Fundamentals Chapter 8

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should: A) smile at the client and apologize. B) ignore the statement and empty the urinary catheter. C) inform the client that the unit was very busy that day. D) sit at the bedside and allow the client to explain the statement.

D

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive? Hand gestures Posture Eye contact Facial expressions

Facial expressions

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique? Seeking clarification Encouraging elaboration Giving information Giving false reassurance

Giving false reassurance

In SBAR, what does R stand for? Response Recommendations Report Reinforcing data

Recommendations

Which is an open-ended question? "When was the last time you had your prescription refilled?" "Why did the health care provider prescribe this medication for you?" "How many tablets do you take at one time?" "Do you take this medication daily?"

Why did the health care provider prescribe this medication for you?

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? Working phase Orientation phase Evaluation phase Termination phase

Working phase

A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse? A) "Legal policy requires nursing practice to be permanently integrated into the client record." B) "The electronic health record we use does not allow us to use different formats." C) "The facility requires us to document client care this way because of the computer application used." D) "It would be easier to do it that way. You could develop a tool to use."

A

A nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond? A) "This must be very difficult for you to hear. How do you feel right now?" B) "What would help you accept that this is best for both of you?" C) "Why do you think that the care team has made this recommendation?" D) "Do you understand that everyone here has your spouse's best interest at heart?"

A

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse? A) "You're worried about how you will tolerate the pain associated with labor." B) "There are many good medications to decrease the pain; it will not be so bad." C) "I would recommend keeping a positive attitude." D) "Don't worry about labor, I have been through it and it is not so bad."

A

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase? A) Examine goals of the relationship to determine whether they were achieved B) Create a contract regarding the relationship C) Make formal introductions D) Provide assistance to achieve goals

A

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? A) "A coronary artery bypass graft will benefit your heart." B) "The CABG procedure will help increase intestinal motility and prevent constipation." C) "The CABG procedure will help identify nutritional needs." D) "A complete ablation of the biliary growth will decrease liver inflammation."

A

A nurse is calling a health care provider 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? A) "My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." B) "My name is Sue, and I am calling about Mrs. Jones, a client of yours at Jefferson Hospital." C) "Good morning, I am calling about Mrs. Jones, who is a client of yours." D) "I have a client of yours at Jefferson Hospital who is experiencing a change in condition and needs to be seen immediately!"

A

A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, "I do not know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening? A) "You seem unsure. Tell me your concerns about your surgery." B) "I understand you are not sure about having the surgery. Why do you think you really do not need the surgery?" C) "I understand your confused, what do you think you should do?" D) "You seem unsure, please let me know if you decide to postpone the surgery until you are no longer unsure."

A

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: A) "What did your health care provider tell you about your need to be admitted?" B) "Can you tell me the medications you take on a daily basis?" C) "Do you have an advanced directive or a living will?" D) "Are you allergic to any medications?"

A

In which situation would the SBAR technique of communication be most appropriate? A) A nurse is calling a health care provider to report a client's new onset of chest pain. B) A nurse is facilitating a family meeting to coordinate a client's discharge planning. C) A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke. D) A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure.

A

The nurse is caring for a client who is a victim of sexual assault. Which action would the nurse take to develop a trusting rapport with the client? A) Approach the client with empathy and understanding and allow the client to share feelings without being judged. B) Use strategic pauses to allow the client to provide information that will be used to help officials in their investigation. C) Exhibit a professional demeanor while examining the client and obtaining specimens, asking questions that are not intrusive. D) Practice active listening by allowing the client to express fears and concerns then restating in the nurse's own words to demonstrate understanding.

A

Which contains all the components of a valid order? A) John Smith, atenolol 50 mg, twice a day, by mouth B) John Smith, 70 units, b.i.d., SL C) John Smith, enoxaparin sodium 120 mg, subcutaneously, periumbilical D) John Smith, warfarin, once a day, by mouth

A

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. A) any abnormal occurrences with the client during the shift B) what time the nurse will return for the next shift C) current orders D) what the client watched on television during the shift E) identifying demographics, including diagnosis

A, C, E

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. A) The nurse keeps communication simple and concrete. B) The nurse communicates in a busy environment to hold the client's attention. C) The nurse gives lengthy explanations of the care that will be given. D) The nurse shows patience with the client and gives the client time to respond. E) If there is no response, the nurse does not repeat what is said and takes a break. F) The nurse maintains eye contact with the client.

A, D, F

Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic? "Did a police officer take a report at the accident scene?" "Was there any cracking of the windshield?" "All of the people got themselves out of the car?" "Were there any fatalities in the other vehicle?"

All of the people got themselves out of the car?

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation? A) Indifference B) Empathy C) Pity D) Sympathy

B

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a non-emergent client situation. What is the nurse's appropriate response? A) Refuse to implement the order and notify the nurse manager. B) Tactfully request the provider to input the order into the computerized provider order system. C) Have another nurse witness and record the order into the medication administration record (MAR). D) Input the order into the computerized provider order system.

B

A nurse and client are in the working phase of the helping relationship. What outcome statement developed by the nurse and client correlates with this phase? A) The client and nurse will establish goals of the relationship. B) The client will express feelings and concerns to the nurse. C) The nurse and client will determine where and when they will meet. D) The client will identify the goals that have been accomplished during the relationship.

B

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? A) Place the client's hand on the parent's hand and reassure the parent that things will be fine. B) Place a chair next to the bed and encourage the parent to hold the client's hand. C) Encourage the parent to bring in pictures of the family that can be displayed in the room. D) Place a chair next to the bed and then leave the room to allow the parent to grieve.

B

A pregnant client presents to the emergency department with vaginal bleeding. A trans-vaginal ultrasound is performed, and the health care provider informs the client that there are normal fetal heart tones noted. The client begins to tear-up and has a worried appearance. To facilitate therapeutic communication, what statement would the nurse make after observing the client's nonverbal communication? A) "Close your eyes and take a deep breath. I know you were frightened, but the baby is healthy and everything is going to be okay." B) "Take your time and tell me how you are feeling. I have plenty of time to answer your questions and discuss any thoughts or feelings with you." C) "I can help you, please talk to me so that I know how I can help you." D) "This is great news. You don't have anything to worry about and the baby is doing well."

B

Which outcome for a client with a new colostomy is written correctly? A) The client will be able to care for stoma and cope with psychological loss by 3/29/20. B) The client will demonstrate proper care of the stoma by 3/29/20. C) The client will know how to care for the stoma by 3/29/20. D) Explain to the client the proper care of the stoma by 3/29/20.

B

While the nurse is caring for a hearing impaired client, and a family member of the client states, "What do you think is the best way to communicate?" What is the best response by the nurse? A) "Encourage family members to increase their vocal pitch." B) "Use flash cards and writing pads." C) "Use words that begin with 'f,' 's,' 'k,' and 'sh' to communicate." D) "Limit communication to avoid frustration."

B

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: A) ask the client for a urine specimen for urine drug use screening. B) consult with the social worker regarding inpatient drug rehabilitation. C) remain honest, open, and frank. D) ask if the client realizes the infection is a direct result of the drug use.

C

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not often performed wound care on a complex wound. Using effective intrapersonal communication, this nurse should: A) inform the client that several nurses will be needed to care for this wound. B) tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound. C) tell oneself to "remain calm" and remember that the nurse was trained to perform this skill. D) ask the charge nurse to change the assignment.

C

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse? A) A nurse posts pictures of a client who accomplished a goal of losing 100 lb and later deletes the photo. B) A nurse describes a client on Twitter by giving the client's diagnosis rather than the client's name. C) A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's. D) A nurse describes a client on Twitter by giving the room number rather than the name of the client.

C

The nurse attempts to notify a health care provider about a client's elevated temperature but does not get a response. Which statement, if documented by the nurse, would indicate that the nurse is following proper protocol for nursing documentation? A) 1300: Client temperature elevated. Health care provider paged, but did not respond. Administered acetaminophen without an order because I knew this health care provider does not return calls. B) 1300: Client temperature elevated. Telephoned health care provider 3 times. As usual, health care provider did not respond. C) 1300: Client temperature elevated. Telephoned health care provider's service 3 times without a response. Tepid sponge bath given and nursing supervisor notified. D) 1300: Client temperature elevated. Telephoned health care provider's service several times with no response. Will notify nursing supervisor during rounds.

C

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others? A) Intrapersonal communication B) Purposive communication C) Therapeutic communication D) Metacommunication

C

Which is a skill appropriate to use in therapeutic communication? A) Avoid the use of periods of silence. B) Be precise and inflexible regarding the intent of the conversation. C) Control the tone of the voice to avoid hidden messages. D) Use cliches to enhance a client's understanding of information.

C

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication? A) Use facial and hand gestures B) Contact a person skilled in sign language C) Provide paper and pencil for written communication D) Assess how the client would like to communicate

D

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client? A) Use a text-telephone device (TTD) for daily communication. B) Talk with the client's children to determine needs. C) Consult the oncology nurse specialist. D) Arrange for a sign language interpreter when discussing treatment.

D

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

D

The nurse is providing care to an older adult client who has visual and hearing deficits. What action by the nurse is appropriate to help with communication? A) Obtain the client's attention by calling out the client's first name. B) Remove the COVID protection face mask while speaking with the client. C) Speak in a loud voice over the volume of the television set. D) Identify oneself by name and title with each entry into the client's room.

D

What nursing care behavior by the nurse engenders a client's trust in the nurse? A) A nurse tells the client, "My shift will be over in 45 minutes, I will let the oncoming nurse know you have questions about tomorrow's test." B) A nurse tells the client, "Do not worry about the test, I have never cared for anyone that had problems with it." C) A nurse answers the client's questions about an upcoming test while completing documentation in the EHR. D) A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client.

D

Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached? Commiseration Sympathy Kindness Empathy

Empathy

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique? Encouraging elaboration Restating Clarification Reflection

Encouraging elaboration

A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause? "Have you ever had kidney disease?" "Have you ever had an elevated blood sugar?" "Have you ever had urinary retention before?" "Is it uncomfortable to urinate?"

Have you ever had an elevated blood sugar?

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy? Identifying with the client's feelings Caring for the client without negative judgment Conveying genuine care to the client Experiencing feelings similar to those of the client

Identifying with the client's feelings

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? Working phase Termination phase Orientation phase Evaluation phase

Orientation phase

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship? Termination phase Orientation phase Working phase Intimate phase

Orientation phase

A nurse is caring for a client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment? Bring the client into the hallway to discuss the treatment plan. Direct the client in the other bed to walk in the hallway. Ask all visitors to leave the room. Pull the curtain dividing the two beds.

Pull the curtain dividing the two beds

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? Environmental dimension Emotional dimension Physical dimension Sociocultural dimension

Sociocultural dimension

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into 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. Which phase of the working relationship is best described in this scenario? The working phase The termination phase The orientation phase The introduction phase

The working phase

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: passive. assertive. nurturing. aggressive.

aggressive

The nurse makes a contract with the client during which phase of the nurse-client relationship? Orientation phase Termination phase Intimate phase Working phase

orientation phase