Fundies Communication PrepU
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? "Client is reporting that her abdominal pain is rated at 8/10." "Client is guarding her abdomen and occasionally moaning." "Client has a history of recent abdominal pain." "2 mg hydromorphone hydrochloride PO was administered with good effect."
"Client is reporting that her abdominal pain is rated at 8/10." The SOAP method of charting (subjective data, objective data, assessment, plan) begins with the information provided by the client, such as a report of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry. "Client is reporting that her abdominal pain is rated at 8/10" is subjective data from the client. "Client is guarding her abdomen and occasionally moaning," while subjective, does not contain any objective data that are measurable. "Client has a history of recent abdominal pain" is an historical assessment. "2 mg hydromorphone hydrochloride PO was administered with good effect" is a intervention.
The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety? "I will start an IV, which should not take much time." "I will start an IV with the number 18 catheters." "I will start an IV that will add fluids directly to the blood stream." "I will start an IV, which should not cause you too much pain."
"I will start an IV that will add fluids directly to the blood stream." The nurse should explain the procedure and its purpose. The nurse telling the client that it should not take much time does not convey the purpose of the procedure. It is unnecessary for the nurse to inform the client about the technical details of the catheter. Additionally, the nurse should not give false reassurance by telling the client that the procedure will not be painful.
A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Furthermore, when he questioned the nurse, she said that she had other clients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? "I am sorry that you had to suffer this way. The nurse on night duty should be disciplined." "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." "You seem to be feeling impatient. The nurses work very hard and they do whatever they can." "I can see that you are angry. What the nurse did is wrong, and I'll see to it that it won't happen again."
"It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." The nurse should empathize with the client to perceive how the client is feeling. The nurse shares her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The nurse should avoid conveying pity for the client, which is inappropriate. The nurse must avoid labeling the client as impatient. The nurse cannot guarantee that this will not happen again; claiming that the nurse was wrong is presumptuous without knowing all the facts.
The nurse enters a client's room and observes that the client is hunched over and appears to be breathing rapidly. What type of question should the nurse first ask the client in this interaction? A yes or no question A directing question An open-ended question A reflective question
A yes or no question Sometimes a yes or no question is appropriate. In this case, the nurse may want to ask, "Do you feel short of breath?" or something similar. Directing questions and reflective questions follow up on earlier communication. An open-ended question may elicit the necessary assessment data, but a yes or no question accomplishes this goal more directly. Chapter 6: Communication in the Nurse-Patient Relationship - Page 98
The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply. Spoken words Intuition Sight Telepathy Touch Observation
Spoken words Sight Touch Observation Nurses use auditory (spoken words and cues), visual (sight, observations, and perceptions), and kinesthetic (touch) channels to communicate. Intuition may be a determinant of independent nursing interventions but is not a component of effective communication. Telepathy is not a form of nurse-client communication.
The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? The client is receiving sufficient relief from pain medication, stating no pain in either knee. The client appears comfortable and is resting adequately and appears to not be in acute distress. The client reports that on a scale of 0 to 10, the current pain is a 3. The client appears to have a low tolerance for pain and frequently reports intense pain.
The client reports that on a scale of 0 to 10, the current pain is a 3. The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.
A nurse and client are in the working phase of the helping relationship. What outcome statement developed by the nurse and client correlates with this phase? The client will express feelings and concerns to the nurse. The client and nurse will establish goals of the relationship. The nurse and client will determine where and when they will meet. The client will identify the goals that have been accomplished during the relationship.
The client will express feelings and concerns to the nurse. The working phase of the nurse-client relationship is when the nurse and the client work together to meet the client's physical and psychosocial needs. The client expressing feelings and concerns demonstrates the work that is going on to meet the specific goals that are set in the orientation phase. Determining when and where they will meet is established in the orientation phase of the relationship. Identifying the goals that have been accomplished during the relationship is established in the termination phase of the relationship.
The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. Which expectation should the nurse have when developing the relationship? The relationship will occur spontaneously. The nurse and client will have a social relationship. The nurse is accountable for the outcome. The relationship is based on the needs of the nurse.
The nurse is accountable for the outcome. The person-centered or nurse-client relationship does not occur spontaneously, as do most social relationships. It occurs for a specific purpose with a specific person. The client shares information related to personal health problems, whereas the nurse shares information in terms of a professional role. The person-centered or nurse-client relationship is built on the client's needs, not on those of the helping person. The nurse is accountable for the outcome of the relationship.
A nurse is communicating the plan of care for a client who is unconscious. Which nursing actions best facilitate this process? Select all that apply. The nurse speaks to the client in a louder-than-normal voice. The nurse is careful what is said in the client's presence because hearing is the last sense to go. The nurse assumes the client can hear and discusses things that would ordinarily be discussed. The nurse raises environmental noises to help stimulate the client. The nurse does not use touch to communicate with the client. The nurse speaks with the client before touching the client.
The nurse is careful what is said in the client's presence because hearing is the last sense to go. The nurse assumes the client can hear and discusses things that would ordinarily be discussed. The nurse speaks with the client before touching the client. The nursing actions that best facilitate communication with a client who is unconscious would include being careful what is said in the client's presence because hearing is believed to be the last sense to go. The nurse would assume the client can hear and discuss things that would ordinarily be discussed. The nurse would speak with the client before touching the client. The nurse would not speak to the client in a louder-than-normal voice. The nurse would minimize environmental noises to facilitate communication. The nurse would use touch to communicate with the client.
A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse communicates in a busy environment to hold the client's attention. The nurse keeps communication simple and concrete. The nurse gives lengthy explanations of the care that will be given. If there is no response, the nurse does not repeat what is said and takes a break.
The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete. There are several nursing actions that would be appropriate to facilitate. The nurse would maintain eye contact with the client. The nurse shows patience and gives the client time to respond. The nurse keeps communication simple and concrete. The nurse would not communicate in a busy environment because this could be distracting to the client. The nurse would not give lengthy explanations to the client regarding the care to be given. The nurse would repeat the information if no response was shared by the client. Chapter 6: Communication in the Nurse-Patient Relationship - Page 93-95
A nurse in the intensive care unit has just reported for duty. A client is being transferred to the medical floor after change of shift. Which action would the nurse take to ensure maximum efficiency of change-of-shift or transfer reports? Call the receiving nurse with a list of the client's medication. Ask the health care provider to provide transfer report to the receiving nurse. Print the client's medical record to accompany the client during transfer. Utilize the electronic medical record while providing report to the receiving nurse.
Utilize the electronic medical record while providing report to the receiving nurse. To ensure that all information is relayed to the receiving nurse, the nurse should utilize the electronic medical record to report vital signs, medications, and appropriate lab values to the receiving nurse. The nurse would not print the entire electronic medical record for a transfer in the same facility. The health care provider would not provide transfer report to the receiving nurse. When providing transfer report, the nurse would include more information than only medications.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a flow sheet acuity charting forms a medication record a 24-hour fluid balance record
a flow sheet A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs. Chapter 16: Documentation and Communication in the Healthcare Team, p. 262.
A nurse anticipates collaborating with the nurse aide, physical therapist, surgeon, and respiratory therapist in which circumstance? caring for a client following a total hip replacement preparing a client to receive treatment for partial-thickness or second-degree burns feeding a client who has difficulty swallowing after a stroke ambulating a client with a new leg cast and crutches
caring for a client following a total hip replacement The nurse acts as a collaborator and is responsible for managing client care and delegating care to others, such as an unlicensed assistive personnel (UAP). Collaboration also occurs with other members of the health care team, such as the physician. In this case, the client would benefit from physical therapy and respiratory therapy following surgery. The client preparing to receive treatment for a partial-thickness or second-degree burn, the client who has trouble swallowing, and the ambulating client with a new cast would not benefit as much from the collaboration with the nurse, nurse aide, physical therapist, surgeon, and respiratory therapist.
A nurse is working on a medical surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which information will the nurse consider when deciding what nursing actions to delegate to the LPN/LVN? Select all that apply. hospital policy client stability scope of practice LPN/LVN teaching ability LPN/LVN proficiency level
hospital policy client stability scope of practice LPN/LVN proficiency level As nurses perform the role of delegators, they must know which tasks are legal and appropriate for particular healthcare providers to perform, or the scope of practice. They must also know the policy for the facility at which they are employed. Nurses must ensure that the person they are delegating the task to has the expertise and knowledge to perform it correctly, that the client is stable, and the task does not require the expertise of the registered nurse to perform. Teaching is not in the current scope of practice for a LPN/LVN. Chapter 6: Communication in the Nurse-Patient Relationship - Page 244
The nurse encourages a client to participate in the communication process by using an opening remark based on observations and assessment. Which approach would be most effective for the nurse to use to promote trust? intrusive neutral interrogative probing
neutral The nurse should use opening remarks which are neutral and tentative to begin a conversation. Interrogative, probing, and intrusive remarks are threatening and nontherapeutic. They may block further communication between the client and the nurse. Chapter 6: Communication in the Nurse-Patient Relationship - Page 98
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? closed question reflective question open-ended question validating question
open-ended question The nurse's question allows for a wide range of responses and encourages free verbalization, characteristics of a useful open-ended question. Validating questions allow the nurse to confirm what was previously said, while closed questions necessitate a "yes" or "no" answer. A reflective question or comment repeats what the client has recently said. Chapter 6: Communication in the Nurse-Patient Relationship - Page 98
