VNSG 1304: Ch. 7 Prep U Questions

An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should:

Recommend 40 mg of furosemide be administered because the client had improvement with past administration Explanation: SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a consistent method for hand-off communication that is clear, structured, and easy to use. The S (Situation) and B (Background) provide objective data, whereas the A (Assessment) and R (Recommendations) allow for presentation of subjective information. Discussing the situation occurs during the (Situation) component of SBAR reporting. Detailing the client's past medical history is not a component of SBAR. Providing detailed findings of the head to toe assessment does not occur during SBAR reporting.

The 32-year-old client in a mental health unit discusses his personal thoughts and feelings with the nurse. The nurse is maintaining the circle of confidentiality by reporting this information to which individuals? Select all that apply.

The client's physician The nurse from the oncoming shift The unit's mental health technicians Explanation: Unless the client has specifically given permission to provide information to family and friends, this information should remain among individuals on the health care team that are directly involved with care of the client.

A client with chronic hyperparathyroidism expresses that she is fed up with her diet and can no longer continue with it. What should the nurse's appropriate response to the client be?

"You may be having a difficult time staying on that diet; let's discuss it." Explanation: The nurse should reflect her understanding of the client's condition and encourage her to verbalize her concerns. The open statement by the nurse is an invitation to lengthy discussion on the topic. In contrast, the first response may block further communication. Also, the third response asks the client about reasons that client may not reveal. Finally, the fourth response devalues the client and is not appropriate.

A nursing student caring for an unconscious client knows that communication is important even if the client does not respond. Which nonverbal action by the nursing student would communicate caring?

Holding the client's hand while talking Explanation: Tactile sense, such as holding the client's hand while talking, is a form of nonverbal communication and is viewed as one of the most effective nonverbal ways to express feelings of comfort. Making constant eye contact for some cultures may be disrespectful. Sighing and waving by the nurse can also be viewed as condescending to the client.

A nurse is interviewing a client for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the client's past medical history. The nurse is the:

Sender. Explanation: A sender is a person or group with a purpose for the communication.

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"Can you tell me why your physician sent you here to be admitted?" Explanation: When obtaining a nursing history, use the open-ended question technique to allow the client a wide range of possible responses. It allows the client to express what he understands to be true, yet is specific enough to prevent digressing from the issue at hand. It encourages free verbalization. The greatest advantage of this technique is that it prevents the client from giving a simple "yes" or "no" answer that has the effect of limiting the client's response. Eliciting medication use, allergies, or advanced directive determination are examples of closed communication where only one or a few words are required for an answer.

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 Explanation: The nurse acts as a collaborator and is responsible for managing client care and delegating care to others, such as an unlicensed assistive personal (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.

Which is a client responsibility in the nurse-client relationship?

Comply with the therapeutic regimen Explanation: Complying with the therapeutic regimen is a client responsibility. Remaining nonjudgmental, functioning as a advocate, and performing a prescribed skill safely are nurse responsibility

A client has just learned that she has Stage 2 breast cancer. She appears distant and withdrawn. Her shoulders are slumped. She explains "I just never thought this could happen to me." Which answer best describes the client's response?

Congruent Communication Explanation:The client's actions, expressions, and words all "fit together" following the receipt of a difficult diagnosis. Her communication would be incongruent in this same scenario if she was described as "beaming from ear to ear." Verbal communication is not the best choice because it does not take into account the whole picture. Although verbal communication is used as a part of the client's response, the nurse must also consider her posture and her facial expressions. Nonverbal communication is not the best choice either because it does not take into account the whole picture. Although nonverbal communication is used as a part of the client's response, the nurse must also consider the client's words.

When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is:

Conveying information. Explanation: Documentation of care in the client's record is most important for communicating with other health care team members that are involved in the care of the client.

A nurse is performing a wet to dry dressing change on a client's lower abdomen. The nurse should be aware that which zone is the nurse encroaching on?

Intimate Zone The intimate zone refers to interactions between parents and children or people who desire close personal contact. The personal zone refers to the distance when interacting with close friends. The social zone refers to the space when interacting with acquaintances, such as in a work or social setting. The public zone refers to communication when speaking to an audience or small groups.

Which nursing role is primarily performed during the working phase of the helping relationship?

Counselor Explanation: The nursing roles of educator and counselor are primarily performed during the working phase of the helping relationship. This is where the nurse's interpersonal skills are used to the fullest. Nurse managers help patients by managing the nurses who care for them. Nurses can have leadership ability when caring for clients at the bedside while in interdisciplinary teams but this is above and beyond the working phase of the helping relationship. A research nursing is a nursing professional that works hard to help create, evaluate, and perfect new and old medications and treatments for various medical problems and this is not in the setting necessary for the working phase.

The nurse caring for a client with a recent head injury asks the client to raise his left arm as high as possible. The client repeatedly raises his right arm. What does this indicate?

Difficulty with decoding messages Explanation: Decoding refers to the receiver of communication being able to understand the sender's message. This client does not have difficulty with compliance or difficulty following commands since he repeatedly raises the opposite arm. It is likely that the head injury has affected the client's ability to understand. The nurse is not seeking feedback.

When assessing a client's nonverbal communication, the nurse will assess which characteristic as the most expressive part of the body?

Facial expressions Explanation: The face is the most expressive part of the body. Eye contact, the lack of eye contact, posture, gesture, and silence are other methods of nonverbal communication.

What is a therapeutic use of silence?

It encourages a client's verbal communication. Explanation: Silence is the art of remaining quiet. One of its therapeutic uses is to encourage a client's verbal communication. Affective touch is typically used to demonstrate concern or affection. Its intention is to communicate caring and support. The nurse uses affective touch therapeutically in many situations, including when a client is uncomfortable.

When caring for a psychiatric client, a formal contract is made with the client during which phase of the nurse-client relationship?

Orientation phase Explanation: In the psychiatric setting, the orientation phase of the relationship represents the first phase of therapeutic work and involves signing of formal contracts. Formal contracts in this setting are used as a therapeutic tool to help a client develop more insight and control over behavior.

A nurse enters the client's room and introduces himself stating, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and I will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." He then gives the client a printed card with this information. In the helping relationship, what does this represent?

Orientation phase Explanation: The orientation phase consists of introductions and an agreement between the nurse and the client about their mutual roles and responsibilities.

While obtaining a client's past medical history, the nurse repeats the content of the client's message to verify understanding. The nurse is using which technique?

Restatement Explanation: The nurse has restated the client's information regarding his past medical history to verify understanding about the content of the client's message. Reflection means identifying the main emotional themes contained in a communication and directing them back to the client. Seeking clarification helps the client put unclear thoughts and ideas into words. Listening actively involves the ability to focus on the client and the content of the client's messages.

The student nurse is studying the concepts of communication. Which description demonstrates the student understands the concept of feedback?

The sender and the receiver use one another's reactions to produce further messages. Explanation: Feedback can occur when a message is decoded and received.