PrepU chapter 8: Communication
The nurse is admitting a client directly from a healthcare clinic. The healthcare provider's orders are illegible. What should the nurse do next? Select all that apply.
-Hold all orders. -Call the healthcare provider to clarify orders. -Correct response: -Hold all orders. -Call the healthcare provider to clarify orders.
A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say?
"I'm sorry, but I can't share confidential information."
A client asks the nurse why it is necessary to complete an advanced directive on admission to the hospital. The nurse's best response is:
"It is your chance to make your wishes known if you ever become incapable of making your own decisions."
A mother brings her newborn in for a well-child check-up. During the visit, the mother tells the nurse that she is concerned about having her baby vaccinated because she heard that vaccinations can cause autism. Which response by the nurse would be most appropriate?
"Let us talk about your concerns."
A client comes to the clinic for evaluation. The client tells the nurse, "I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor." The client hands the nurse a printout of what the client found. Which response by the nurse would be most appropriate?
"Tell me more about where you found this information that you gave me."
While changing her newborn's diaper, a mother states: "there is some bleeding from the vagina." Which of the following is the nurse's appropriate response?
"This is in response to your hormones and will stop within a week of life."
A nurse is admitting a client to the palliative unit and discussing advanced directives. Which of the following statements made by the client leads the nurse to believe the client requires clarification around advanced directives?
"This will stop my daughter-in-law from putting me in a home."
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?
"What does the pain feel like?"
A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priory intervention?
Ask for additional information from the client.
The nurse is caring for a 5-year-old child in pain. Which of the following methods should the nurse use to most accurately assess the child's pain?
Ask the child to point to a face drawing that indicates pain intensity
A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
Assess urine for excessive bleeding
The nurse manager is holding a meeting with the nursing team to discuss management's decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening "to take this decision further." To defuse this situation, which of the following would be the best step for the nurse manager to take?
Call a break in the meeting and talk to the nurse in a private place.
A client who recently immigrated from Korea to the U.S. or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?
Checking vital signs and assessing for nonverbal indications of pain
The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?
Contact the surgeon for clarification because this is not a complete order.
A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program?
Creating a safe environment for sharing information
A nurse hears a staff member giving incorrect information to the family of a client newly diagnosed with diabetes mellitus who is being discharged to home. The nurse wants to make sure the family has the proper information before the client is discharged. What should she do?
Have the nurse step outside of the room, discuss the situation, and use it as a learning opportunity.
A client's spouse has arrived prior to surgery. When the client is transferred to the operating room, what would be appropriate for the nurse to tell the spouse?
Inform the spouse that the client will be going to the recovery room after the operation, and that someone will notify the unit when the client is ready to come back.
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
Limiting abbreviations to those approved for use by the institution.
The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client?
Enlist the help of a hospital interpreter; ask the son to translate if none is readily available.
Which strategy will be most effective in improving transcultural communications with oncology clients and their families?
Establish a rapport and listen to their concerns.
A diabetic patient is reviewing the hospital menu to order lunch. The client asks the nurse suggestions for "cold" foods to order. What is the nurse's understanding of why the client asking about suggestions for "cold" foods?
The client is balancing the disease with cold foods
A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations, and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations, and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse?
The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization.
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?
When communicating a change in a client's condition to his or her physician.
The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting:
clang association
When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which intervention should the nurse employ as the first step?
eliminating distracting stimuli such as turning off the television
A nurse is providing care to a client with cancer. The client tells that nurse that the care provider is not giving enough information about the client's condition. Which behavior by the nurse demonstrates advocacy?
helping the client create a list of questions to ask the care provider
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
progress note
The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The mother does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his mother, the nurse should consider that:
these circumstances may allow the child to translate.
A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying:
"Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."
A client who has tested positive for the human immunodeficiency virus (HIV) gives birth to a girl. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?
"She may have acquired HIV in utero, but we won't know for sure until she's older."
A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. To assist the client, which of the following questions would be most appropriate for the nurse to ask?
"What have you done so far to try to solve this problem?"
The nurse is caring for a client with histrionic personality disorder. The client's family member asks, "How do I handle the drama that occurs when she doesn't get her own way?" What information should the nurse provide this family? Select all that apply.
-"Do not argue or try to rationalize things with the person." -"State your responses in a non-emotional manner." -"Maintain a serious and personal interest in the person." -"Remember to give positive feedback whenever possible."
A pregnant client is seeking information from the nurse about a home birth with registered midwives. Which of the following statements lets the nurse know that the client has considered the risks and benefits of using a midwife? Select all that apply.
-"I understand the complications that could occur in a home birth setting." -"I realize that I may need to be transferred to a hospital if complications develop." -"I will develop a list of questions to use in interviewing potential midwives."
The nurse is caring for a client who is in the transitional stage of labor. The client's partner is concerned and asks, "What else can I do for my wife? She is so irritable." Which of the following interventions would the nurse suggest? Select all that apply.
-"Stay by your wife's side. It is important that she know you are there to support her." -"Encourage your wife to rest in between contractions." -"Continue to praise your wife and give her encouragement."
A pediatric nurse preceptor working on an oncology floor observes a new graduate crying in the nurses' lounge. What is the nurse's best action?
Ask the graduate what's going on.
What should be charted by the nurse when the client has an involuntary commitment or formal admission status?
The client's receipt of information about status and rights should be charted.
The client presents at the clinic but does not speak the same language as the nurse. What actions by the nurse are most appropriate? Select all that apply
Use a trained medical interpreter to communicate. When using an interpreter, obtain feedback to be sure the client understands. When using an interpreter, talk to the client, not the interpreter.
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
A client is receiving cilostazol for intermittent claudication. What should the nurse ask the client to determine the effectiveness of the drug?
"Do you have less pain in the legs?"
A nurse manager overhears a nurse caring for a client with an IV make the following statement: "If you don't stop playing with your IV, I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation?
"I need to inform you that your behavior is within the definition of assault."
What important considerations would the nurse make when teaching and caring for a newly diagnosed client with diabetes mellitus?
Involving the client in the development of the teaching plan and encouraging questions and active participation
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings
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