test 1 nursing
In SBAR, what does R stand for?
Recommendations
A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? A)"Do you take two injections of insulin to decrease the complications?" B)"Most health care providers recommend diet and exercise to regulate blood sugar." C)"Most complications of diabetes are related to neuropathy." D)"What specific complications have you experienced?"
d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.
When documenting client care in the client's health record, which abbreviations would be appropriate for the nurse to use? Select all that apply. D/C per os PO mL cc
PO mL
A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?
Translators may need additional explanations of medical terms.
Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice? empathy positive regard analysis comfortable sense of self
analysis
An informatics nurse specialist is describing the role of informatics in health care to a group of staff at a facility. The nurse specialist determines that the teaching was successful when the group identifies which as a core practice area? You Selected:
electronic health record Page 485
A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?
progress notes
The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy? "I know how you feel. I was the primary caregiver for my father when he was dying." "It's okay to cry. Sometimes that helps us to feel better." "Just take your time. I am listening." "It is difficult when family members are ill. It helps if you take some time for yourself."
"Just take your time. I am listening." pg.165
A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? Pain Anxiety Depression Fluid volume deficit
a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior.
A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? "I am so sorry you are going through this. Can we talk?" "I know this is hard for you. Is there any way I can help?" "Sitting in the dark is not going to cure your cancer. Let's open the curtains." "Can you please tell me why you are crying?"
"I know this is hard for you. Is there any way I can help?" pg.165
A client comes into the urgent care center to have sutures removed on an arm. The nurse finds significant crusting along the suture line. The client states not having time to get the sutures removed a week prior, as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls the arm away and tells the nurse, "You are taking too long and it is hurting a little bit. Just pull them out and get it over with." Which statement is an example of appropriate therapeutic response?
"It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them."
A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response? "You should follow your physician's recommendation and have the surgery." "When you see the physician this morning, request more information about the surgery." "It is a minimally invasive surgery with rapid recovery time, so you will do fine." "Share with me the advantages and disadvantages of your options as you see them."
"Share with me the advantages and disadvantages of your options as you see them." pg.173
A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply. Cheer up. Tomorrow is another day." "Your doctor knows best." "That's a lot of information to take in. Would you like to talk about it?" "Don't worry. You will be just fine in another day or two." "Everything will be all right."
"Your doctor knows best." "Everything will be all right." "Cheer up. Tomorrow is another day." "Don't worry. You will be just fine in another day or two." pg.172
The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? 8:00: Pt is resting in bed and appears to be comfortable. 0800: Resting in bed, eating some breakfast. Complains of headache. 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. 0800: Side rails up, call light in reach. Bed in high position.
0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.
A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? Notifying the nursing team of the client's condition Documenting client data on the flow sheet Keeping an accurate medication record Accurately documenting client care on the client record
Accurately documenting client care on the client record
The nurse is caring for a client who is a victim of sexual assault. Which action would the nurse take to develop a trusting rapport with the client?
Approach the client with empathy and understanding and allow the client to share feelings without being judged.
A client reports to a primary health care provider with aggravated chest pain. The health care provider prescribes a stress test. The client tells the nurse about not wanting to take the test and wanting to continue taking medication for now. Understanding that the client is anxious, which action should the nurse take first to provide education needed for this client? Instruct the client to find information about the test online. Ask the client "What has your health care provider shared with you about stress tests?" Provide the client with an educational booklet about stress tests. Tell the client about the stress test procedure.
Ask the client "What has your health care provider shared with you about stress tests?" pg.168
An informatics nurse specialist is working as part of a team that will be developing and implementing a new client assessment tool. During which phase of the system development lifecycle would the team be integrating information about workflow patterns, standard terminology, and recommendations for screen layout from supportive research?
Design and build p490
A nurse working in a primary care provider's office is using the clnical information system to review a client's health information. The nurse is able to review the client's last visit to the primary care provider as well as information from a recent hospitalization, and also a visit that the client made to the cardiologist last week. The nurse's ability to review this information is based on which aspect of the clinical information system? You Selected:
Interoperability
A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?
Problem-oriented method
The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?
Review the hospital's process for allowing clients to view their health care records.
The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?
The client reports waking up this morning with a severe headache.
The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities? The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needless syringe. The nurse continues with the instructions and makes a mental note to repeat the initial instructions at the end of the training. The nurse stops the instruction and tells the client that a call will be placed to the health care provider to get an order to have a home health nurse administer the medication. The nurse asks the client if he or she is worried about giving oneself an injection.
The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needless syringe. pg.352
During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. A)Group decision making B)Group leadership C)Group power D)Group identity E)Group patterns of interaction F)Group cohesiveness
a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes.
When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? Cliché Giving advice Being judgmental Changing the subject
a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition.
A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? "New mothers need support." "The lack of a father is difficult." "How are you today?" "It is a very sad situation."
a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles.
An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse that the client is afraid of waking up during surgery. The best response by the nurse is to: look directly at the client and state, "You are afraid of waking up during surgery." ask the surgeon to come to the bedside to reassure the client. state "everyone is afraid of that." ask why the client thinks the client will wake up during surgery.
ask why the client thinks the client will wake up during surgery. pg.161
A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? "Would you prefer a bath or a shower?" "May I help you with a bed bath now or later this morning?" "I will be giving you your bath. Do you use soap or shower gel?" "I prefer a shower in the evening. When would you like your bath?"
b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones.
A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A)A closed-ended answer B)Information clarification C)The nurse to give advice D)Assertive behavior
b. The patient's question allows the nurse to clarify information that is new to the patient or that requires further explanation.
A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? Determining the established goals of the institution Ensuring that verbal and nonverbal communication is congruent Engaging in self-talk to plan the day and decrease fear Speaking with fellow colleagues about how they feel
c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety.
During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? A)"You need to speak to the patient quietly so you don't disturb the other patients." B)"Let me help you with your transfer technique." C)"When you are finished, be sure to apologize for your rough demeanor." D)"When your patient is safe and comfortable, meet me at the desk."
d. The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. interpretation of data. important information. relevant data.
interpretation of data.
A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by: asking the client to provide a stool specimen for guaiac testing. asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate. determining whether the client has any food or drug allergies. insisting that the client not eat or drink anything until further instructed.
pg.170
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should: ask the client for a urine specimen for urine drug use screening. consult with the social worker regarding inpatient drug rehabilitation. ask if the client realizes the infection is a direct result of the drug use. remain honest, open, and frank.
remain honest, open, and frank. pg.165
The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?
"I will arrange access for you to review the record after you put your request in writing."
An informatics nurse is planning a training program for the staff of a facility. A new module for outcome identification and evaluation will be added to the current clinical information system. Which type of training would be most appropriate for the staff? Select all that apply. Classroom educational sessions Online training Web-based training Tip sheets Just-in-time training.
Classroom educational sessions Tip sheets
An informatics nurse is demonstrating how to use an updated version of an electronic documentation system to a group of staff nurses. The nurse shows the staff that they can follow the same steps that they used with the previous system but need to add one additional final step to the process. The informatics nurse's actions reflect which concept of usabilty?
Consistency
A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety? "This must have been caused from you moving your arm around." "Just be very still; the procedure is very minimal and will be over soon." "I know that you are anxious, but the IV location needs to be changed." "It will be a painless procedure and there is nothing to worry about; many clients experience this."
"I know that you are anxious, but the IV location needs to be changed." pg.166-167
Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies? "We will discuss the new policies at the change-of-shift report." "You will demonstrate the use of the cardiac monitor on the nursing rounds." "You will see the procedure for using the new equipment in the client assignments." "We will be having a team conference to discuss concerns that clients' relatives have raised."
"We will be having a team conference to discuss concerns that clients' relatives have raised."
A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? "You can fill in information from your own records and store it on your computer or the Internet." "You can link your record to a specific health care organization's electronic health record system." "Your health care provider is obligated to read your personal health record and share it with your insurance provider." "Your entire health care team may access and securely share your vital medical information electronically."
"You can fill in information from your own records and store it on your computer or the Internet." pg.467
A facility plans to implement a new electronic medication documentation system. An informatics nurse specialist conducts a focus group with staff nurses to gather information. The nurse specialist asks the group about the current system being used, including a step-by-step account of the actions they perform. The nurse specialist also asks the nurses how they see this new system affecting this process and their overall daily tasks. The informatics nurse specialist is demonstrating which ANA informatics competency?
Assessment
A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?
Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?
Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10." pg.468
An informatics nurse is assisting with the evaluation of a newly implemented system for electronic documentation of client assessments. The nurse is planning to involve staff nurses in this process. When beginning the evaluation process, the informatics nurse would focus on which area first?
Identifying what will be evaluated
The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?
Inform the health care provider that a written order is needed.
he nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? Problem-oriented recording gives clients the right to withhold the release of their information to anyone. Problem-oriented recording makes it difficult to demonstrate a unified approach for resolving clients' problems among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording has numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client's care.
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. pg468
The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important? Speak directly to the client. Ensure that family members are present. Give all of the discharge instructions at once. Have the interpreter write out all of the information listed in the unit brochure.
Speak directly to the client pg.157
27s Report this Question A nurse is assessing a client who comes to the clinic for an evaluation. During the assessment, the client tells the nurse, "I have this thing on my phone that reminds me to take my medicines when I'm supposed to." The nurse identifies this as reflecting which concept?
Telecare
An informatics nurse specialist is working with a team designing an update to a clinical information system being used by the nursing staff. When selecting the language to be used with the system, which characteristic would be most appropriate to address? Select all that apply. Terminology is clear and concise for the nurses Terminology reflects the technological aspects of a system Terminology is familiar to the user Terminology reflects the users work context Terminology is ambiguous to the user
Terminology is clear and concise for the nurses Terminology is familiar to the user Terminology reflects the users work context pg.494
A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? A)Determining the progress made in achieving established goals B)Clarifying when the patient should take medications C)Reporting the progress made in teaching to the staff D)Including all family members in the teaching session
a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care.
For which purposes would observing silence be appropriate? Select all that apply. To allow the client time to reflect on the client's thoughts To allow the client time to reflect on communication that has occurred To allow the client time to formulate an answer after asking the client a question To allow the client time to compose oneself when the client is upset To allow the nurse time to think of something to say when the nurse doesn't know the answer to a question
all but to allow the nurse time to think of something to say when the nurse doesn't know the answer to a question
A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech? Aggressive Assertive Nonassertive Therapeutic
assertive pg.171
A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? A)"I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." B)"I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" C)"I will need to call in on the 8th of August because I have a doctor's appointment." D)"Since you didn't give me the 8th of August off, will I need to find someone to work for me?"
b. Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time.
During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply: A)Fill the silence with lighter conversation directed at the patient. B)Use the time to perform the care that is needed uninterrupted. C)Discuss the silence with the patient to ascertain its meaning. D)Allow the patient time to think and explore inner thoughts. E)Determine if the patient's culture requires pauses between conversation. F)Arrange for a counselor to help the patient cope with emotional issues.
c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.
When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?
clients tone of voice Chapter 8: Communication - Page 151-152
A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? A)"I'm just the IV therapist checking your IV." B)"I've been transferred to this division and will be caring for you." c)"I'm sorry, my name is John Smith and I am your nurse." D)"My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."
d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient.
A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? The use of reflective questions The use of closed questions The use of assertive questions The use of clarifying questions
d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication.
A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action?The nurse stands at the patient's bedside and states, A) "I understand how you feel. My mother said the same thing when she was ill." B)The nurse places a hand on the patient's arm and states, "You feel so alone." C)The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." D)The nurse holds the patient's hand and asks, "What makes you feel so alone?"
d. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.