Exam #2
A client in a cardiac rehabilitation program says to the nurse, "I have to eat a low-sodium diet for the rest of my life, and I hate it!" Which is the most appropriate response by the nurse? 1. "I will get a dietary consult to talk to you before next week." 2. "What do you think is so difficult about following a low-sodium diet?" 3. "At least you survived a heart attack and are able to return to work." 4. "You may not need to follow a low-sodium diet for as long as you think."
2
A nurse is teaching a client about a dressing change that should be done three times a day, and the client is from a culture that is "present oriented." The nurse should instruct the client to perform the dressing change at which of the following times? A.Whenever the client chooses, as long as it gets done three times daily b. At times that the client selects, as long as they are 8 hours apart c. After breakfast, lunch, and dinner d. At 9 a.m., 3 p.m., and 9 p.m.
C
Two single mothers are active professionals and have teenage daughters. They also have busy social lives and date occasionally. Three years ago they decided to share a house and housing costs, living expenses, and child care responsibilities. The children consider one another as their family. What type of family form does this represent? A Diverse family relationship B Blended family relationships Incorrect C Extended family relationship D Alternative family relationship
D (Alternative family relationships include multi-adult households, "skip-generation" families, and communal groups with children; "nonfamilies"; cohabitating partners; and homosexual couples.)
In viewing the family as context, what is the primary focus? A Family members within a system Incorrect B Family process and relationships C Family relational and transactional concepts D Health needs of an individual member
D (When you view the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). Although the focus is on the individual's health status, it is also important to assess how much the family provides the individual's basic needs)
A female nurse is caring for a 21-year-old male client with a questionable gastrointestinal blockage. The physician has ordered an enema. The nurse is planning care and anticipates which of the following reactions by the client? a. "I am afraid of having an enema." b "May I have a visitor as support in the room?" c "I have never had an enema before." d "I would rather have my doctor perform this procedure."
D embarrassed due to gender differences
A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A. Reposition the client to help with breathing. B. Notify the physician. C.Administer 10 L of oxygen per face mask. D.Complete a thorough cardiopulmonary assessment.
D repositioning without assesment could cause more harm
A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? a. Validation b. Empathy c. Sarcasm d. Humility
D. Humility is admitting to limitations in knowledge and skill. This enables the nurse to admit a knowledge deficit so guidance is sought from the patient. Humility helps improve the therapeutic relationship and enables a nurse to provide safe and effective care.
what are the 8 stages of the family life cycle?
* know chart on family powerpoint
Definition of family?
--two or more individuals who are joined together by marriage, blood, or adoption, and are residing in the same household --no typical family --defined by its members
stepfamilies in the US
1 out of 3 in US member of a step family
phases of therapeutic communication
1.Preinteraction phase-planning 2.Introductory phase-orientation, nurse and client interact, trust and respect developes 3.working 4.termination
Single Parent family statistics?
11.7 mil in the US....10 mil headed by women
normal serum sodium levels?
135-145 mEq/L
During a visit to a family clinic, a nurse teaches a mother about immunizations, car-seat use, and home safety for an infant and toddler. Which type of nursing interventions are these? A Health promotion activities Correct B Acute care activities C Restorative care activities D Growth and development care activities
A
When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A.Length of time the current treatment has been in place B.The spouse's reaction to the client's dressing change C.Client's concern about the current treatment D.Physician's reluctance to change the current treatment plan
A (A is objective.. the others are subjective/emotional and may cause bias in the decision of a treatment plan)
The nurse is caring for a female client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. What should the nurse do? A Gain knowledge about the client from family to gain compliance. B Proceed to get help to get the client out of bed. C Leave the client alone until ready to get out of bed. D Notify the physician of the client's noncompliance.
A The nurse would use knowledge and creativity to think critically about getting the client to cooperate with the medical regimen. For example, the nurse would ask the family to become involved in order to gain compliance. It is not an option to leave the client alone and not address some method of ensuring intact skin. The compliance of the client rests with the nurse, not the physician. It would not be a good idea to force the client against the client's will; the nurse would use critical thinking to find another way to meet the goal.
The community nurse identifies that a family new to the community needs assistance with family dynamics and material resources. What should the nurse consider offering to the parents of this family to support their needs? A.Hours of the local health clinic B. Location of the community library C. Location of the community co-op food bank D. Hours when the park is open E. A list of free counseling services to assist with parental stress
A, C, E The hours for the library and the park would not help the family with the issues that the nurse observed.
The nurse is providing care to a client who is newly diagnosed with human immunodeficiency virus (HIV). Which statements by the nurse could inhibit the development of a therapeutic communication with this client? A "I am so happy today! I found out that I got accepted into nurse practitioner school, isn't that great?" B "Well, I guess your homosexual lifestyle finally caught up to you, huh?" C "Tell me your feelings about the diagnosis." D "Perhaps you would like to talk about the new medications that you have been prescribed?" E "One of my cousins has AIDS. It is hard to watch him die."
A,B, E The use of open-ended questions and providing general leads in are actions that enhance therapeutic communication.
A nurse on a busy medicine unit is assigned to four patients. It is 10 am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? (Select all that apply.) A.Consider availability of assistive personnel to obtain the specimen Correct B. Combine activities to resolve more than one patient problem Correct C. Analyze the diagnoses/problems and decide which are most urgent based on patients' needs Correct D. Plan a family conference for tomorrow to make decisions about resources the patient will need to go home E. Identify the nursing diagnoses for the patient going home
A,B,C
Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (Select all that apply.) A.Initiative in reading current evidence from the literature Correct B.Application of nursing theory Correct C.Reviewing policy and procedure manual D.Considering holistic view of patient needs Correct E. Previous time caring for a specific group of patients
A,B,D (A nurse's specific knowledge base will vary but includes basic nursing education, continuing education courses, and additional college degrees. In addition, it includes the knowledge gained from a nurse reading the nursing literature and acquiring information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Nurse's knowledge base also involves a different way of thinking holistically about patient problems.)
In which of the following examples is a nurse applying critical thinking skills in practice? (Select all that apply.) A. The nurse thinks back about a personal experience before administering a medication subcutaneously. Correct B. The nurse uses a pain-rating scale to measure a patient's pain. Correct C. The nurse explains a procedure step by step for giving an enema to a patient care technician. D. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis. Correct E. A nurse offers support to a colleague who has witnessed a stressful event
A,B,D Reflection, using a pain-rating scale to be precise and specific, and nursing assessment (the first step of the nursing process) are examples of critical thinking skills. Explaining a procedure based on policy is not critical thinking. However, performing a procedure following policy is basic critical thinking. Offering support to a colleague is an important way to help another manage stress but is not a critical thinking skill.
Which of the following are possible outcomes with clear family communication? (Select all that apply.) A. Family goals B. Increased socialization C. Decision making D. Methods of discipline E. Improved education F. Impaired coping
A,C,D
The nurse in the clinic is assessing a 60-year-old client who has 2+ ankle edema, crackles throughout the lung fields, and dyspnea on exertion. The nurse concludes that the client will need lifestyle-change teaching and asks: A. If the client eats foods high in salt. B. If the client is married or divorced. C. About the client's family history. D. How many children the client has.
A.
The nurse is caring for a 10-year-old client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client? a. Ask the dietary worker to come back later. b. Order chicken nuggets because most children like this meal. c. Ask the parents to bring dinner from home for the client. d. Wake the child to choose a meal for dinner.
A. The nurse would ask the dietary worker to come back later rather than risk making an error picking a meal or insulting the client. The nurse could use deductive reasoning and pick a meal that most children like, but the client could be allergic to certain foods or just not like them. Waking the client is not an option because the body heals during sleep. If the parents are present, the nurse might ask them if they are comfortable making choices for the child, but asking them to bring food in is inappropriate.
A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. When the nurse visits, the focus is on symptom management for the grandmother and helping the family with coping skills. This approach is an example of which of the following? A Family as context B Family as patient C Family as system D Family as structure
B
A nurse has just received a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A.The client who needs assistance with activities of daily living B.The client experiencing shortness of breath C.The client with a pain rating of 3/10 D.The client who needs help ambulating to the bathroom
B
A nurse is caring for a preschool-age client who was admitted for dehydration. The child lives with the parents and maternal grandparents. In which type of family does this child reside? A) Blended family B) Extended C) Two-career family D) Traditional family
B
The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A.A client who is ambulatory. B.A client, who has a fever, is diaphoretic and restless. C.A client scheduled for OT at 1300. D.A client who just had an appendectomy and has just received pain medication.
B
What is the most common reason for calling on grandparents to raise their grandchildren? A. Single parenthood B. Legal interventions C.Dual-income families D. Increased divorce rate
B
When establishing realistic goals, the nurse: A.Bases the goals on the nurse's personal knowledge. B.Knows the resources of the health care facility, family, and the client. C.Must have a client who is physically and emotionally stable. D.Must have the client's cooperation.
B
The nurse is caring for a client with a new colostomy. The client has been taught care and has been successful with return demonstration to the staff. Although the client is able to perform care independently, the charge nurse has instructed the nursing staff to continue performing colostomy care for this client. The client has expressed interest in performing care independently and the nurse plans to address the issue with the charge nurse by stating which of the following? A.The client's family is included in the process and exchange of information to ensure complete understanding. B. They ask the interpreter to translate as closely as possible the same words used by the professional staff. C. The staff addresses the questions to the interpreter, so nothing is missed. D. The interpreter uses a dialect the client is familiar with for the best understanding.
B An interpreter is an individual who mediates spoken or signed communication between people using different languages without adding, omitting, or distorting meaning or editorializing. The objective of the professional interpreter is for the complete transfer of the thought behind the utterance in one language into an utterance in a second language (California Healthcare Interpreters Association, 2002). It is not the interpreter's responsibility to determine the dialect with which the client is most familiar. The questions should be addressed to the client, not the interpreter. Asking the client's family, especially a child or spouse, to act as an interpreter should be avoided
A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers: A.Notifying the physician B.Calling the wound care nurse C.Changing the wound care treatment D. Consulting with another nurse
B (Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. d. Another nurse most likely will not be knowledgeable about wounds)
The nurse is caring for a client who is admitted to the Emergency Department with abdominal pain. The client speaks very little English and requires an emergency appendectomy. The nurse has enlisted the hospital interpreter to explain the procedure and help with informed consent. When the interpreter arrives, the staff should make sure that: A. The client's family is included in the process and exchange of information to ensure complete understanding. B. They ask the interpreter to translate as closely as possible the same words used by the professional staff. C. The staff addresses the questions to the interpreter, so nothing is missed. D. The interpreter uses a dialect the client is familiar with for the best understanding.
B It is not the interpreter's responsibility to determine the dialect with which the client is most familiar. The questions should be addressed to the client, not the interpreter. Asking the client's family, especially a child or spouse, to act as an interpreter should be avoided.
The nurse educator is teaching a group of students about health promotion and disease prevention. Which nursing activities promote health and health maintenance? (select all that apply) A. Teaching parents how to perform pulmonary drainage and cupping on their ill child. B. Teaching a school-age child how to use dental floss C. Helping a mother determine a daily feeding schedule for her infant D. Administering the flu vaccine for an infant who is 9 months of age E. Treating a child diagnosed with pneumonia
B,C ,C Treatment of pneumonia, Teaching parents how to perform pulmonary drainage and cupping on their ill child is not considered health promotion and maintenance, as it is treating an acute illness.
the nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) a.Prevent the nurse from saying the wrong thing b.Prompt the patient to talk when he or she is ready Correct c.Allow the patient time to think and gain insight Correct d.Allow time for the patient to drift off to sleep e.Determine if the patient would prefer to talk with another staff member
B,C Silence can provide the patient an opportunity to think and gain insight. Often the patient feels compelled to break the silence and is prompted to talk.
A nurse enters a client's room to check on the client's response to IV pain medication she gave on request 20 minutes earlier. She finds the client on her side lying very still and not wanting to move, and asks the client about her current pain level. Which aspect(s) of the nursing process does this action represent? A. Diagnosis B. Implementation C. Evaluation D. Planning E. Assessment
B,C,E
A nurse is working with a client who is nonverbal. The nurse wants to implement strategies that will promote communication with this client. Which intervention(s) would be appropriate for the client in this situation? A. Facing the client when speaking B.Having pen and paper on hand for the client C.Making sure that the language spoken is the client's D. dominant language E.Employing an interpreter F.Using a picture board to facilitate communication
B,F The client who is nonverbal would respond best to using a picture board during communication and allowing the communication through pen or paper. The client is nonverbal, so speaking en face, using an interpreter, or using the client's dominant language would not address the client's inability to communicate verbally.
A nurse explains to a client that there is a need for the client to have a bowel prep before undergoing a colonoscopy. The client is visually impaired. How would the nurse best approach this educational session so the client has the best chance of understanding? A. Provide clarity. B. Use words that are commonly understood in the neighborhood and culture. C. Speak slowly to the client. D. Focus on intonation
B. Good verbal communication incorporates simplicity, which includes the use of commonly understood words, brevity, and completeness. The term "bowel prep" may be completely meaningless to a client, but telling the client that there is a need to drink a gallon of laxative-like medication gets the point across better. Colonoscopy is a complicated word. Explaining the procedure by using words like "small camera inserted into your rectum" will make much more sense to the client. Pace and intonation indicate interest, anxiety, boredom, or fear, all of which modify the feeling and impact of the message. Clarity implies that the message is direct and simpledash-saying precisely what is meant and using the fewest words necessary.
A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? a.Prioritizing the client's care b.A response to a change in the client's condition c.Meeting a client goal d.Time management skills
B. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks
A nurse is preparing to teach a group of college students about organ donation. What should the teaching include to follow andragogic concepts? A.Information on how this group can influence their parents about organ donation B. Past statistics about organ donors C. Directions about how to become an organ donor D. Written pamphlets on organ donation
C. An adult is more oriented to learning when the material is useful immediately, not sometime in the future. For this audience, giving clear directions on how to become an organ donor would be more helpful than providing information about past or future activities, such as influencing their parents. Written information may or may not be helpful, depending on what types of learners are included in the group.
The nurse is providing care for a client who is about to be discharged. The nurse is discussing medical interventions that have been prescribed for this client with the primary care provider. Which nurse statement is the best example of appropriate assertive communication? A."Excuse me, Doctor, I think you need to do something about the client's blood pressure." B."That new medication you prescribed for the client is ineffective." C."I am worried about the client's blood pressure. It remains high even with the new medication." D."Can we talk about this client prior to discharge?"
C. Focus on feelings
A client is wheezing and short of breath. The physician orders a medicated nebulizer treatment now and in 4 hours. The nurse is providing what aspect of care? A) Planning B) Evaluation C) Assessment D) Implementation
D
A 13-year-old child is in the hospital preparing for major surgery for the removal of a tumor on the kidney. The mother of the child tells the nurse that she doesn't want the child to receive narcotics for pain postoperatively. Which is the best response by the nurse? A."You do not have a choice of medication. Decisions involving pain relief are up to the healthcare providers." B."The pain will be severe. Why don't we ask your child about this?" C."Okay, I'll tell the doctor not to order any. Are you sure you want to do this?" D."The pain for your child will be severe after surgery. Can you tell me why you feel this way?"
D
Collaborative interventions are therapies that require: A.Physician and nurse interventions. B.Nurse and client interventions. C.Client and Physician intervention. D.Multiple health care professionals
D
The nurse is caring for a client who has been diagnosed with high cholesterol. When the nurse plans topics to teach, it is important to keep in mind that adult learners: A. Do not need to be evaluated for understanding as children do. B. Usually can find information on their own. C. Are more likely to adhere to a regimen than are children. D. Are more oriented to learning when the material is useful immediately.
D
The nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." The nurse is displaying which skill that is often associated with the working phase of the nurse-client relationship? A. Concreteness B. Confronting C. Genuineness . D Respect
D. Respect is correct because the nurse is validating the client's feelings. It is not genuineness because the nurse is giving information versus making a personal statement.
A graduate nurse is planning care for an older client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking? A. Place the plan on the client's chart. b. Request that the client review the plan. c. Discuss the plan with the physician. D. Request a review of the plan with the nurse's preceptor.
D. Seeking out other opinions increases the knowledge base and exposes the new nurse to other ways of thinking, which will enhance critical thinking. The nurse would seek the opinion of another nurse, not the physician or the client, as the goal is to enhance the nurse's ability to use the nursing process.
*be familiar of the factors influencing the communication process
Development: 1.Infants and toddlers: use touch 2.Older children: pictures as adjunct to words 3.Adolescents and adults: verbal communication 4.Older adults: adjust methods to physical changes of aging Gender 1. boys establish independece 2. girls seek validation/intimacy Socio cultural characteristics Values and perceptions Personal Space Territoriality Roles and Relationships Environment Congruence
know the characteristics of physical attending
Face the person squarely Adopt an open posture Lean toward the person Maintain good eye contact Try to be relatively relaxed
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?
Hyperactive bowel sounds
What are the four phases of therapeutic empathizing?
Identification Incorporation Reverberation Detachment *guards against overidentification and burnout
characteristics of therapeutic communication
Intellectual and emotional bond Focused on client Respects client as individual Respects client confidentiality Focuses on client's well-being Based on mutual trust, respect, acceptance
common family features?
Interdependence Maintaining boundaries Adapting to change Performing family tasks
Characteristics related to verbal communication?
Pace and intonation Simplicity Clarity and brevity Congruence Timing and relevance Adaptability Credibility Humor
Characteristics related to non verbal communication?
Personal appearance Posture and gait Facial expressions Eye contact Gestures Sounds Territoriality and personal space
Binuclear family?
Postdivorce family/ children members of two nuclear households
four levels of family flexibility?
Rigid (low flexibility) Structured (more flexibility Flexible shared leadership changes as necessary Chaotic (no real leadership and too much change)
4 parts of the communication process?
Sender Message Receiver Response
Place the steps of the scientific method in their correct order with number 1 being the first step of the process. 1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis. a. 4, 3, 1, 5, 2 b. 3, 4, 1, 2, 5 c. 4, 3, 2, 1, 5 d. 3, 4, 1, 5, 2
a
The nursing care plan is: a.A written guideline for implementation and evaluation. b.A documentation of client care. c.A projection of potential alterations in client behaviors d.A tool to set goals and project outcomes.
a
The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which area(s) should the nurse focus when performing this reflection? (select all that apply) a.Things that could have been done differently b.Resources that were needed but not available c.Gut reactions to the situation d. Resources that were used at the time e.Things that were done well
a,b,d,e A "gut reaction" describes intuition, which is not a part of reflective thinking.
The nurse knows that confrontation can be used to therapeutically communicate with clients. Which response by the nurse is an example of informational confrontation with a client diagnosed with hypertension? a. "I noticed you rubbing your head and your eyes, are you hurting? Let's take your blood pressure." b. "I heard raised voices when I was coming down the hall to your room. Are you upset?" c. "It is 3 p.m. and time to take your blood pressure before I give you your medication." d."Is the blood pressure medication making your head hurt?"
a. goal oriented; open and two-way communication
A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of: a. A teaching plan. b. A learning objective. c. Reinforcement of content. d. Enhancing the children's self-efficacy.
b
The nurse is making a health promotion teaching plan for a client. Why will the nurse plan to ask the client about the types of food the client likes and for information regarding the client's food budget prior to the teaching? a. to set a goal for the client. b. to make a decision about what to teach. c. to solve a problem. d. to evaluate the client.
b
When using a rigorous approach to critical thinking, clinical decision making, and clinical practice, what must the nurse avoid? A. Logical thinking. B. Haphazard thinking. C. Independent thinking. D. Systematic thinking.
b
During a home visit, the nurse decides that care interventions are needed to address alcohol and substance abuse by family members. Which intervention(s) should the nurse consider when planning care for this family? A. Be alert to behaviors that indicate sibling jealousy. B. Evaluate family members' potential for being a danger to self or others. C.Suggest grief counseling. D. Suggest engaging in educational activities. E.Recommend community resources to assist with substance abuse behavior.
b,e Grief counseling would be appropriate for the family who has suffered a loss of a family member. Educational activities and being alert to sibling jealousy would be appropriate for the antepartum or postpartum family.
Planning is a category of nursing behaviors in which: a.The nurse determines the health care needed for the client. b.The Physician determines the plan of care for the client. c.Client-centered goals and expected outcomes are established. d.The client determines the care needed.
c
A nurse changed a patient's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (Select all that apply.) a. Clinical inference b. Basic critical thinking Incorrect c.Complex critical thinking Correct d.Experience Correct e.Reflection
c,d
A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? a."Why did you drive after you had been drinking?" b. "We have multiple patients to see tonight as a result of this accident." c. "Tell me what happened before, during, and after the automobile accident tonight." Correct d. "It will be okay. No one was seriously hurt in the accident."
c. Focusing gives direction, which enables the nurse to obtain clearer information without probing. Asking "why" questions can convey judgment on the part of the nurse. Giving false reassurance is not a therapeutic communication technique.
A pediatric home health care nurse is making an initial visit to assess the parenting style for a family in preparation for treating a child with drugs to reduce hyperactivity. Which approach should the nurse use for this assessment? a. Observe the parent interacting with the child for 5 minutes. b. Ask the child, "What rule is hardest for you to obey?" c. Ask the parents, "How do you handle situations that require limit setting?" . d. Ask the parents, "What are the house rules?"
c. Parental styles are best assessed while the family explains how it handles situations that require limit setting.
What is congruent communication?
congruent communication is when verbal and nonverbal aspects match -incongruence occurs when nonverbal body language reveals the real meaning of a message
A nurse enters a 72-year-old patient's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of: a. Inference. b. Basic critical thinking. c. Evaluation. d. Diagnostic reasoning.
d
A patient needs to learn to use a walker. Which domain is required for learning this skill? a. Affective domain b. Cognitive domain c. Attentional domain d. Psychomotor domain
d
The nurse is caring for a 25-year-old woman who has had a cervical biopsy. The client has expressed anxiety about the results. The resident physician peeks into her room and says, "The biopsy is negative." The nurse later finds the client in her room sobbing. What is the nurse's best response to this situation? A."Why are you crying with such good news?" B."The term 'negative' in this case is good!" C."What did the physician tell you about the biopsy?" D."You seem upset. Do you want to talk to me about the test results?"
d
The nursing process organizes the nurse's approach when delivering nursing care. To provide the best professional care to patients, what must nurses incorporate into the nursing process? A. decision making. B. problem solving. C. intellectual standards. D. critical thinking skills.
d
A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of: a. Accuracy. b.Reflection. c. Risk taking. Incorrect d. Basic critical thinking.
d (Basic critical thinking is concrete and based on a set of rules or principles such as the guidelines in a hospital procedure manual. The nurse's approach is not accurate because accuracy requires use of all of the facts (e.g., the patient's discomfort). A critical thinker is willing to take risks to try different ways to solve problems; following one basic approach is not risk taking. This is also not an example of reflection.)
After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: a.Encourage client to implement guided imagery when pain begins. b.Determine effect of pain intensity on client function. c.Administer analgesic 30 minutes before physical therapy treatment. d.Pain intensity reported as a 3 or less during hospital stay.
d (measurable and objective)
A home health nurse is precepting a new nurse during a routine wound care visit. The new nurse is assessing the client's wound and notes that the wound is showing signs and symptoms of infection. The client's spouse asks the new nurse how the wound looks. The new nurse responds by stating, "It looks fine," but the new nurse's face indicates a different story. When evaluating the new nurse the preceptor should note that work is needed on which aspect of communication? a.Clarity and brevity b.Credibility c.Timing and relevance d.Adaptability
d. Adaptability is adjusting tone of speech and facial expression to match the spoken message. Clearly, if the nurse's facial expression does not match the words, the client's family will identify a problem with the situation. Credibility means worthiness of belief, trustworthiness, and reliability. Timing and relevance affect how the message is taken or heard. Clarity and brevity are characteristics involving preciseness and use of few words.
Characteristics of assertive communication
direct, non-confrontational, FOCUS ON FEELINGS
Intragenerational family?
more than 2 generations together
Electronic communication
not good for confidential, abnormal or urgent information
Heterosexual cohabiting family?
unrelated individuals togheter
