Wk 7 nurse client relationship
The nurse is caring for a geriatric client who has decided to move to a skilled nursing facility. The nurse assisted with the arrangements and, when leaving the room, touched the client on the shoulder. Which therapeutic technique was the nurse demonstrating?
affective touch ✓
Advocacy and support are activities associated with which learning style?
affective ✓
A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?
"Is that a new shirt you're wearing?" ✓
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?
"I know that you are anxious, but removal will be painless and the IV location needs to be changed." ✓
A nurse is caring for an older adult client who has just died in a hospice unit. The child of the client arrives and asks, "Can I please stay and sit at the bedside? I really wanted to be here so they did not die alone." Which statement made by the nurse best demonstrates the use of empathy?
"I will close the door so you can spend some quiet time at the bedside." ✓
Which of the following nurse statements is completed in the working phase of the nurse- client relationship?
"I will put a chair in the bathroom so you can begin personal care. I will return to assist you as needed." ✓
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 that will add fluids directly to the blood stream." ✓
A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse?
"Tell me more about how it feels to eat with your family." ✓
A female client reports to her primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that she does not want to take the test and feels she should instead continue with the medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?
"Tell me more about how you are feeling." ✓
A nurse visits a female victim of sexual assault for the fourth visit. The client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?
"Tell me more about the aspects that make you feel as if it happened yesterday." ✓
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?
"The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position." ✓
A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack. What should be the nurse's reply?
"The physician wants to monitor you and control your pain." ✓
The charge nurse delegates the administration of a pain medication to a practical nurse. Which statement, made by the charge nurse, indicates that the final step in the delegation process has been completed?
"What is the client's pain level since administering the pain medication 30 minutes ago?" ✓
A nurse is examining a 3-year-old child with conjunctivitis. During the examination, the child starts crying and refuses to sit still. Which statement is appropriate for the nurse to tell the child?
"Would you like to see my flashlight?" ✓
Which of the following nursing statements, made to the client, best provides an example of a broad opening?
"Wow, the weather is looking nice outside." ✓
A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?
"You said that you do not smoke, but you have an open package of cigarettes in your pocket." ✓
A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?
"You're worried about how you will tolerate the pain associated with labor." ✓
The nurse is instructing a client in a crowded semiprivate room. The nurse approaches and moves equipment to allow for a comfortable conversation. At which distance should the nurse stand?
2 to 3 feet ✓
A nurse is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate to delegate to the LPN/LVN? (Select all that apply.)
Administer oral aspirin and lisinopril to the client with hypertension. ✓ Insert a nasogastric tube in a client with absent bowel sounds. ✓ Reinforce a post-surgical abdominal dressing. ✓
A nurse needs to complete and assessment and vital signs on a client who has Alzheimer's disease. How should the nurse approach this client to gain cooperation? (Select all that apply.)
Approach the client from the front. ✓ Smile and maintain eye contact. ✓ Use the client's name. ✓
The nurse has been caring for a client and family for 6 months in the long-term care facility. Which of the following nursing actions is appropriate during the terminating phase of the nurse-client relationship? Select all that apply.
Arranging health-related services to support home care ✓ Coordinating medication regimen for home care ✓ Relaying well wishes from the staff ✓ Teaching the client and family about care needs at home ✓
A nurse is interviewing an American Indian client who has come to the clinic for a follow- up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?
Assume a position at eye level with the client and continue with the interview. ✓
The nurse is caring for a client who is newly diagnosed with atrial fibrillation. The client states he has many questions. At what point in the client contact experience does assessment for learning begin?
At the time of arrival to the hospital for care ✓
The nurse is employed at a diabetic clinic and is assisting a client with maintenance of blood glucose status. When assessing nurse-client responsibilities, which responsibility does the nurse most expect of the client?
Comply with the set regimen. ✓
Which of the following is a client responsibility in the nurse-client relationship?
Comply with the therapeutic regimen. ✓
Which of the following is a purpose of affective touch in the context of nursing?
Demonstrating concern ✓
Which of the following is least effective in encouraging a client to follow a medication regimen?
Discuss perspective from the nurse's personal experience. ✓
A nurse is caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family. Which intervention is most appropriate?
Encourage family discussions of feelings. ✓
A nurse is caring for a client who is newly diagnosed with cancer and receiving a peripherally inserted central catheter (PICC). Upon analysis, the nurse determines that the client is an affective learner. Which type of learning situation would the client learn from best?
Having the client attend a group support meeting of people with PICC lines
The nurse is evaluating the comprehension of a client's knowledge of the subcutaneous administration of Lovenox, an anticoagulant. Which method provides the best feedback?
Having the client prepare the syringe and independently administer the injection ✓
Which of the following is a reason why silence is considered therapeutic?
It encourages a client's verbal communication. ✓
The nurse is preparing a community education program about a new treatment for prostate cancer. At what level would the nurse prepare the distributed educational materials?
Middle school, 7th- to 9th-grade level ✓
A nurse is working with a client who is in postoperative day 2 following a total knee replacement. The client has briefly mobilized using a wheeled walker and with the assistance of the physical therapist. However, the client is reluctant to progress further with mobilization for fear of injuring herself. In response to this, the nurse has liaised with the physical therapist to create a plan of care that creates specific goals for the client's mobility. In doing so, this nurse has exemplified what role?
Nurse as collaborator ✓
A nurse who has been practicing for three decades has seen significant changes in the roles that clients are expected to perform in the course of their care. What is a role that clients are normally expected to perform while they are receiving care?
Participate actively in the planning and execution of their care. ✓
The student nurse is providing skilled care for a palliative care client. The client is bedbound, requiring skin care during bathing, oral care, and every 2 hours positioning. Which NCLEX-PN test category would the student anticipate finding questions related to this clinical care situation?
Physiologic integrity ✓
The nurse is discharging a client with an indwelling Foley catheter. Which instructional method is best when teaching a psychomotor learner about the care necessary?
Provide the Foley catheter and equipment to handle and practice care. ✓
Which of the following is one of the four categories of client needs identified by the National Council of State Boards of Nursing?
Psychosocial integrity ✓
Which nursing action is most therapeutic when a client says, "My daughter wants me to go to a nursing home to get rid of me; I am just a burden."
Pull up a chair and sit down to talk. ✓
A nurse is caring for a client with myasthenia gravis. The client is having difficulty forming words and his tone is nasal. Which communication strategy is an effective one for this client?
Repeat what the client has said to verify the meaning. ✓
A nurse working with an experienced licensed practical/vocational nurse (LPN/LVN) delegates the task of administering oral medications to a team of clients. The nurse observes the LPN/LVN document a client's medication administration before entering the client's room. What is the most appropriate action of the nurse?
Stop the LPN/LVN immediately and discuss the possible consequences of this action. ✓
A wound care nurse approaches a client to instruct in home care needs. In which clinical scenario would the nurse delay teaching owing to learning readiness?
The client is anxious about physical therapy. ✓
The nurse cares for multiple ethnic populations. Which of the following examples best demonstrates a facility adhering to The Joint Commission requirements that health care workers facilitate communication with all clients?
The facility requests bilingual staff and community members to voluntarily provide contact information for interpreter services. ✓
Which of the following means of comprehending new information best describes a cognitive learner?
The learner processes information by listening to facts. ✓
Which of the following teaching scenarios best illustrates the nurse providing informal teaching on a low-sodium diet?
The nurse discusses dietary guidelines while the client watches a cooking show on television. ✓
An experienced nurse is evaluating a new nurse to the unit who is providing discharge instructions to an adult client. The experienced nurse views the following: The nurse approaches and decreases the volume on the television and then sits beside the client, presenting the information to the client and spouse. The nurse states, "You are to take Cipro 250 mg, two tablets b.i.d. A regular diet is ordered, and you are to follow up with your physician in 2 weeks. Here is printed information on the medication ordered." The nurse obtains appropriate signatures and leaves. Which point would the experienced nurse address?
The nurse should minimize medical terms when teaching. ✓
The nurse is caring for a client and family who are awaiting the results of a diagnostic test. Which of the following acts, made by the nurse, best demonstrates therapeutic nonverbal communication?
The nurse smiles and rubs the shoulder of the client. ✓
A nurse and an older adult client with chronic back pain are in the working phase of the nurse-client relationship. Which activity occurs in the working phase?
The nurse tries to avoid hampering the client's independence. ✓
A nursing student is conducting a client interview in order to determine the client's health history. The student's instructor observes that the student frequently twists her hair with her fingers while asking the client questions. What is the most plausible meaning of the student's nonverbal communication?
The student feels insecure during the interview ✓
A nurse is working with an adult client who has been admitted with hyperglycemia following a period of poor glycemic control. The nurse has many similarities to the client with regard to age, gender, and socioeconomic status but is careful to utilize therapeutic communication techniques rather than social communication. How does therapeutic communication differ from social communication?
Therapeutic communication is focused on a particular goal while social communication is more superficial in content. ✓
The nurse is caring for a client who has been diagnosed with a cerebral vascular accident and subsequent expressive aphasia. In which manner does the nurse best promote communication?
Use a picture board with common responses. ✓
A nurse is caring for an older adult client. What strategy should the nurse include in order to facilitate effective communication?
Use active listening during communication. ✓
A nurse is completing a health history on a client who has a hearing impairment. Which actions can the nurse take to enhance communication? (Select all that apply.)
assessing how the client would like to communicate ✓ providing paper and pencil for written communication ✓
41. A nurse is asking a client health-related questions during a medical assessment. The client has developed lesions on the skin and warts around the mouth. Which factor affects oral communication?
attention and concentraTION ✓
The nurse is caring for a client with a hearing difficulty. The nurse is in the room during client and physician discussion and will relate the information to the client's power of attorney. Which term best describes the role the nurse is assuming?
caregiver ✓
Which type of learner processes information more adequately by listening or reading facts?
cognitive ✓
A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?
empathy ✓
The nurse enters the client's room and assesses that the client's affect appears sad. The client is sitting near the window, staring into the distance with a tear in the eye. The nurse approaches and places a hand on the client's shoulder asking for the client's thoughts. What type of emotion is the nurse projecting?
empathy ✓
A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions made by the nurse will promote the development of a therapeutic relationship? (Select all that apply.)
encouraging the client to talk about the client's life ✓ asking the client when the client would like to have the bed linens changed ✓
Which of the following is a person's intellectual ability to remember and apply new information?
learning capacity ✓
The charge nurse in a long-term facility is addressing a breach in care with a client's family. Which body language would the family interpret as being sincere in the statement?
open hands ✓
Which of the following is a component of nonverbal communication?
paralanguage ✓
The nurse is providing therapeutic communication while changing a client's linen. The client states, "Every time I urinate, I still feel the need to urinate again. This is so disappointing." The nurse states, "You don't feel that you are emptying your bladder." Which communication technique has the nurse used?
paraphrasing ✓
The nurse is caring for a client who received a poor prognosis when the physician made rounds. The client is quiet, tearful at times, and prefers to be in a darkened room. The nurse observes an unlicensed assistive personnel entering the room, turning on the lights, and stating, "Are we ready to get out of bed yet, the day is half over?" When addressing the statement of the unlicensed assistive personnel, which communication technique would the nurse be most correct to discuss?
patroniizing ✓
Which of the following is a positive interpretation of body language?
tilt of head ✓