EAQ Communication
A client has been taking escitalopram (Lexapro) for treatment of a major depressive episode. On the fifth day of therapy the client refuses the medication, stating, "It doesn't help, so what's the use of taking it?" What is the best response by the nurse? 1 "It can take 1 to 4 weeks to see an improvement." 2 "It takes 6 to 8 weeks for this medication to have an effect." 3 "I'll talk to your doctor about increasing the dosage. That may help." 4 "You should have felt a response by now. I'll notify the doctor right now."
1 "It can take 1 to 4 weeks to see an improvement." It usually takes 1 to 4 weeks to attain a therapeutic blood level of escitalopram (Lexapro). Six to 8 weeks is too long. The client needs more time, not an increased dosage, to see an effect of the medication. There is no need for the nurse to notify the health care provider yet.
An adolescent is admitted to the unit with a tentative diagnosis of a bone tumor of the left femur. During the admission procedure the adolescent casually asks, "Do they ever have to cut off a leg if someone has bone cancer?" How should the nurse respond? 1 "Sometimes it's necessary. What do you think about that treatment?" 2 "Most times the leg can be saved, but sometimes it may be necessary." 3 "I don't understand why you're asking. Do you think that this will happen to you?" 4 "The decision can't be made now, because the kind of bone cancer must be determined first."
1 "Sometimes it's necessary. What do you think about that treatment?" Acknowledging that amputation may be necessary and asking an open-ended question encourages further discussion of feelings. Telling the adolescent that most of the time the leg can be saved is evasive, provides false reassurance, and does not address the adolescent's feelings. This response is demeaning. A direct response not only does not address the adolescents feelings but also attacks the basis of these feelings. Telling the adolescent that the tumor is cancerous before a diagnosis has been made constitutes misinformation, which is unsafe nursing practice.
A client undergoes dilation and curettage (D&C) after an early miscarriage (spontaneous abortion). The nurse finds her crying later in the day. What is the most appropriate statement by the nurse? 1 "This must be a very hard experience for you to deal with." 2 "You'll have other children to take the place of the one you lost." 3 "Of course you're sad now, but at least you know you can get pregnant." 4 "I know how you feel, but when a woman miscarries it's usually for the best."
1 "This must be a very hard experience for you to deal with." Saying that this must be a hard experience acknowledges the validity of the client's grief and provides the client an opportunity to talk if she wishes. Other children cannot and should not be substituted for a lost fetus. Getting pregnant is not the issue; this statement belittles the lost fetus. The nurse cannot know how the client feels. Stating that a miscarriage is for the best is patronizing and diminishes the significance of the lost fetus.
A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left occiput posterior position. The client's membranes rupture spontaneously. What observation requires the nurse to notify the practitioner? 1 Greenish amniotic fluid 2 Shortened intervals between contractions 3 Clear amniotic fluid with specks of mucus 4 Maternal temperature of 99.1° F (37.3° C)
1 Greenish amniotic fluid Greenish amniotic fluid indicates the presence of meconium and should be reported to the health care provider. The interval between contractions should shorten as labor progresses. Clear fluid with specks of mucus is the description of normal amniotic fluid. There may be a slight increase in temperature related to the stress of labor, and it should be monitored.
An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. The nurse explains that the abilities that will be affected include: 1 Stating wishes verbally 2 Recognizing familiar objects 3 Comprehending written words 4 Understanding verbal communication
1 Stating wishes verbally Stating wishes verbally is a characteristic of expressive aphasia from damage to Broca's area in the dominant hemisphere of the brain. Recognizing familiar objects is known as agnosia; it is not related to expressive aphasia. Comprehending written words is known as alexia or dyslexia, a type of receptive aphasia. Understanding verbal communication is related to receptive aphasia.
A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse? 1 "I'll get your grandchild. You must be very excited." 2 "Please go on to see your daughter. I'll bring the baby to her room." 3 "Show me your identification. I need to see it before I can give you the baby." 4 "Only the mother can ask for the baby. Have her call us to bring the baby to her."
2 "Please go on to see your daughter. I'll bring the baby to her room." Telling the couple that the baby will be brought to the client's room maintains the nurse's legal responsibility of providing for the infant's safety while still promoting a positive interaction with the client's family. Giving the infant to another person without the mother's knowledge or consent is illegal. Legally the nurse may not give the infant to the grandparents. Although insisting that only the mother can ask for the infant may follow legal policy, it is an abrupt nontherapeutic response to the grandparents.
An adolescent who has just been found to have type 1 diabetes asks a nurse about exercise. What is the best response by the nurse? 1 "Exercise should be restricted." 2 "Exercise will increase blood glucose." 3 "Extra snacks are needed before exercise." 4 "Extra insulin is required during exercise."
3 "Extra snacks are needed before exercise." Exercise lowers the blood glucose level; an extra snack can prevent hypoglycemia. Exercise is encouraged, not restricted. Exercise lowers, not increases, blood glucose. Extra insulin is contraindicated because exercise decreases the blood glucose level; extra insulin may precipitate hypoglycemia.
A depressed older client has not been eating well since her admission to the hospital. The client repeatedly states, "No one cares." What is the most appropriate response by the nurse? 1 "We all care about you; now please eat." 2 "We all care about you; you have to eat to stay alive." 3 "I care about you. What are some foods you especially like?" 4 "I care about you. Will you please eat some of this food for me?"
3 "I care about you. What are some foods you especially like?" The statement "I care about you. What are some foods you especially like?" is a direct response to the client's concern and permits some exploration of food choices. Focusing on several caretakers does little to meet the client's basic security needs. "We all care about you; you have to eat to stay alive" does not address the client's comment that no one cares. "I care about you. Will you please eat some of this food for me?" encourages dependence on the nurse; the message is "Do it for me, not because it is important for you."
A client with an obsessive-compulsive disorder completes a compulsive ritual and says to the nurse, "Boy, you must really think I'm weird." What is the most appropriate response by the nurse? 1 "Are you weird?" 2 "Do you really think I feel that way?" 3 "It sounds like you're concerned about my feelings toward you." 4 "You do have a serious problem, but I don't think that you're weird."
3 "It sounds like you're concerned about my feelings toward you." The response "It sounds like you're concerned about my feelings toward you" addresses the client's concern and provides an opportunity to clarify the nurse's role in the therapeutic process. The response "Are you weird?" does not promote exploration of the client's feelings. The response "Do you really think I feel that way?" does not address the client's concern; also, it expects the client to interpret the nurse's thinking. The response "You do have a serious problem, but I don't think that you're weird" communicates that the client's problem is "serious," which may be discouraging for the client.
During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond? 1 "The medicine protects your baby — that's why it's used." 2 "You'll have to check with your baby's doctor about this." 3 "Let's talk about why you don't want the medicine to be put into your baby's eyes." 4 "This medicine is required by law and should be administered right after the baby is born."
3 "Let's talk about why you don't want the medicine to be put into your baby's eyes." Talking about why the client doesn't want the medicine to be put into her baby's eyes provides the mother with an opportunity to express her concerns regarding prophylactic eye medication. Saying that the medicine protects the baby and that's why it's used cuts off communication and does not reflect back the mother's statement. It is the nurse's responsibility to discuss this issue with the mother. Stating that the medicine is required by law and should be administered right after the baby is born blocks communication; instillation may be delayed for an hour.
An infant with a myelomeningocele undergoes surgery and is returned to the pediatric unit. The father appears anxious and tends to avoid physical contact with the infant. Later he says to the nurse, "My wife seems so wrapped up with the baby; I hope she has time for me." What is the most therapeutic response by the nurse? 1 "Are you feeling that you'll have to fend for yourself?" 2 "Do you think maybe your parents will be able to help out?" 3 "You'll both be so busy, you won't even miss her attention." 4 "I can understand your concern about the changes you'll have to make."
4 "I can understand your concern about the changes you'll have to make." Validating the father's feelings lets the father know that the nurse understands that adjustments will have to be made. Also, it is open-ended enough to let him talk about feelings. Stating that the father is afraid that he will have to fend for himself is a premature assumption and is not open-ended enough to foster expression of feelings about what is bothering the father. The father has not expressed his feelings enough for the nurse to offer any specific suggestions for help. Saying that the father may be too busy may compound the father's anxiety; also, it does not let him explore feelings.
While speaking with a client with schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse? 1 "You aren't making any sense; let's talk about something else." 2 "You're so confused; I can't understand what you're saying to me." 3 "Why don't you take a rest? We can talk again later this afternoon." 4 "I'd like to understand what you're saying, but I'm having difficulty following you."
4 "I'd like to understand what you're saying, but I'm having difficulty following you." The statement "I'd like to understand what you are saying, but I'm having difficulty following what you are saying" lets the client know the nurse is trying to understand; it increases the client's self-esteem and points out reality. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic. The statement "You're so confused; I can't understand what you're saying to me" cuts off communication and tells the client that the nurse will speak only if the client's communication makes sense. Telling the client to take a rest and promising to talk about the client's concerns again later in the day" cuts off communication and tells the client that the nurse will speak only if the client's communication makes sense.
A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong? 1 "You seem very concerned. I don't see anything unusual." 2 "Your baby appears to have a problem. I'll notify the pediatrician." 3 "The swelling and discharge will go away. It's nothing to worry about." 4 "The swelling and discharge are expected. They're a response to your hormones."
4 "The swelling and discharge are expected. They're a response to your hormones." This response emphasizes that the findings are to be expected and explains why they occur; this may relieve the client's anxiety. Claiming not to see anything unusual denies that there is anything to explain to the mother and is somewhat belittling. Calling the pediatrician is not necessary; these findings are expected. The comment that the swelling and discharge will go away tells the mother that the findings are expected but provides no explanation and is somewhat belittling.
What is the best nursing intervention to encourage a socially withdrawn client to talk? 1 Focusing on nonthreatening subjects 2 Trying to get the client to discuss feelings 3 Asking simple yes-or-no questions of the client 4 Sitting quietly while looking through magazines with the client
1 Focusing on nonthreatening subjects Nursing care involves a steady attempt to draw the client into some response. This can best be accomplished by focusing on nonthreatening subjects that do not demand a specific response. The client is not ready yet to discuss feelings; the first step is to focus on nonthreatening subjects. Yes-or-no questions do not encourage communication. By sitting quietly with the client the nurse is showing acceptance of the client but doing nothing to encourage communication.
A recently hired nurse is caring for several clients on a mental health unit at a local community hospital. The nurse manager is evaluating the nurse's performance. What situation indicates that the nurse-client boundaries of the recently hired nurse are appropriate? 1 The nurse shares with the entire treatment team vital information the client disclosed in a private session. 2 The nurse is often busy doing other tasks when the client and nurse are scheduled for a counseling session. 3 A client enters the therapeutic group late with the nurse's permission even though group rules say that this is not allowed. 4 A client's overall behavior is significantly more independent and demonstrates higher function on the days that the nurse is not working.
1 The nurse shares with the entire treatment team vital information the client disclosed in a private session. The nurse is part of the treatment team and must share vital information with its members. When the nurse is underinvolved in the nurse-client relationship, respect and trust, which are necessary for therapy, do not develop. The nurse must not place other responsibilities over the commitment made to the client. A nurse who becomes overinvolved in the nurse-client relationship may bend the rules for a specific client. This is detrimental to that client and other clients who see the preferential treatment. A nurse who becomes overinvolved in the nurse-client relationship may also foster regressive behaviors that make the client more dependent.
After a mastectomy or a hysterectomy a client may feel incomplete as a woman. What statement should alert the nurse to this feeling in a client who has undergone total hysterectomy? 1 "I can't wait to see all my friends again." 2 "I feel washed out; there isn't much left." 3 "I'm planning to recuperate at my daughter's home." 4 "I can't wait to get home; I so want to see my grandchild."
2 "I feel washed out; there isn't much left." The client's statement implies emptiness with an associated loss. Resumption of social activities indicates acceptance by the client of her condition and a willingness to move on with life. Stating that she is to recuperate at her daughter's home indicates that the client is planning for the future, not expressing a sense of loss. Being excited to get home is a response typical of a grandmother anxious to resume her life.
A married couple has been using oral contraceptives to delay pregnancy. When the wife misses her regular menstrual period, she decides to find out whether she is pregnant. She tells the nurse that pregnancy may have occurred because she missed her contraceptive pills for 1 week when she had the flu. How should the nurse respond? 1 "That's the trouble with using contraceptive pills. People frequently forget to take them." 2 "You may be correct. The effect of contraceptive pills depends on their being taken on a regular schedule." 3 "Let's find out whether you really are pregnant. If you are, you may want to consider having an abortion." 4 "Contraceptive pills are unpredictable. You could have become pregnant even if you had taken them regularly."
2 "You may be correct. The effect of contraceptive pills depends on their being taken on a regular schedule." An oral contraceptive program requires the client to take one tablet daily from the fifth day of the cycle and continue taking tablets for 20 or 21 days. Interrupting the monthly dosage program may permit release of luteinizing hormone, resulting in ovulation and possibly pregnancy. Stating that people often forget to take oral contraceptive pills is judgmental; contraceptive practice is the client's choice. It is premature to discuss abortion. Oral contraceptives are taken on an exact schedule have a very high rate of success.
The clinic nurse is providing home care instructions for a client with pelvic inflammatory disease. What resting position should be recommended by the nurse? 1 Sims 2 Fowler 3 Supine with knees flexed 4 Lithotomy with head elevated
2 Fowler The Fowler position facilitates localization of the infection by pooling exudate in the lower pelvis. The Sims position and supine position with knees flexed do not use gravity to promote pooling of exudate in the lower pelvis. The lithotomy position with head elevated does not use gravity to promote pelvic drainage despite an elevated head.
fter a deep vein thrombosis developed in a postpartum client, an IV infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do? 1 Increase the intravenous rate of heparin 2 Interrupt the infusion and notify the practitioner of the aPTT result 3 Document the result on the medical record and recheck the aPTT in 4 hours 4 Call the practitioner to obtain a prescription for a low-molecular weight heparin
2 Interrupt the infusion and notify the practitioner of the aPTT result The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25 to 36 seconds) and prolonged bleeding may result; the therapeutic range for heparin is one-and-a-half to two times the normal range. The primary health care provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.
A housekeeping staff member in a mental health unit reports to the nurse that food was found hidden in a client's room. Knowing that the client was admitted with a fluid and electrolyte imbalance because of anorexia nervosa, the nurse should ask housekeeping personnel to: 1 Point this out to the client and remove the food 2 Report it to the nursing staff if this happens again 3 Disregard this because it is a common behavior in clients with anorexia 4 Keep a record of when this happens and report it to the nursing staff weekly
2 Report it to the nursing staff if this happens again Asking the housekeeping staff to keep the nursing staff informed shows that housekeeping members are part of the health team and their input is valued; this will help keep lines of communication open. Pointing this out to the client and removing the food is not the responsibility of the housekeeping staff. Disregarding input from members of the health care team does not promote collaboration. Client behaviors should never be disregarded. The housekeeping staff should notify a nursing team member if this behavior occurs again. Keeping a record of when this happens and reporting to the nursing staff weekly is not the responsibility of the housekeeping staff.
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? (Select all that apply.) 1 Describes how others have caused the addiction 2 Verbalizes difficulty identifying personal strengths 3 Expresses uncertainty about meeting with the nurse 4 Acknowledges the effects of the addiction on the family 5 Addresses how the addiction has contributed to family distress
2 Verbalizes difficulty identifying personal strengths 4 Acknowledges the effects of the addiction on the family 5 Addresses how the addiction has contributed to family distress Looking at one's strengths in addition to areas that need growth is difficult work, and sharing this difficulty demonstrates that the client is willing to work with the nurse to address personal issues. When he or she is willing to address cause and effect issues of personal behavior, the client is in the working phase of a therapeutic relationship. When people in a therapeutic relationship are able to address how their behavior affects others, they are taking the first step toward taking responsibility for their actions. The use of projection is a defense from taking responsibility for the addiction; this will impair the effectiveness of a working therapeutic relationship. Ambivalence about working with the nurse usually occurs during the introductory phase of the nurse-client relationship.
A 35-year-old client is scheduled for a vaginal hysterectomy. She asks the nurse about the changes she should expect after surgery. How should the nurse respond? 1 "You will stop ovulating." 2 "Surgical menopause will happen immediately." 3 "Sexual intercourse will be uncomfortable when you resume it." 4 "A hysterectomy doesn't affect the chronological age when menopause usually occurs."
4 "A hysterectomy doesn't affect the chronological age when menopause usually occurs." As the term hysterectomy implies, only the uterus is removed. The ovaries remain; therefore, the client will experience menopause around the same time as women who have functioning ovaries. The client will ovulate and will not experience surgical menopause because the ovaries are not removed with a hysterectomy. There should be no discomfort if there is an appropriate period of healing before the resumption of sexual intercourse.
A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client states: 1 "X-rays will be taken to identify where I may have lost calcium from my bones." 2 "Portions of my bone marrow will be removed and examined for cell composition." 3 "A radioactive chemical will be injected into my vein that will destroy cancer cells present in my bones." 4 "A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."
4 "A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited." A bone scan maps the uptake of a bone-seeking radioactive isotope; an increased uptake is seen in metastatic bone disease, osteosarcoma, osteomyelitis, and certain fractures. A bone scan measures the uptake of radioactive material, not the absence of calcium, which is seen in an x-ray examination of bone. The response "Portions of my bone marrow will be removed and examined for cell composition" is a bone marrow aspiration, in which a small amount of marrow is examined to determine the presence of abnormal cells in diseases such as leukemia. A bone scan involves a small diagnostic dosage of a radioactive substance; it is not therapeutic.
A mother with newly diagnosed ovarian cancer knows that she must tell her 8-year-old child about the diagnosis and how her upcoming treatment will affect their family life. She asks the nurse how she should answer if her child asks, "Are you going to die?" What should the nurse advise the mother to answer? 1 "No, but why do you ask that?" 2 "I might, but can we talk about this later?" 3 "Everyone dies, but I'll be around for a long time." 4 "I don't know, but I'm going to try very hard to stay alive."
Correct4 "I don't know, but I'm going to try very hard to stay alive." In the first discussion the mother should convey some facts, but not overload the child with details, and offer hope; honest answers are important for the child's sense of security and well-being. A 5-year-old child may not be able to respond to the "Why?" question and become anxious, overwhelmed, and defensive. Avoiding an answer may close off communication and increase feelings of uncertainty and anxiety. Promising to stay alive constitutes false reassurance because the mother's prognosis is uncertain at this time.
A woman at 22 weeks' gestation is admitted with heavy bleeding and severe abdominal cramping. When told that no fetal heart sounds can be detected, the client says to the nurse, "We wanted this baby so badly." How should the nurse respond? 1 "It must be difficult to lose this baby that was important to you both." 2 "This is nature's way of dealing with babies that may have problems." 3 "A curettage will give you a new start. I'll bet you'll get pregnant again soon." 4 "You must be disappointed, but don't feel guilty. These things sometimes happen."
1 "It must be difficult to lose this baby that was important to you both." The correct response acknowledges the loss and the grieving process. It also encourages the expression of feelings. Suggesting that "this is nature's way" minimizes the loss and may reflect the nurse's beliefs. Predicting that another pregnancy will occur soon does not acknowledge the loss and cuts off communication. Guilt feelings were never expressed by the client.
A 17-year-old mother is to sign the consent for her son's myringotomy. What should the nurse say to the mother about this procedure? 1 "This procedure may not help." 2 "Tell me what you know about this procedure." 3 "Your son will need to have this done again when he's older." 4 "One of your parents must also sign this because you're too young."
2 "Tell me what you know about this procedure." Informed consent requires that the responsible person understand the procedure. Predicting therapeutic outcomes is not within the role of the nurse. A 17-year-old mother is an emancipated minor who has the legal authority to sign her child's consent form. Predicting future surgical interventions is not within the role of the nurse.
he parents of a school-aged child with fever, headache, and a stiff neck ask that the child be tested for meningitis. Which test should the nurse tell the parents is used to confirm the diagnosis of meningitis? 1 Blood culture 2 Lumbar puncture 3 Meningiomyelogram 4 Peripheral skin smear
2 Lumbar puncture
The mother of an 18-month-old boy with a cleft palate asks the nurse why the pediatrician has recommended that closure of the palate be performed before the child is 2 years old. How should the nurse respond? 1 "As he gets older, the palate gets wider and more difficult to repair." 2 "Eruption of the 2-year molars often complicates the surgical procedure." 3 "You need to have the surgery performed before he starts to use faulty speech patterns." 4 "After a child is 2 years old, surgery is frightening, so you need to avoid it if at all possible."
3 "You need to have the surgery performed before he starts to use faulty speech patterns." Children with cleft palate have distinctive speech because they cannot control the airflow required for articulate speech; although affected children usually need speech therapy after surgery, correct speech will be easier to learn when surgery is performed before they start to speak. Although the palate does widen with age, this is not the reason that the repair is made at this age; these children may need multiple surgeries as the palate develops. A child with a cleft palate requires orthodontic and prosthodontic treatment for many years because of the malformed palate and the malposition of the teeth; the eruption of the teeth may be considered relative to the timing of surgery throughout childhood, but the 2-year molars are of little importance when the overall problem is considered. Invasive procedures are more frightening for a preschooler than for a toddler.
nurse is reinforcing previous learning about cystic fibrosis and its treatment with a 9-year-old child. What is the most suitable information to present to this child? 1 "The chest physical therapy will help you feel better." 2 "Your meal schedule was designed by the dietitian just for you." 3 "Your mucus is thick because cystic fibrosis interferes with how your mucous glands work." 4 "The medication is scheduled for specific times because your doctor has prescribed it that way."
3 "Your mucus is thick because cystic fibrosis interferes with how your mucous glands work." An explanation of the mechanism of cystic fibrosis takes into account the child's capacity to understand cause-and-effect relationships and offers information to increase the child's understanding of the illness. Telling the child that the treatment will improve the condition is too general and does not explain why the child will feel better. Telling the child that others will make schedules is too authoritarian; the child needs information that will increase understanding and foster compliance with the regimen.
A client with pain and paresthesia of the left leg is scheduled for an electromyogram. What should the nurse discuss with the client before the test is performed? 1 Bed rest must be maintained after the procedure. 2 The involved area will be shaved before the procedure. 3 Needles will be inserted into the affected muscles during the test. 4 Monitoring of the heart rate and rhythm will be done throughout the test.
3 Needles will be inserted into the affected muscles during the test. Needles will be inserted into the affected muscles during the test to assess electrical activity and to determine whether symptoms are primarily musculoskeletal or neurological. Special care is not required after the procedure. Special preparation is not required for electromyography. Special care is not required during the procedure.