Target time Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair."

The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? A. The professional nurse consults the health care provider for direction in establishing goals for patients. B. The professional nurse depends on the latest literature to complete an excellent plan of care for patients. C. The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. D. The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

D. The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

What phase of the therapeutic relationship is characterized by gathering information before meeting the client?

Phase 1 - Pre-Interaction phase

What phase of the therapeutic relationship is characterized by meeting clients, making conversation, and establishing rapport?

Phase 2 - Orientation phase

What phase of the therapeutic relationship is characterized using techniques related to therapeutic communication and allowing the client to clarify any concerns?

Phase 3 - Working phase