Communication PNC

The nurse is updating the records of a 10-year-old girl who had her appendix removed. Which action could jeopardize the privacy of the child's medical records?

Letting another nurse use the nurse's log-in session.

A client is discussing the client's problems at the workplace. Which nonverbal cues would indicate that the nurse is attentive to the client?

Maintaining eye contact with the client Leaning toward the client

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?

Partial laryngectomy

phases of the therapuetic relationship

Preparation Orientation Working Termination

A nurse is assessing a little boy who has been diagnosed with Tourette syndrome. Which finding would the nurse expect to see?

Speaks sudden, fast phrases out of context

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client

That medication will be prescribed for pain relief

pilot projects

limited trials to try out a solution, reduce risks and identify problems

Developing a therapeutic relationship

listen actively help identify what the patient is feeling put yourself in their shoes be honest be genuine and credible use your ingenuity be aware of cultural differences maintain patient confidentiality know your roles and limitations

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

conduction

While observing a group of 9-year-old children at school, the nurse is concerned that one of the children is not cognitively developing according to Piaget's stage of concrete-operational thought processes. With which activity is the nurse concerned?

does not understand the phrase "slow as molasses" when used by the teacher

scenario planning

identifies alternative future scenarios and makes plans to deal with each

credibility

the quality of being believable or trustworthy

working phase

empathetic listening and responding respect genuineness concreteness, reflecting, paraphrasing, clarifying and confronting

A healthcare agency has set a plan to apply for accreditation. A nurse on the accreditation committee has been assigned to audit clients' medical records for appropriate documentation. What information would the nurse assess in the audit?

evidence that nursing interventions have been evaluated in terms of the client's response

The parents of an 8-year-old girl with a slow-to-warm temperament are concerned about their daughter's reaction when she visits the dentist for the first time after having a cavity filled at the last visit. How should the nurse respond?

"Remind her in simple terms what will happen in the dentist's office."

A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?

"The antibodies may be those transferred across the placenta; the baby may not develop AIDS."

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat.

PIE documentation model

Problems Interventions Evaluation of nursing care

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing?

Unresolved grief

narrative charting

a descriptive record of client data and nursing interventions, written in sentences and paragraphs

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

making a copy of the incident report for the client

An informatics nurse is assisting with the design of an clinical information system for use by the staff of a health center. The nurse is working to ensure that the system reflects usability by making sure that the screen display is visually clean and uncluttered and that it provides only the information needed for decision making. Which concept of usability is the nurse incorporating?

simplicity

A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse?

"Even a perfect match does not guarantee organ success."

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay?

"How is this illness impacting you and your family?"

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing?

SOAP charting

A nurse is administering an intradermal injection to a client for a skin allergy test. When the nurse is finished, there is no sign of a wheal or blister at the site of injection. What is the nurse's best action in this situation?

Document the administration and inform the primary care provider.

POR

also known as POMR

variance

goal that is not met

The nurse is assessing the language development of a 3-year-old girl. Which finding would suggest a problem?

speaks in 2- to 3-word sentencesA client needs to be transferred to the oncology unit for further care.

proxemics

study of personal space

When assessing the growth and development of a 4-year-old, which would the nurse note as being appropriate?

tells a fantasy story about a bear and a car

values

the ideas, beliefs, and attitudes about what is important that help guide the way you live

transference

the patient's transfer to the analyst of emotions linked with other relationships

The nurse is administering a new medication to an elderly male client and begins instruction about the medication. The client states, "Tell my wife. She takes care of all this kind of stuff." The nurse replies

"When your wife comes in to visit, I will return and provide the information to both of you."

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

While providing personal care for a client, the nurse observes that the client is not comfortable with the close physical proximity. How will the nurse alleviate the discomfort of the client during personal care?

Provide simple explanations of the need for physical proximity.

response

an action or change in behavior

Individual psychotherapy consists of three phases. Which statement by the group therapist would reflect that the group is in the working phase of therapy?

"James, when Shane speaks, it seems you become angry and tend to withdraw."

A nurse is changing the wound dressing on a coccyx-region pressure injury of an immobilized client. The existing dressing is saturated with both watery, clear discharge and foul, grayish-colored liquid. Which entry in the client's chart most accurately documents these findings?

"Large amounts of suppurative and serous exudates noted."

While interviewing the wife of a patient with multiple health problems, the spouse states, "I'm not the one who is ill, but I feel like I'm getting sick all the time." Which response by the nurse would be most appropriate?

"When one family member becomes ill, other members are affected."

CBE

charting by exception

assertive communications

communicating thoughts while respecting the thoughts and feelings of other people

public distance

(12 to 25 feet) the distance used for public ceremonies such as lectures and performances

A nurse admitting a client to the emergency department with a suspected fracture notes a deep abrasion with bruising. The client reports receiving a hard tackle during a football game. Which grade of tissue damage accompanies this fracture?

grade 2

monopolizing

hogging the stage by continuously focusing communication on oneself instead of on the person who is talking

scapegoat

one who bears the blame for others

What should the nurse avoid when demonstrating genuine interest for a client by making a self-disclosure?

shifting the emphasis to the nurse

Which is often considered the most difficult yet most effective communication technique?

silence

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions?

"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Does it hurt when I touch you here?" "Is there any chance you might be pregnant?"

self-help group

A group made up of people with similar problems who help and support one another without the direct leadership of a clinician. Also called a mutual help group.

The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse?

Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan.

groupthink

A situation in which group members seek unanimous agreement despite their individual doubts

Source-Oriented Medical Record (SOMR)

a type of patient chart record keeping that includes separate sections for different sources of patient information, such as laboratory reports, pathology reports, and progress notes.

The nurse is educating the family of a 2-year-old boy with bronchiolitis about the disorder and its treatment. The family parents speak only Chinese. Which action, involving an interpreter, can jeopardize the family's trust?

asking the interpreter questions not meant for the family

Change of shift report

communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped

nonverbal communication

communication using body movements, gestures, and facial expressions rather than speech

purposes of patient records

communication, planning patient care, auditing health agencies research, education reimbursement legal documentation healthcare analysis

A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which is the best action for the first nurse to take?

Discuss the conversation directly with the other nurse.

A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting?

Empathy

feedback

the response to a message

personal space

the surrounding area over which a person makes some claim to privacy

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication?

Give the charge nurse information about what care should be given while the nurse is at lunch.

decision tree

Graph of decisions and their possible consequences, used to create a plan to reach a goal

The nurse is caring for a child with a life-threatening illness. The parents of the child want to introduce acupuncture and herbal medicines into the treatment regime. What is the most effective way for the nurse to react to this request?

Have the family discuss the options with the physician.

aggressive communications

People who aim to hurt or put down other people and show disrespect

In SBAR, what does R stand for?

Recommendations

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?

Form understandable words and comprehend spoken words

B in SBAR stands for

background

passive communication

the avoidance of self-expression, or the accommodation to others' concerns over your own A form of communication in which the individual fails to say what is meant

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?

"Any information that can identify a person is considered a breach of client privacy."

A client with post-polio syndrome displays fatigue and decreased muscle strength. How should the nurse best respond to the client?

"Intravenous immunoglobulin infusion may help you."

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response?

"The operating table is a firm surface; we need to be sure your skin looks okay."

personal distance

(18 inches to 4 feet) the space used when interacting with friends and acquaintances

POMR

Problem Oriented Medical Records that divide records into four sections - the database, problem, plan of care, and progress

process of making an entry on a patient record

recording, charting, and documenting

A client needs to be transferred to the oncology unit for further care. Which information is necessary to include in the transfer report?

current client assessment

A nurse caring for a client being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation?

Information is documented in separate forms by each healthcare professional.

Impaired verbal communication related to hearing deficit is categorized into which type of nursing diagnosis?

Actual

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

Assess for cultural differences.

A client's temperature readings are as follows: 99.6°F (37.5°C) at 4 pm; 102°F (38.9°C) at 8 pm; and 97.9°F (36.6°C) at 12 am. The nurse's hand-off should include which note?

Intermittent fever

An informatics nurse specialist is working with a team to design a clinical information system. To ensure system usability, the team would make sure that the language meets which criterion?

Conciseness Familiarity for the user Clarity

A woman has come to the clinic for her first prenatal visit. Which method would be the most effective way for the nurse to initiate data gathering for a health history?

Conduct an interview in a private room to obtain her health history.

interpersonal communication

direct, face-to-face communication between two or more people

intrapersonal communication

self-talk

During a therapy session, a client with anorexia tells the nurse, "I measured my thighs today. They are a quarter-inch larger than they were yesterday. I feel like a pig; I'm so fat." Which potential response by the nurse is most therapeutic?

"Has something occurred that caused you to measure your thighs?"

The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse?

"I might. I'll give it some..."

A nurse is caring for a client diagnosed with borderline personality disorder. The nurse has instructed the client about using the communication triad. The nurse determines that the client has understood this technique when stating what?

"I should start by stating my feelings as an 'I' statement."

apathy

a lack of feeling, emotion, or interest

A in SBAR stands for

assessment

key elements of CBE

flow sheets standards of nursing care bedside access to chart forms

MAR

medication administration record

gestures

motions of a speaker's hands or arms during a speech

S in SBAR stands for

situation

reciever

the person for whom the message is intended

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

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?

Orientation phase

verbal communication

Use of sounds, letters, words, pictures, and symbols to convey a message

territoriality

Defense of a space against encroachment by other individuals.

A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?

"I think the client would benefit from intravenous furosemide."

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?"

techniques for assertive communication

"I" statements Fogging Negative assertion Repetition Confidence Managing nonverbal communication Thinking before speaking Avoiding apologizing whenever possible Performing a post conversation evaluation

After teaching the parents of a child with Tourette syndrome about motor and vocal tics, the nurse determines that the teaching was successful when the parents state:

"If we get him focused on an activity, the tics will be less pronounced."

.The parents of a pregnant adolescent are outraged that they are being refused medical information about their daughter's condition. What is the best response by the nurse to address their anger?

"If we obtain permission from her, we can include you in our discussions."

A nurse has been teaching an adolescent how to self-administer insulin. Despite repeated instruction, the adolescent will use only the left thigh for insulin administration. What is the best question for the nurse to ask the adolescent before conducting further teaching?

"Is it less painful for you when you use the same site?"

The nurse is caring for a 3-year-old at a well-child checkup. The parent states that her child still has an afternoon nap but she has a friend whose toddler no longer naps in the afternoon. She is seeking advice on what do to. When providing anticipatory guidance to the parent about sleep patterns, what is the most appropriate response by the nurse?

"Often, the afternoon nap will be no longer needed after 4 years."

characteristics of effective written communication

1. appropriate language and terminology 2. correct grammar, spelling, and punctuation 3. logical organization 4. appropriate use and citation of resources

The nurse is caring for a hospitalized toddler who is having a temper tantrum. What is the most realistic approach for the nurse to use to manage the child's temper tantrum?

Offer disapproval and then ignore the tantrum

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting

Which circumstance likely requires the most documentation and communication on the part of the nurse?

A geriatric client is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia.

The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse?

Ask the family to identify a spokesperson to be the communicator with the team.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member

focus charting

Charting methodology for structuring progress notes according to the focus of the note (e.g., symptoms and nursing diagnosis). Each note includes data, actions, and patient response.

SOAP

subjective, objective, assessment, plan

sender

a person who transmits a message

social distance

the perceived difference or similarity between oneself and another person

encoding

the processing of information into the memory system

congruent communication

the verbal and nonverbal aspects match and reinforce each other

intimate distance

the zone of space willingly occupied only with intimate friends, family members, and romantic partners

The nurse is caring for an adult client who is post-abdominal surgery and has a Jackson-Pratt (JP) drain in place. What does the nurse state to the client as the priority indication for JP use?

to prevent fluid from accumulating in the wound

electronic communication

use of technology to create ongoing relationships with patients and their health care team

A client tells the nurse of being able to see everything in the distance very clearly. The client has difficulty seeing clearly close up. The nurse has to document in the electronic medical record what condition for this client?

Hyperopia

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times.

The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make?

"You are not authorized to view all of the details on the client."

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response?

Place a chair next to the bed and encourage the parent to hold the client's hand.

The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse?

Seek input from all groups and strive for consensus on what would benefit most or all of these people.

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.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus

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 familiar to the user Terminology is clear and concise for the nurses Terminology reflects the users work context

A nurse on a surgical unit is caring for a client who needs to provide informed consent for surgery. When the surgeon arrives on the unit to obtain consent, which client condition must the nurse immediately bring to the surgeon's attention?

The client was given morphine 6 mg IM 20 minutes ago

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

Usability

A nurse is doing discharge teaching with a client who is hearing impaired. What is the best way to make sure the client understands the teaching?

Use illustrations

A 22-year-old male college student goes to clinic distraught at the emergence of numerous small blisters on the shaft of his penis. On examination, the provider notes the lesions are between 2 and 4 mm in diameter and filled with serous fluid. Which term will the clinician document in the record?

Vesicles

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

Will you prescribe a complete blood count to check the white blood cell count and a culture?"

The nurse admits a 13-year-old client with possible appendicitis to the hospital, accompanied by the parent. The client and parent are both deaf and use sign language to communicate. The nurse needs to assess baseline vital signs and the intake assessment. What should the nurse do while awaiting the arrival of the sign language interpreter?

Write a note to explain the need to assess vital signs.

Which form of messaging contain figures of speech that are difficult to interpret and can be a barrier to communication?

abstract

perceptions

an awareness of objects through the five senses

A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address the disrespectful remark.

A nurse is communicating with a client who is being prepared for a mastectomy to treat breast cancer. What is the primary issue for the nurse to discuss?

concerns regarding the cancer and how the surgery will affect the client

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes:

demonstrating or pantomiming ideas to clients with hearing impairments.

The nurse working in the emergency department receives a call from the x-ray department communicating that the client the nurse is caring for has a fracture in the shaft of the tibia. The nurse tells the physician that the client's fracture is in the

diaphysis.

A nurse determines that medications are known by different names. What are the different classifications of names assigned to medications?

generic name trade name chemical name

The nurse is teaching a 15-year-old boy with type 2 diabetes and his parents how to monitor glucose levels. Which communication technique is least effective?

ignoring the adolescent's tirade about his therapy

elderspeak

infantilizing and demeaning language used by a health professional when speaking to an older adult

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:

low calcium.

active listening

paying close attention to what someone is saying and communicating

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:

pus

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:

remain honest, open, and frank.

cohesivness

solidarity, loyalty, and a sense of group membership

SOAPIER

subjective, objective, assessment, plan, intervention, evaluation, revision

The nurse is caring for a client who is very confused. In addition to verbal communication with the client, which intervention should the nurse use?

using gentle touch during activities of daily living

While responding to a client's call for help, the nurse finds the client lying on the floor. After assisting the client to bed and performing an assessment, the nurse informs the healthcare provider. In completing an incident report, the nurse documents that the client:

was found lying on the floor.

A nurse is caring for a client in an inpatient mental health setting. The nurse notices that when the client is conversing with other clients, the client repeats what they are saying word for word. The nurse interprets this finding and documents it using which term?

Echolalia

Because of symptoms experienced after a cerebrovascular accident (CVA), the nurse discovers that a client needs assistance using utensils while eating. What would the nurse do to support this activity of care?

Encourage participation in the feeding process to the best of the client's abilities.

The nurse is preparing to assess the pain of a developmentally and cognitively delayed 8-year-old. Which pain rating scales should the nurse choose?

FACES pain rating scale

Which speech pattern is exhibited by the client stating, "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill?"

Clang association

The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data?

Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway.

While caring for a client admitted with a Clostridium difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem?

Diarrhea related to infectious process as evidenced by three loose bowel movements in 3 hours

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the past 24 hours, but the client now has a temperature of 101.1 degrees F (38.4 degrees C), a heart rate of 116 beats/min, and a respiratory rate of 26 breaths/min. Using SBAR communication, which of the following recommendations should the nurse make when calling the health care provider?

Draw CBC, CRP, ESR, and UA with culture and sensitivity if indicated. Draw stat blood cultures x 2. Ensure patent I.V. access for fluid bolus.