Fundamentals of Nursing Chapter 8 Course Point +

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?

"All of the people got themselves out of the car?"

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.

Which nurse would most likely be the best communicator?

A nurse who easily develops a rapport with clients

A nurse and an older adult client with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?

Being sensitive to the client's emotional barriers

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

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

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:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

"Let us know if we can answer any further questions after you obtain your second opinion."

The nurse makes a contract with the client during which phase of the nurse-client relationship?

Orientation phase

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

Swaddling the child and gently stroking its head

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse that the client is nervous about the surgery. The best response by the nurse is to:

ask the client "Can you tell me more about what is worrying you?"

The following is a conversation between the nurse and the client. - Client: "I know this house is too much for me to manage. I know I am having difficulty." -Nurse: "Have you thought about moving to Tennessee to be near your son? -Client: "No, I am not going to move to Tennessee." -Nurse: "Another option is to have someone help you for a few hours every day. Is this acceptable to you?" -Client: "Yes, I would like that. I am lonely being by myself. I would have someone to talk to and help me with the house." What is the technique used by the nurse in this exchange?

direct questioning

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:

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

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?

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

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse?

"I know this is hard for you. Is there any way I can help?"

A nurse is obtaining a history from an adult female client. When the nurse ask 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?"

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"What did your health care provider tell you about your need to be admitted?"

Which is an open-ended question?

"Why did the healthcare provider prescribe this medication for you?"

The client is being discharged, and the nurse observes the client crying. What is the nurse's most appropriate response?

"Would you like to talk about anything before you go home?"

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?

"You're worried about how you will tolerate the pain associated with labor."

A nurse needs to complete an assessment and vital signs on a client who has Alzheimer disease. How should the nurse approach this client to gain cooperation? Select all that apply.

- Smile and maintain eye contact. - Use the client's name. - Approach the client from the front.

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?

Arrange for a sign language interpreter when discussing treatment.

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?

Assess how the client would like to communicate

During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "Have you been hospitalized this year for your back pain?" This is an example of which type of question?

Closed question

A client is diagnosed with diabetes. The client's adult child offers to serve as an interpreter, because the client does not speak the dominant language. Which is the best action for the nurse to take?

Contact a professional interpreter.

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

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?

Empathy

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

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?

Orientation phase

The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities?

The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using needleless syringe.

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:

allow the client to set the pace.

A nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the new nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to:

ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel.

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:

remain honest, open, and frank.