Taylor's FON Ch. 7 & 8

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information? "Have you ever had chest pain prior to this admission?" "Could you tell me more about how you are feeling right now?" "I have had chest pain before, and it is really scary!" "Did you take any medication when you had the pain?"

"Could you tell me more about how you are feeling right now?"

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse? "A living will can only be used in the state in which it was created." "Take it with you. It is recognized universally in the United States." "As long as your family knows your medical wishes, you will not need it." "We have it on file here, so any hospital can call and get a copy."

"Take it with you. It is recognized universally in the United States."

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation? "Is your name Evelyn?" "Are you in a hospital?" "Is today the first day of the month?" "What day of the week is it?"

"What day of the week is it?"

In which situation would the SBAR technique of communication be most appropriate?

A nurse is calling a physician to report a client's new onset of chest pain.

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor?

Battery

The nurse is providing care to a client whose condition has progressively declined. The nurse assesses and makes appropriate interventions as well as notifies the health care provider. Despite the nurse's efforts, the client expires. What element of liability has the nurse demonstrated? Duty Breach of duty Causation Damages

Duty

What governing body has the authority to revoke or suspend a nurse's license?

The State Board of Nurse Examiners

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report? To document everyday occurrences To document the need for disciplinary action To improve quality of care To initiate litigation

To improve quality of care

When collecting data on a client, the nurse implements which nonverbal communication form as one of the most effective to express feelings? Eye contact Touch Gait Body posture

touch

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

"Why did your physician send you here to be admitted?"

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing?

Certification

The client is an 18-month-old in the pediatric intensive care unit. The client is scheduled to have a subgaleal shunt placed tomorrow, and the client's mother is quite nervous about the procedure. The nurse tells the client's mother, "The surgeon has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication? Rescue feelings False reassurance Giving advice Being moralistic

False reassurance

A nurse is providing care to an older adult client. The client has been alert and independent with ambulation but now is exhibiting some confusion along with being unsteady when getting out of bed and walking. The nurse fails to report and document this change in status. No safety measures are taken and the client falls while getting out of bed to use the bathroom and fractures a hip. The client is experiencing significant pain from the fractured hip and requires surgery to repair the fracture. The nurse is sued for malpractice. Which action reflects the element of causation in this case? Responsibility to report changes in status Failure to document and report the change Lack of safety measures implemented with status change Fractured hip, pain, and need for surgery

Lack of safety measures implemented with status change

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case? The Good Samaritan law will provide legal immunity to the nurse. The Good Samaritan law will not protect the nurse because the nurse did not accept compensation. The Good Samaritan law is not applicable to health care workers. The Good Samaritan law will provide absolute exemption from prosecution.

The Good Samaritan law will provide legal immunity to the nurse.

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation?

The nurse should ask the physician to come back and write the order.

A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report? To determine the nurse's fault in the incident To evaluate the quality of care provided and assess the potential risks for injury to the client To provide information to local, state, and federal agencies To evaluate the immediate care provided by the nurse to the client

To evaluate the quality of care provided and assess the potential risks for injury to the client

While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects:

invasion of privacy.

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation? "Good morning, I am calling about Mrs. Jones, who is a client of yours." "My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." "My name is Sue, and I am calling about Mrs. Jones, a client of yours at Jefferson Hospital." "I have a client of yours at Jefferson Hospital who is experiencing a change in condition and needs to be seen immediately!"

"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital."

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: plan a meeting where the dominant person cannot attend. pick a team leader who is not the dominant member. have group members confront the dominant member to promote the needed team work. have group members issue a written warning to the dominant member.

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

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?" "All right, you have four children, is that correct?" "How old are your children?" "Were these term births?"

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