Fundamentals of Nursing Ch 20 PrepU 2

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which of the following activities would the nurse be carrying out? a) Establishing trust and rapport b) Reviewing health changes c) Attending physical health care needs d) Developing solutions that are enacted

b) Reviewing health changes

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be: a) nurturing. b) passive. c) aggressive. d) assertive.

c) aggressive.

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse she is afraid of waking up during surgery. The best response by the nurse is to: a) ask the surgeon to come to the bedside to reassure the client. b) ask the client why she thinks she will wake up during surgery. c) look directly at the client and state, "you are afraid of waking up during surgery." d) state "everyone is afraid of that."

b) ask the client why she thinks she will wake up during surgery.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by a) staring into the neonate's eyes and smiling. b) offering the neonate infant formula. c) swaddling the child and gently stroking its head. d) softly humming a song near the neonate.

c) swaddling the child and gently stroking its head.

The knowledge of the nursing process guides nurse-client communication. Arrange the steps of the nursing process in sequential order: 1) Outcome Identification and Planning 2) Assessing 3) Implementation 4) Evaluation 5) Diagnosing

2) Assessing 5) Diagnosing 1) Outcome Identification and Planning 3) Implementation 4) Evaluation

Which term describes a nurse who is sensitive to the client's feelings, but remains objective enough to help the client achieve positive outcomes?

Empathic

Which communication technique is being utilized, when the nurse states, "That's not true, where did you get that idea"? a) Giving disapproval b) Disagreeing c) Giving advice d) Defending

b) Disagreeing

Which phase of the nurse-client relationship involves the mutual planning of care and putting the plan into action? a) Introductory b) Termination c) Working d) Pre-introductory

c) Working

Which of the following is a positive interpretation of body language? a) Rubbing nose b) Clenched jaw c) Arms crossed d) Tilt of head

d) Tilt of head

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a client's room to empty his or her urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the patient to explain the statement.

The nurse interviews a client during which step of the nursing process? a) Assessment b) Diagnosing c) Evaluation d) Planning

a) Assessment

The nurse is having a discussion with a client diagnosed with breast cancer. Which of the following would be most effective in promoting communication? a) "Can you say more about your experience of your sister's mastectomy?" b) "What are some of your ideas about how to handle this?" c) "You should go for surgery, followed by chemotherapy." d) "I'm not sure I understand what you mean by alternate therapy."

b) "What are some of your ideas about how to handle this?"

A client is having difficulty with self-administration of insulin. The nurse states, "Many people learn to give themselves insulin." The nurse is using which nontherapeutic communication technique? a) Disagreeing b) Belittling c) Giving false reassurance d) Giving advice

b) Belittling

Care provided to a client following surgery and until discharge represents which phase of the helping relationship? a) Evaluation phase b) Orientation phase c) Working phase d) Termination phase

c) Working phase

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

A client has been recently diagnosed with diabetes. He is seen in the emergency room every day with high blood sugar. The client apologizes to the nurse for bothering them every day, but he cannot give himself insulin injections. What should the nurse's response be? a) "Has someone taught you how to take them?" b) "You should learn to take injections yourself." c) "Ask the doctor to change the medications." d) "I myself cannot take insulin injections."

a) "Has someone taught you how to take them?"

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? a) "I understand you have four kids, how many times have you actually been pregnant?" b) "Were these term deliveries?" c) "All right, you have four children, is that correct?" d) "How old are your children?"

a) "I understand you have four kids, how many times have you actually been pregnant?"

A dialysis nurse is educating a client on caring for the dialysis access that was inserted in the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. What phase of the working relationship is best described in this scenario? a) The working phase b) The termination phase c) The introduction phase d) The orientation phase

a) The working phase

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: a) have group members confront the dominant member to promote the needed team work. b) pick a team leader who is not the dominant member. c) plan a meeting where the dominant person cannot attend. d) have group members issue a written warning to the dominant member.

a) have group members confront the dominant member to promote the needed team work.

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? a) Check the client's skin turgor. b) Determine whether the prescribed treatment was effective. c) Formulate a plan of care based on risk for dehydration. d) Administer an additional liter of intravenous fluids.

b) Determine whether the prescribed treatment was effective.

When assessing a client's nonverbal communication, the nurse will assess which of the following as the most expressive part of the body? a) Posture b) Facial expressions c) Eye contact d) Hand gestures

b) Facial expressions

The nurse has to complete a cardiac assessment on a client. Which level of human proxemics would be appropriate for the nurse in completing this assessment on the client? a) Intimate b) Personal c) Public d) Social

b) Personal

What is the goal of the nurse in a helping relationship with a client? a) To facilitate the client's interactions with others b) To assist the client to identify and achieve goals c) To provide hands-on physical care d) To ensure safety while caring for the client

b) To assist the client to identify and achieve goals

A client arrives at an emergency department after experiencing several black, tarry stools. The nurse will develop a cause and effect by: a) asking the client to provide a stool specimen for guiac testing. b) asking the client if he or she has recently taken ferrous sulfate (iron) or bismuth subsalicylate (Pepto Bismol). c) insisting the client not eat or drink anything until further instructed. d) determining if the client has any food or drug allergies.

b) asking the client if he or she has recently taken ferrous sulfate (iron) or bismuth subsalicylate (Pepto Bismol).

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should: a) show the child the intravenous catheter and explain how it works. b) involve the child's stuffed animal in the educational session. c) ask the child's parents to leave the room while the nurse and child talk. d) provide both verbal and written information to the child.

b) involve the child's stuffed animal in the educational session.

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: a) "Do you have and advanced directive or a living will?" b) "Can you tell me the medications you take on a daily basis?" c) "Can you tell me why your physician sent you here to be admitted?" d) "Are you allergic to any medications?"

c) "Can you tell me why your physician sent you here to be admitted?"

The mother of a toddler is trying to decide if she wants to allow her child to receive the recommended immunizations. The clinic nurse responds, "If you don't immunize your child you are jeopardizing the health of other children." What type of approach does this response indicate? a) Dictatorial or bossing b) Authoritarian or belittling c) Guilt inducement or approval/disapproval d) Advocacy or enforcing rights

c) Guilt inducement or approval/disapproval

A patient comes to the emergency department for a wound to the right great toe. The assessment reveals a necrotic toe with the presence of maggots. The nurse uses her personal phone to take a picture of the wound and uploads it onto a social networking site. Which of the following statements is true? a) As long as the patient provides verbal consent the nurse may post the picture on the social networking site. b) As long as the patient provides a written consent the nurse may post the picture on the social networking site. c) The nurse violated the patient's Health Insurance Portability and Accountability Act (HIPAA) rights. d) As long as the patient's face does not appear in the picture it is acceptable to upload the photo.

c) The nurse violated the patient's Health Insurance Portability and Accountability Act (HIPAA) rights.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult: a) a clinical psychologist. b) an ophthamologist. c) an audiologist. d) an optometrist.

c) an audiologist.

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 healthcare provider. In the final step of the report the nurse should: a) detail the client's past medical history and active medication orders. b) discuss the client's situation and request a chest xray to assess lung function. c) recommend 40 milligrams of furosemide (Lasix) be administered because the client had improvement with past administration. d) provide detailed findings of the head to toe assessment.

c) recommend 40 milligrams of furosemide (Lasix) be administered because the client had improvement with past administration.

A nurse is caring for a client who presents with a skin infection. While obtaining the patient's medical history, it is determined that the client is an intravenous drug abuser. To foster effective communication, the nurse should: a) consult with the social worker regarding inpatient drug rehabilitation. b) ask if the client realizes the infection is a direct result of the drug abuse. c) remain honest, open, and frank. d) ask the client for a urine specimen for urine drug of abuse screening.

c) remain honest, open, and frank.

A client tells the nurse that he is very worried about his surgery. Which of the following responses by the nurse is a cliché? a) "Tell me what you are worried about." b) "Do you want to cancel your surgery?" c) "Have you spoken to your family about your concerns?" d) "Don't worry, everything will be fine."

d) "Don't worry, everything will be fine."

A client has just been diagnosed with cancer. As part of the plan of care, the nurse attempts to explore the client's feelings about the diagnosis to foster looking at alternatives. The nurse implements this action based on the understanding that looking at alternatives promotes which of the following? a) Assistance for the client to unclear thoughts into words b) Sharing of information about the client's health c) Aid for the client to describe concerns and problems d) Exploration of options for the client's consideration

d) Exploration of options for the client's consideration

A nurse understands the need for effective communication with clients during assessments. The nurse is completing the admission history for a client admitted to the healthcare facility. Which can result from the nurse using open-ended questions during the client admission history assessment? a) Brief interview b) Predictable responses c) Simple responses d) In-depth information

d) In-depth information

Which of the following is a component of the termination phase of the nurse-client relationship? a) Identification of the client's health problems b) Accepting that a client has a potential for change c) Mutually planning the client's care d) Mutual agreement that the client's health problem has improved

d) Mutual agreement that the client's health problem has improved

A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques? a) Reflective question b) Closed question c) Validating question d) Open-ended question

d) Open-ended question