Ch. 8 and Ch.33 Prep U for NUR 225
"Do you have any questions about your cholecystectomy?"
The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed?
thrombus formation
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?
"Do you have any questions about your cholecystectomy?" The nurse should be careful to use lay terminology when speaking with clients unless the nurse knows the client is a health care professional. The client may not understand what a cholecystectomy is. The other questions are appropriate and the client should be able to understand them.
The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed?
Orientation phase
*A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?
closed-ended questions.
*Each of the following facilitates a therapeutic nurse-client relationship except:
aggressive
A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:
"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital."
A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?
be aware of one's own personality.
In the provision of care and the establishment of the therapeutic relationship, the nurse must first:
Speak directly to the client. When utilizing an interpreter, speak clearly in a conversational tone and directly address the client
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?
Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider.
The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action?
Raise the head of the bed to a sitting position.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?
supporting the client's back
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?
true
When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet." t or f
maintain the natural alignment of the client's body.
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
1)Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function 2)Assess cardiovascular function and blood pressure 3)Ask the client to provide details of the exercise regimen including frequency and type 4)Evaluate for diabetes mellitus
A client expresses concern that there is an increase in urine output after exercising. How would the nurse address the client's concern? Select all that apply.
"I see you are upset. Would you like to talk?" Nurses use empathy, an intuitive awareness of what a client is experiencing, to perceive the client's emotional state and need for support.
A client was recently diagnosed with metastatic lung cancer. The nurse finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy?
"I think there is a better way to handle this."
A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?
The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.
A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?
"Have you ever thought of laser surgery?"
A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic?
Group members support, praise, and critique one another. Group members elicit mutually respectful relationships.
Nurses on a hospital burn unit meet as a group to discuss procedures. Which statements accurately describe effective functioning in a group? Select all that apply.
The client is aware of spatial relationships to avoid the table.
The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?
"Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions.
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?
Orientation phase
The nurse makes a contract with the client during which phase of the nurse-client relationship?
Acts to prevent injury to the client and/or nurse
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?
Shift their weight back and forth, from back leg to front leg.
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?
decreased heart rate
What is a benefit of regular exercise over time?
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?
removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.
Use of nonpharmacologic methods can diminish the emotional component of pain. Nonpharmacologic methods of pain management can diminish the emotional components of pain, strengthen coping abilities, give clients a sense of control, contribute to pain relief, decrease fatigue, and promote sleep.
A nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain?
