Prof Role 1 Midterm professional nursing behaviors
A nurse auscultates a client's breath sounds after the client receives an albuterol nebulizer treatment secondary to wheezing. The nurse finds that the client is still wheezing despite the therapy. Which aspect of the Tanner clinical judgment model is the nurse displaying? 1. Noticing 2. Responding 3. Reflecting 4. Interpreting
1 According to the Tanner clinical judgment model, the nurse is displaying noticing by recognizing the presence or absence of expected significant cues from the client's response to an illness or medical condition. Interpreting involves using logical reasoning to determine appropriate action after noticing a clinical finding. Responding occurs when the nurse acts based on what is found and interpreted. When the nurse reviews the clinical action, the nurse is reflecting.
The nurse is caring for a client diagnosed with pulmonary hypertension. Which intervention can be considered a direct, dependent intervention? 1. Assisting with the prescribed cardiac catheterization 2. Monitoring pulse oximetry for a client receiving oxygen by nasal cannula 3. Teaching the client about a prescribed medication 4. Calling the primary care provider and suggesting a physical therapy evaluation
1 Assisting with catheterization is an example of a direct, dependent intervention. It is direct in that the nurse is providing direct care to the client, and dependent in that a prescription is required; the nurse cannot initiate the care without a prescription. Monitoring pulse oximetry for a client on oxygen is an independent intervention as it is an ongoing assessment. Client teaching is an indirect intervention. Suggesting a referral for physical therapy is both indirect and dependent.
The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which nursing action supports collaboration, which is essential to planning care? 1. Discussing appropriate smoking cessation programs with the client, upon request 2. Facilitating a home health consult when the client is discharged 3. Adjusting the head of the client's bed to ease breathing effort 4. Administering a breathing treatment to the client, as ordered
1 Each step of the nursing process is ongoing, including the planning phase. The nurse who discusses smoking cessation with the client at the client's request is allowing the client to collaborate on the care that is received. Collaboration is essential for the plan of care to be effective. The other actions indicate the nurse is providing care to the client, but not collaborating with the client.
Prior to meeting a client, the mental health nurse reviews the client's demographics, including the client's name, address, age, medical history, and social history. Which phase of the therapeutic relationship is reflected by this action? 1. Preinteraction 2. Working 3. Introductory 4. Termination
1 In the preinteraction phase, the nurse reviews information about the client before the first face-to-face meeting. The introductory phase is the initial face-to-face meeting and sets the tone for the interaction. In the working phase, the nurse helps the client to discover thoughts, feelings, and actions and to plan an action to meet goals. Termination occurs at the end of the therapeutic relationship.
The nurse leader is planning an in-service about integrity in nursing practice. Which statement regarding integrity in nursing is most appropriate for the nurse leader to include in the in-service? 1. "Nurses with integrity adhere to a strict moral or ethical code." 2. "Integrity means internalizing professional practices that the nurse prefers to follow." 3. "Integrity means understanding that negative feedback from peers has little value." 4. "Nurses with integrity provide excellent care and do not make errors."
1 Integrity requires adherence to a strict ethical or moral code, such as the ANA Code of Ethics for Nurses. Integrity involves practicing consistent behaviors based on the internalization of the ethics, values, and best practices of the nursing profession. Integrity in nursing includes accepting positive or negative feedback as a tool for improving the delivery of client care. Nurses with integrity are not perfect; however, they admit to their mistakes.
As part of hospital orientation for a group of nurses, the human resources representative is discussing intimidation. Which information is most appropriate for the human resources representative to include in the discussion? 1. Intimidation may include unintentional nursing behaviors and statements made to clients. 2. Overt forms of intimidation may include standing too close to someone. 3. Intimidation may include repeatedly asking another individual for favors. 4. Covert forms of intimidation may include making verbal threats.
1 Intimidation includes threatening, bullying, or forcing someone who is emotionally or physically weaker to do something in order to avoid retribution or negative consequences. Asking an individual for favors without any associated retribution or negative consequences is not reflective of intimidation. Subtle, or covert, forms of intimidation include standing close to someone while maintaining a hostile facial expression. Intimidation may also be overt, such as threatening an individual with consequences for not obeying an order. On the nurse's part, intimidation may be unintentional; for example, making statements such as, "If you do not take your medicine (or go to physical therapy, or follow the treatment plan), you're going to get worse."
A nurse caring for clients across the life span must consider the age, development level, and functional status of clients when helping them in clinical decision making. Which action by the nurse indicates support for a preschooler's decision making ability? 1. Asking the client if she would like to have her snack before or after going for an x-ray 2. Showing the client the materials that will be used to stich up the wound in her knee 3. Inviting the client to the interdisciplinary meeting 4. Soothing the client by rocking her until she calms down
1 Preschoolers are able to make some decisions related to preference when information is provided to them in a way that makes sense to them. Asking the preschooler if she would like snack before or after a procedure is an example of assisting a preschool child in decision making. Because adolescents are capable of participating in making decisions on their own behalf, it would be appropriate to invite an adolescent client to come to an interdisciplinary meeting. School-age children benefit from direct explanations and would likely be interested in seeing and handling materials that will be used in their own care. Although infants cannot make decisions, they need to feel secure during care; soothing and rocking the infant client is appropriate.
While providing care in the emergency department, the nurse asks the victim of a pedestrian accident "why did you cross the street in the middle of the block?" Which communication barrier is this nurse demonstrating? 1. Probing 2. Being defensive 3. Challenging 4. Testing
1 Probing is asking for information chiefly out of curiosity rather than with the intent to assist the client. This approach is considered prying and violates the client's privacy. Asking open double quote"whyclose double quote" is often probing and places the client in a defensive position. Challenging is giving a response that makes a client prove his or her statement or point of view. Being defensive is attempting to protect an individual or healthcare service from negative comments. Testing is asking questions that make the client admit to something. These responses permit the client only limited answers and often meet the nurse's need rather than the client's.
The staff nurse is caring for a client who has recently undergone surgical repair of an inguinal hernia. Despite administration of pain medications as ordered, the client continues to complain of excruciating pain. When the staff nurse offers to reposition the client, the client states, "You don't have any idea what you're doing. I need more medication. I need a nurse who can help me!" Which behavior best illustrates demonstration of compassion by the staff nurse? 1. Notifying the primary care provider about the client's complaints of pain despite receiving medication 2. Seeking out a nursing colleague to privately vent about the client's rudeness and inconsideration 3. Explaining that inguinal hernia repairs usually require significantly less medication for adequate pain relief 4. Collaborating with the charge nurse and requesting that another nurse assume the client's care
1 Professionalism in nursing requires demonstrating a positive attitude while working with clients, their family members, and other healthcare professionals. Venting to a nursing colleague is not reflective of a positive attitude. Professionalism in nursing also requires compassion, which is an awareness of and concern about other individuals' suffering. Requesting that the client's care be reassigned to another staff nurse is not reflective of compassion. Demonstrations of compassion in nursing include recognizing and meeting clients' needs and treating each client as a unique and special individual and not as a diagnosis (for example, "an inguinal hernia repair") or number. Notifying the primary care provider about the client's complaints of pain despite receiving pain medication best reflects recognizing and meeting the client's needs.
The nurse is implementing care for clients in an acute care facility. Which guidelines should the nurse use when choosing interventions for goal achievement? 1. They are consistent with clients' values, beliefs, and culture. 2. They are identified with specific laws and regulations. 3. They can be performed with limited resources. 4. They are interchangeable among clients for optimal applicability.
1 The challenge is for the nurse to identify the best interventions to ensure goal achievement. The best interventions are those that are safe and appropriate for the client; performed with available resources, consistent with client values, beliefs, and culture; consistent with other prescribed treatments and therapies; evidence-based; and provided within established standards of care and applicable laws and regulations.
The nurse is working with an adult client who has a diagnosis of posttraumatic stress disorder (PTSD). The client shares that he has begun exercising daily at a local gym, and states that this lowers his daily stress level. Which type of nursing diagnosis would best capture the client's exercise behavior? 1. Wellness diagnosis 2. Health promotion diagnosis 3. Syndrome diagnosis 4. Risk diagnosis
1 The client has already modified his behavior to improve his health status; a wellness diagnosis would be appropriate. A health promotion diagnosis may be made when clients express a desire to improve their health. A risk diagnosis is used to capture client risk factors for illness or alterations in health. A syndrome diagnosis is a type of nursing diagnosis that may be used when a cluster of nursing diagnoses will help improve client outcomes if addressed at the same time.
The nurse is caring for several clients during a shift. Which observation made during a nursing assessment would be priority? 1. The client who complains of shortness of breath when walking from room to room 2. A client with a BP of 96/54 mmHg, HR of 70 bpm, RR of 20 breaths per minute, and T 97.6°F 3. A client who begins coughing after 6 minutes of walking 4. A client with an oxygen saturation of 94%
1 The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. At all times, the nurse needs to be aware that airway, breathing, and circulation are vital for life. The client who is complaining of shortness of breath when walking from room to room may have airway issues: This is the priority. The other clients may require interventions, but the client with shortness of breath takes priority.
What is the first action that should be made when prioritizing care? 1. Assess client situations 2. Assign staff to clients 3. Ascertain interventions 4. Analyze collected data
1 The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. This assessment includes knowing individual clients' health statuses in order to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to clients would occur after knowing the number and level of care givers available to provide care.
What is used as the framework for identifying nursing interventions? 1. Etiology of the problem 2. Signs and symptoms 3. Healthcare provider's orders 4. Previous health history
1 The framework for selecting nursing interventions is created when the correct problem etiology is identified during the assessment and nursing diagnosis phases. Healthcare provider's orders are not used as the framework for identifying nursing interventions. Signs and symptoms help explain how a problem is affecting a client. A client's previous health history is not used as the framework for identifying nursing interventions.
During a home visit, the nurse observes a client perform wound care that is different from the verbal instructions. The written instructions are crumpled and located at the bottom of a stack of papers. Which action by the nurse is the most appropriate? 1. Verbally review the wound care process with the client again 2. Place the instructions on the top of the stack for the client to use 3. Tell the client that a new set of instructions will be brought at the next visit 4. Explain that the client is at risk for a wound infection
1 The issue is the client is not performing wound care correctly. Verbal and written instructions were provided; however, the written instructions are not being used. This could indicate two things: the client cannot read, or the client does not understand the terminology in the instructions. The nurse should use the communication method that the client is most comfortable using. In this case, providing the client with verbal instructions is likely to be the most helpful, as it provides the client with an opportunity to ask questions. The client may not read another set of written instructions. Placing the instructions on the top of the stack of papers does not mean that the client will read them. Explaining that the client is at risk for a wound infection is using a threat to motivate the client; this does not strengthen the nursedash-client relationship.
A nurse is caring for a client with a history of diabetes mellitus. The nurse notices an upward trend to the client's daily fasting serum blood glucose and notifies the client's healthcare provider. Which level best describes this nurse according to Benner's skill acquisition model? 1. Proficient 2. Novice 3. Competent 4. Advanced beginner
1 The nurse is proficient according to Benner's skill acquisition model. In this level of the model, the nurse develops her own rules for actions by analyzing significant cues and sees open double quote"the big picture.close double quote" The novice level includes those without any nursing experience who act only by rules, not cognition. The advanced beginner is typically a new graduate who begins to recognize significant cues using cognition, but is unable to piece all clinical cues into a whole picture. The competent nurse, according to Benner, has 2dash-3 years of nursing experience. However, the competent nurse is still unable to see the open double quote"big picture.close double quote
A nurse is caring for a pediatric client who requires IV antibiotic therapy. Prior to inserting the IV catheter, the client asks the nurse, open double quote"Is this going to hurt me?close double quote" Which response by the nurse best promotes rapport and trust with the client? 1. "It is going to hurt, but once I am done it shouldn't hurt anymore." 2. "It might hurt, but I am not sure." 3. "Yes, it is going to hurt. Hold really still or it will hurt much worse." 4. "No. As long as you hold still it shouldn't hurt."
1 To establish rapport and trust with a pediatric client and family, the nurse must be honest. The nurse should tell the client that the procedure will hurt, but follow the statement with a positive one. The other statements are not appropriate or therapeutic.
While talking with a nursing colleague, the staff nurse states, "I don't drink alcohol, but I smoke marijuana." Which response by the nursing colleague best reflects correct understanding of professional behaviors? 1. "Even in your personal life, the same rules of professionalism still apply to your behavior." 2. "Even though you're a nurse, what you do in your personal life is your business." 3. "If your client care is negatively affected, then you should stop smoking marijuana." 4. "If you're arrested for smoking marijuana, your professional credibility will be negatively affected."
1 Unprofessional behaviors include substance abuse. The rules of professionalism and the dangers of unprofessional behavior extend to social situations. The effects of unprofessional behavior may include adversely affecting client outcomes, but unprofessional behavior is inappropriate with or without consequences. Engaging in unprofessional behavior, regardless of whether it leads to an arrest, can negatively impact the nurse's credibility.
The nurse preceptor is designing a nursing orientation program that addresses abuse of power in the workplace. Which information should the nurse preceptor include in the program? 1. Bullying behaviors and incivility are among the leading causes of sentinel client events. 2. The Joint Commission has not taken an official stand on addressing workplace intimidation. 3. Nursing research finds limited evidence of bullying and lateral violence among nursing professionals. 4. Improper use of authority in the workplace is a form of sexual harassment.
1 Intimidation, sexual harassment, bullying, and lateral violence are forms of abuse of power. In the healthcare setting, evidence of bullying, lateral violence, and incivility has been well documented in nursing research for more than three decades. The Joint Commission has identified bullying behaviors and incivility in health care as being among the leading causes of sentinel client events. The Joint Commission calls for zero tolerance of workplace bullying and intimidation and recommends that healthcare facilities implement policies to stop such behaviors.
Following the collection of assessment data, what does the nurse do next? (Select all that apply.) 1. Clusters cues to generate tentative hypotheses 2. Measures the data against standards to identify significant cues 3. Analyzes the data for gaps and inconsistencies 4. Compares the data with suspected medical problems 5. Identifies strengths and resources
1, 2, 3 Once assessment data are collected, the nurse begins the process of data analysis. This process includes three steps: comparing data against standards to identify significant cues, clustering cues to generate tentative hypotheses, and identifying gaps and inconsistencies. Listing client strengths and resources occurs later in the process of writing a nursing diagnosis. Comparing data with medical problems is not done when analyzing collected data.
Which skills are used when implementing client care? (Select all that apply.) 1. Interpersonal 2. Psychomotor 3. Cognitive 4. Assessment 5. Physical examination
1, 2, 3 The nurse uses three sets of skills when implementing client care. These skills are cognitive, interpersonal, and technical/psychomotor. Assessment is a type of cognitive or technical skill. Physical examination is a type of knowledge or technical skill.
Which statements are true of nursing diagnoses? (Select all that apply.) 1. Nursing diagnoses describe responses to a health problem. 2. Nursing diagnoses are flexible and change based upon client responses. 3. A nursing diagnosis is a judgment statement. 4. Nursing diagnoses are uniform between clients. 5. A nursing diagnosis is a condition that nurses are licensed to treat.
1, 2, 3 ,5 A nursing diagnosis is a statement of nursing judgment; a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat; and a description of the physical, sociocultural, psychological, and spiritual responses to an illness or health problem. Nursing diagnoses are flexible because they change as the client
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is having difficulty breathing. Which will the nurse include in formulating nursing diagnoses? (Select all that apply.) 1. Evidence of cyanosis in the client's mouth and nail beds 2. The client's pulse oximetry reading of 92% 3. The client's expressed desire to quit smoking 4. The client's twice daily meditation practice 5. The client's report of having difficulty walking in from the parking lot
1, 2, 3, 5 A nursing diagnosis is a statement of nursing judgment that describes a client's physical, sociocultural, psychological, and spiritual response to an illness or health problem, and is flexible in that it will change as the client's responses change. The nurse will consider the client's activity intolerance, low oxygen level and cyanosis when determining actual nursing diagnoses. The nurse will also take into consideration the client's desire to quit smoking, which may be captured in a health promotion diagnosis.
The nurse is preparing to assess an older client with a hearing deficit who has just been admitted to the care unit. Which actions should the nurse take to communicate with this client? (Select all that apply.) 1. Turn down the volume on the television set 2. Close the door to the room 3. Face the client when speaking 4. Ask the family to wait in the hall 5. Ask about the client's meal preferences
1, 2, 3, 5 Closing the door and turning down the volume of the television helps minimize distractions while conversing with the client. Facing the client may assist in communication, especially if the client lip reads. Asking about the client's meal preferences gives an opportunity to allow choices and establish if there are any religious or spiritual practices related to meals. The family does not necessarily need to wait in the hall until the assessment is complete.
During post-clinical conference, a student nurse expresses a desire to work on the same unit where clinical is being held because of the nursing staff. What did the student likely observe to form this opinion? (Select all that apply.) 1. Staff members laugh with each other. 2. Staff members help each other complete assignments. 3. Staff nurses compliment each other for a job well done. 4. Staff members focus on their individual assignments. 5. Staff nurses ask about each other's families.
1, 2, 3, 5 Commitment to the group is an essential aspect of group dynamics and is exhibited among members when they enjoy each other, support each other in difficulty, seek each other for counsel, value the contributions of each member, and are motivated by the group and want to do their tasks well. Staff members who focus on their own assignment are placing individual goals over the goals of the group
When formulating a nursing diagnosis for a client diagnosed with diabetes mellitus, which information should be taken into consideration to mobilize health and the recovery process for this diagnosis? (Select all that apply.) 1. The client joins the ADA support group. 2. The client demonstrates the ability to monitor blood glucose. 3. The client independently administers insulin. 4. The client requests information on how to control blood pressure. 5. The client tells the nurse that he adheres to his 1800 calorie ADA diet.
1, 2, 3, 5 When formulating a nursing diagnosis, it is important for the nurse to considered the client's diagnosis of diabetes.
What are the components of a nursing diagnosis? (Select all that apply.) 1. Defining characteristics 2. Etiology 3. Data clusters 4. Variations 5. Diagnostic label
1, 2, 5 There are three components to a nursing diagnosis: diagnostic label, etiology, defining characteristics. Variations are used when additional information is needed to make the diagnoses more clear and client-specific. Data clusters are created when analyzing assessment information prior to beginning to write a nursing diagnosis.
A nurse educator is teaching a group of student nurses about the development of professional decision making and the types of approaches related to clinical judgment. Which statements made by the student nurse reflect understanding of Benner's skill acquisition model? (Select all that apply). 1. New graduates are typically considered advanced beginners. 2. An advanced beginner is intentional in planning care. 3. A competent nurse usually has 2-3 years of experience. 4. Proficient nurses can see the whole picture. 5. A novice acts by following rules.
1, 3, 4, 5 According to Benner's model, a competent nurse, not an advanced beginner, is intentional in planning care. This statement would reflect the need for further education. All other statements are correct and reflect understanding of this model by the student nurse.
The director of nursing is reviewing a status report provided by the policy and procedure committee. Which information indicates to the director that the committee has been effective? (Select all that apply.) 1. Committee members have attended all scheduled meetings. 2. Committee member vacancies for two areas remain unfilled. 3. Committee members reviewed all policies prior to the scheduled accreditation survey. 4. The committee chair resigned due to the volume of work. 5. Subcommittee members provided recommendations as expected.
1, 3, 5 For a group to be effective, three main functions have to occur. The group has to accomplish goals, maintain cohesion, and develop and modify the structure to improve effectiveness. Reviewing all policies prior to the scheduled accreditation survey indicates that the goals have been accomplished. Regular attendance by members at scheduled meetings indicates that the group is cohesive. Subcommittees providing recommendations as expected indicates that the structure of the group was modified to improve effectiveness. The resignation of the committee chair indicates a lack of cohesion. Committee member vacancies indicate a lack of cohesion and unstable group structure.
How does intellect help nurses with critical thinking? (Select all that apply.) 1. Differentiate fact from opinion 2. Evaluate performance 3. Approach situations objectively 4. Clarify concepts 5. Think outside the box
1, 3, 5 The critical thinking skill of intellect helps nurses differentiate facts from opinions, approach situations objectively, and clarify concepts. The critical thinking skill of creativity helps nurses think outside of the box. The critical thinking skill of inquiry helps nurses evaluate performance.
A pediatric client is alone in the room after the client's mother leaves to make a phone call. The client is crying and tells the nurse, "I want my mommy to come back." The nurse responds by stating, "It's okay to cry when you miss your mommy. I will sit with you until she comes back if you want." Which therapeutic communication techniques is the nurse using to establish rapport with the client? (Select all that apply.) 1. Accepting 2. Exploring 3. Broad openings 4. Offering self 5. Clarifying
1, 4 The nurse is using accepting and offering self to establish rapport with the child. By conveying acceptance, the nurse respects the child's emotions and lets the child know that crying is okay. Offering self indicates that the nurse is accessible and wants to listen to the child. Clarifying is when the nurse asks the child to elaborate in order for the nurse to understand. Broad openings include open-ended questions, which allow the child to provide answers that are longer than one or two words. Exploring encourages the child to discuss the issue in more detail.
The nurse is caring for a client diagnosed with cancer. When formulating the plan of care for this client, what should the nurse consider related to client goals? (Select all that apply.) 1. Goals should be attainable. 2. Goals may address multiple actions. 3. Goals should indicate whether treatment is successful. 4. Goals should be measurable. 5. Goals should center on the client.
1, 4, 5 The client is always the subject of the goal and requires a specific, single action to ensure all nurses understand what the client needs to do to achieve a goal. Goals should be measurable, attainable, relevant, and time limited. An evaluation, not a goal statement, will indicate whether interventions were successful.
Which are characteristics of an advanced beginner within Benner's Skill Acquisition Model of clinical judgment? (Select all that apply.) 1. Begins to recognize cues 2. Is able to intentionally plan care 3. Follows rules when acting 4. Can see the whole picture 5. Is a new graduate
1, 5 Characteristics of an advanced beginner nurse are being a new graduate and beginning to recognize significant cues from internal cognitive processing. A characteristic of a competent nurse is being able to intentionally plan care. A characteristic of a novice nurse is following rules when providing care. Being able to see the whole picture when providing client care is characteristic of the proficient nurse.
During a classroom discussion, the nurse educator asks the nursing students to describe intimidation. Which students' statements most accurately describe intimidation? (Select all that apply.) 1. "Intimidation can include threatening someone with consequences for disobedience." 2. "Nurses always realize when their behaviors toward clients are forms of intimidation." 3. "Intimidation includes experienced nurses who bully new nurses." 4. "Intimidation includes having negative thoughts about nursing peers or colleagues." 5. "Covert and overt behaviors may qualify as being intimidation."
1. "Intimidation can include threatening someone with consequences for disobedience." 3. "Intimidation includes experienced nurses who bully new nurses." 5. "Covert and overt behaviors may qualify as being intimidation."
The psychiatric nurse practitioner is giving a webinar about prevention of burnout in nursing. Which items should the psychiatric nurse practitioner include when describing tips related to having compassion? (Select all that apply.) 1. Acknowledging that most individuals do the best they can do 2. Perceiving errors and failures as opportunities for constructive learning 3. Recognizing the limitations associated with any given situation 4. Joining nursing associations that promote constructive discussion of work issues 5. Learning to ask for help from colleagues or confidantes when needed
1. Acknowledging that most individuals do the best they can do 2. Perceiving errors and failures as opportunities for constructive learning 5. Learning to ask for help from colleagues or confidantes when needed
Which actions are appropriate when the nurse is communicating with a client whose primarily language is not English? (Select all that apply.) 1. Avoid using slang 2. Speak slowly 3. Avoid using medical jargon 4. Use an interpreter 5. Emphasize words with gestures
1. Avoid using slang 3. Avoid using medical jargon 4. Use an interpreter
Jiao Liu, a 64-year-old client, is receiving chemotherapy for breast cancer. After morning report, the nurse finds Ms. Liu nauseated, vomiting light green emesis, and crying because her hair is falling out in clumps. Her pulse is 110 beats per minute and thready, and her blood pressure is 96/50 mmHg. Which intervention should the nurse make a priority for Ms. Liu? 1. Begin intravenous fluids at 100 mL/hr 2. Premedicate for nausea before next chemotherapy dose 3. Teach Ms. Liu some deep breathing exercises to help her calm down 4. Cleanse skin and apply a clean hospital gown
1. Begin intravenous fluids at 100 mL/hr
The nurse leader is presenting an in-service about competence in nursing. Which examples should the nurse leader include in the in-service as examples of nursing competence? (Select all that apply.) 1. Completion of documentation in an accurate, timely manner 2. Acknowledgement of the client's need for individualized care 3. Awareness of factors that positively affect client care 4. Elimination of factors that negatively influence client care 5. Knowledge about the culture of the healthcare institution
1. Completion of documentation in an accurate, timely manner 2. Acknowledgement of the client's need for individualized care 3. Awareness of factors that positively affect client care 5. Knowledge about the culture of the healthcare institution
The nurse is planning to assess a client's communication approach. What client characteristics should the nurse consider when conducting this assessment? (Select all that apply.) 1. Developmental level 2. Primary health problem 3. Culture 4. Age 5. Employment status
1. Developmental level 3. Culture 4. Age
Planning is underway to transfer Agnes Watson, a 76-year-old client, to a long-term care facility. Agnes wants to live near her family; however, the facility that would best meet her needs is a few miles further away. What should the nurse do when helping Agnes make the choice of facility? 1. Discuss with Agnes the advantages of the facility that is a bit further away 2. Tell Agnes that the facility that is closer to family is not accepting admissions 3. List other facilities so that Agnes can make a better decision 4. Tell Agnes that being near family is not always a good idea
1. Discuss with Agnes the advantages of the facility that is a bit further away
What techniques are associated with assertive communication? (Select all that apply.) 1. Fogging 2. Negative assertion 3. Avoidance 4. Name calling 5. Submission
1. Fogging 2. Negative assertion
Which actions can the nurse use to establish rapport with a pediatric client? (Select all that apply.) 1. Listening to the child talk about a favorite teacher 2. Sitting on the bed with the child 3. Telling the child that she has pretty hair 4. Asking the child to choose between milk or juice to drink 5. Coming into the room to hang an IV medication and leaving
1. Listening to the child talk about a favorite teacher 2. Sitting on the bed with the child 3. Telling the child that she has pretty hair 4. Asking the child to choose between milk or juice to drink
The nurse preceptor is discussing integrity with the novice nurse. Which examples should the nurse preceptor use to illustrate integrity in nursing? (Select all that apply.) 1. Maintaining accountability for personal actions 2. Delivering error-free nursing care 3. Accepting negative feedback from clients 4. Accepting positive feedback from peers 5. Working within the scope of practice
1. Maintaining accountability for personal actions 3. Accepting negative feedback from clients 4. Accepting positive feedback from peers 5. Working within the scope of practice
What behaviors will the nurse demonstrate as a member of a group that is highly committed? (Select all that apply.) 1. Members value each other's opinions. 2. Members strive to place blame on one person. 3. Members give priority to the opinions of the leader. 4. Members enjoy working with each other. 5. Members support each other with difficulties.
1. Members value each other's opinions. 4. Members enjoy working with each other. 5. Members support each other with difficulties.
Mike Kellerton is a 64-year-old client admitted for dehydration. During morning care, Mr. Kellerton became irate when the breakfast tray featured items that he does not eat. Later in the day, Mr. Kellerton told a family member that he is not important and everyone is "trying to kill him." What should the nurse do to improve the care that Mr. Kellerton is receiving? 1. Plan to talk with the client about his care needs, priorities, and preferences 2. Explain to the client that his care issues are not life threatening and can be delayed 3. Identify the easiest task to complete for the client and do this first 4. Discuss the importance of other clients' treatments being of greater priority
1. Plan to talk with the client about his care needs, priorities, and preferences
When discussing a painful procedure with a child, how will the nurse answer the child's questions? 1. With honesty, while being sure to end the conversation on a positive note 2. By explaining the procedure to the parents first and having the parents tell the child 3. By giving handouts with more information about the procedure 4. By redirecting the child's attention to something else
1. With honesty, while being sure to end the conversation on a positive note
Scott Nitroskey, a home health nurse, is caring for 67-year-old Martha Miriste, a female client who is diagnosed with diabetes. Scott is completing Mrs. Mireste's client teaching. During the teaching session, which statement might Mrs. Mireste interpret as being Scott's attempt to intimidate her? 1. "If you don't stop eating so much candy, your diabetes is going to get much worse." 2. "Regular exercise can help with the management of your diabetes." 3. "If you cut back on your sugar intake, you might see some improvement in your diabetes." 4. "Increased sugar in your diet can cause your blood sugar to go up and impact your diabetes."
1. "If you don't stop eating so much candy, your diabetes is going to get much worse."
What is the purpose of reflecting within Tanner's clinical decision making model? 1. Sense what is happening in a situation 2. Learn from actions to make adjustments 3. Gain understanding about a situation 4. Analyze a situation to choose action
2 According to Tanner's model, reflecting helps the nurse learn from actions to make adjustments. Interpreting involves using logical reasoning to gain understanding about a situation and determine appropriate actions. Noticing requires a sense about what is happening in the client situation. Responding is analyzing a situation to choose the best course of action.
The staff development trainer provides a program on assertive communication for the staff of a care area. At the end of the program, the trainer states, "I can't believe I had to waste my time on this." Which response made by a nurse who attended the training indicates effective teaching has occurred? 1. "I'm sorry you had to spend so much time with us today." 2. "I needed this training, and it wasn't a waste of time for me." 3. "Maybe you should read your own notes." 4. "It's your job. You want to do mine instead?"
2 Assertive statements use the word "I" to voice feelings and wishes without placing blame on someone else. The statement "I needed this training and it wasn't a waste of time for me" also includes a negative assertion in that the nurse repeats the trainer's phrase about the training being a waste of time. The statement beginning with "I'm sorry" is a passive response. The statements "It's your job?" and "maybe you should read your own notes" are both aggressive responses.
The novice nurse asks the nurse preceptor to explain the relationship between the business of health care and the provision of client care. Which response by the nurse preceptor is the most appropriate? 1. "The business of health care is the same thing as the provision of client care." 2. "The Institute of Medicine compels nurses to preserve a caring model within health care's business model." 3. "Nurses are morally responsible for recognizing the business of health care as the main priority." 4. "When nursing standards conflict with organizational standards, the nurse must maintain commitment to the organization's standards.
2 Because the business of health care and the provision of client care are two distinct issues, corporate goals can collide with nursing ethics. Nurses have the moral responsibility to address client needs and to advocate for safe care within the business of health care. The Institute of Medicine (IOM) compels nurses to lead the healthcare transformation and to preserve a caring model within the business model of health care. The nurse must maintain commitment to the nursing profession even when doing so conflicts with organizational commitment.
The nurse manager is interviewing a candidate for a staff nurse position. During the interview, the nurse manager evaluates the candidate's professional commitment to nursing. Which statement by the staff nurse best reflects commitment to the nursing profession? 1. "Whenever possible, the nurse should try to abide by the professional code of ethics for nurses." 2. "I'm a member of two national nursing organizations, and I belong to one specialty nursing group." 3. "I believe the nurse's choices outside of the workplace are unrelated to the nurse's professional role." 4. "The values and goals of nursing are honorable, but they are unrealistic and difficult to achieve."
2 Factors associated with professional commitment include desire to maintain membership in the profession; strong acceptance of and belief in a profession's role, code, values, goals, standards; willingness to exert considerable personal effort on behalf of the profession; and a pattern of behaviors that is consistent with the nurses' professional code of ethics. The rules of professionalism in nursing extend to behaviors outside the workplace.
Which short-term goal does the nurse view as appropriate for a client newly diagnosed with diabetes mellitus? 1. The client will learn the correct way to inject IV insulin. 2. The client will demonstrate how to self-inject insulin by end of hospital stay. 3. The client will demonstrate how to wrap left leg wound. 4. The client will be able to identify and prepare meals approved by the ADA within 3 weeks.
2 Goal statements include a time frame for completion. Short-term goals are useful for clients needing a limited amount of nursing care. These goals can be achieved in a few hours to a few days. The statement that the client will demonstrate self-injection of insulin by the end of hospital stay is an example of a properly written short-term goal. Long-term goals are generally those that can be achieved by the client in 1 week to several months. Stating that the client will be able to prepare meals approved by the ADA within 3 weeks is a reasonable long-term goal. The remaining goal statements are insufficient in that they do not give a time frame.
Prior to performing an assessment, a nurse states to the client, open double quote"This weather we are having is crazy, isn't it?close double quote" Which phase of the therapeutic relationship is the nurse displaying? 1. Working 2. Introductory 3. Termination 4. Preinteraction
2 In the introductory phase, the nurse may discuss the weather or another general topic to put the client at ease. The preinteraction phase occurs prior to any face-to-face contact. During the working phase, the nurse helps the client identify feelings in order to help the client make decisions. The termination phase occurs at the end of the therapeutic relationship.
The manager appoints a staff nurse to serve as a member of a semi-formal group. What should the nurse expect as a group member? 1. The leader will be replaced if she makes a mistake. 2. Structured activities will take up a large part of the group's meeting time. 3. Interactions with group members will be limited. 4. Members function under a strict code of ethics.
2 In semi-formal groups, the activities are structured and take up a large part of the meeting times. Interactions within formal groups are limited. Informal groups typically replace leaders who make mistakes quickly. Members function under a strict code of ethics in informal groups.
When does a nurse make a scheduling decision? 1. When deciding what can be completed by a nursing assistant 2. When deciding what needs to be done before a client attends therapy 3. When deciding when to change a dressing 4. When deciding what information to share with other healthcare providers
2 Nurses make four types of decisions. A scheduling decision is made when the nurse decides what a client needs before attending a therapy session. A value decision occurs when deciding what information to share with other healthcare providers. A time management decision is made when deciding when to change a dressing. A priority decision is deciding what can be assigned to a nursing assistant to complete.
The nurse is caring for a client with schizophrenia. The client is at risk for disturbed thought processes. What is the priority focus for interventions when caring for this client? 1. Discussing expectations 2. Providing reality testing 3. Being an active listener 4. Providing anxiety medication
2 Nursing interventions are actions, tasks, and documentation taken to help a client achieve identified goals. Interventions for risk nursing diagnoses focus on measures to reduce the client
The nurse is evaluating the current plan of care for a client who is receiving care in a long-term healthcare facility. The evaluation indicates that the client is not meeting goals related to mobility. What is the appropriate nursing action at this time? 1. Asking the client to try harder 2. Revising the plan of care 3. Determining the client does not have any risk factors 4. Concluding that the problem is resolved
2 The client is not meeting goals related to mobility, therefore the care plan must be revised. The nurse will work with the client to determine how the plan might be revised. Perhaps assessment data were not fully considered or goals were not within reasonable expectations for what the client is able to accomplish. Asking the client to try harder is not appropriate. Concluding the problem is resolved would be inaccurate. The nurse would be wise to reassess risk factors as part of reassessment before revising the plan of care.
Which attribute of critical thinking is explained as making neutral judgments without bias? 1. Open-mindedness 2. Fair-mindedness 3. Perseverance 4. Integrity
2 The critical thinking attribute that makes neutral judgments without bias is fair-mindedness. Open-mindedness refers to being open to different ideas or different methods to reach the same goal and is similar to independence. Challenging ideas and methods of doing nursing care explains integrity. Being motivated to find the best solution for quality client outcomes is perseverance.
A nurse working on a telemetry unit is caring for a client with sick sinus syndrome. The client tells the nurse, open double quote"I felt dizzy earlier this morning.close double quote" The nurse responds by asking the client, open double quote"Did this occur after breakfast?close double quote" Which method of therapeutic communication is the nurse using with this client? 1. Acknowledging 2. Clarifying time 3. Giving information 4. Focusing
2 The nurse is using the technique of clarifying time by helping the client clarify an event in relationship to time. Focusing is used when the nurse helps the client expand on and develop a topic of importance, which is often an emotion disguised behind words. Giving information occurs when the nurse provides the client specific factual information. Acknowledging is used when the nurse gives nonjudgmental recognition to the client for a client effort or change in behavior.
A nurse is caring for a toddler who appears frightened by the nurse. To make the child more at ease, the nurse gives the toddler a disposable tape measure to play with. Which critical thinking concept is the nurse using? 1. Independence 2. Creativity 3. Concreteness 4. Confidence
2 The nurse is using creativity, or finding a solution by using a method that is unconventional. In this case, the nurse is "thinking outside the box" to let the toddler play and put the child at ease. Concreteness is a concept of therapeutic communication, which is when the nurse is specific rather than general. Confidence is an attitude that nurses convey by acting on information and experience they know are correct. Nurses exhibit Independence by looking at facts and not being easily influenced by opinion.
What should be done first before implementing a nursing intervention? 1. Ensure the client's privacy 2. Reassess the client 3. Find someone to help 4. Review nursing diagnoses
2 The nurse reassesses the client immediately before implementing an intervention to make sure that the action is still appropriate since the client's condition might have changed. Newly assessed data may indicate a need to change the priorities of care or the nursing activities. Reviewing nursing diagnoses is done while identifying nursing interventions. Finding someone to help may or may not be necessary, based on the results of the reassessment. Ensuring for the client's privacy is done immediately before implementing the intervention.
Which clinical situation best exemplifies a nurse who is choosing between alternatives when making a clinical decision? 1. The nurse has a "gut reaction" to the client's pain and calls the client's physician. 2. The nurse administers an IV narcotic instead of an oral narcotic. 3. The nurse determines the client's nursing diagnosis is acute pain. 4. The nurse changes the client's position numerous times until the client appears in less pain.
2 The nurse who administers an IV narcotic instead of an oral narcotic is choosing between alternatives. The nurse who helps the client change position numerous times is using trial and error. The nurse acting on a "gut reaction" is using intuition. The nurse determining the nursing diagnosis is utilizing the nursing process.
The primary nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse arrives at the client's room to complete the morning assessment and finds the client is upset. The client states, open double quote"My nurse overnight referred to me to the assistant as the COPDer.close double quote" The primary nurse tells the client that she will address the issue with the nurse. Which basis of the therapeutic relationship is the nurse displaying by addressing this client issue with the other nurse? 1. Reflecting 2. Respecting 3. Assuming 4. Identifying
2 The therapeutic relationship is based on mutual trust, respect, and acceptance. The nurse is respecting the client as an individual and not as a diagnosis by addressing the issue with the other nurse. Reflecting, assuming, and identifying are all therapeutic communication techniques, but are not the basis of the therapeutic relationship.
During a staff meeting, the manager asks staff members to identify any and all ways to reduce unnecessary waste of supplies when providing client care. Which type of decision-making technique is the manager using with the staff? 1. Monopolizing 2. Brainstorming 3. Groupthink 4. Delphi technique
2 When brainstorming, group members meet and generate ideas as a solution to a problem. The atmosphere supports the free flow of ideas. Group members are expected to generate as many ideas as possible, and all ideas are initially approved. Later, ideas are examined for viability. Monopolizing is the domination of a discussion by one member of a group and is not a decision-making technique. The Delphi technique is used for decisions that require more time or responses from people in different locations. Groupthink is not a decision-making approach but rather occurs when the group fails to examine its own processes and practices or when group members fail to recognize and respond to change
The nursing student is writing a care plan for a client who was recently cared for during a clinical rotation. What should the student nurse do when planning nursing interventions for the client? (Select all that apply.) 1. Be general and brief 2. Ensure relevancy to situation 3. Be specific and concise 4. Be realistic 5. Include priorities of care
2, 3, 4, 5 Nursing interventions are dated and regularly reviewed for applicability towards goal achievement. Nursing interventions should be client centered; detailed, specific, and concise; realistic, relevant, and limited to the top 3dash-5 priority interventions for each nursing diagnosis.
The nursing student is participating in revising the plan of care for a client diagnosed with myasthenia gravis who did not meet care goals. Which will the nurse consider when revising the plan of care? (Select all that apply.) 1. What nurses were assigned to the client? 2. Were the interventions that were selected appropriate? 3. Did the client have access to planned interventions? 4. Were the goals realistic and attainable? 5. Were interventions implemented as planned?
2, 3, 4, 5 When it is necessary to revise a plan of care because the client did not achieve one or more care goals, the nurse examines the reasons that the goals were unmet. These include whether or not the goals were realistic and attainable, whether the interventions that were selected were appropriate, if the interventions were implemented as planned. The nurse also examines if there were any faulty assessment data. If a client did not have access to planned interventions, that would explain why interventions were not implemented, as well as suggest that assessment of the client was insufficient; a thorough assessment would have determined any limitations the client had to access interventions. Which staff members were assigned to the client is not a consideration.
A client tells the nurse, "My blood sugars have been all over the place lately." The nurse responds, "It sounds like your blood sugar has been difficult to manage. Can I please see your blood sugar log?" Which therapeutic communication skills is the nurse displaying during this interaction with the client? (Select all that apply.) 1. Genuineness 2. Confronting 3. Concreteness 4. Clarifying 5. Paraphrasing
2, 5 The nurse paraphrased the client's statement by re-stating what the client said using the client's words. The nurse also used concreteness by encouraging the client to be specific rather than vague. Confronting and clarifying help the client to recognize inconsistencies that inhibit the client's self-understanding or exploration of specific areas and ideas.
Which behavior indicates a nurse is an aggressive communicator? (Select all that apply.) 1. Denying feelings of anger 2. Blaming others for errors 3. Expressing feelings using "I" language 4. Telling a staff member to move out of the way 5. Stating that a nursing assistant is "worthless"
2. Blaming others for errors 4. Telling a staff member to move out of the way 5. Stating that a nursing assistant is "worthless"
A nurse is participating in a group in which all members are voicing ideas to address an issue. Their ideas will be analyzed later. Which kind of decision-making method is the group using? 1. Consensus 2. Brainstorming 3. Quantitative analysis 4. Nominal group
2. Brainstorming
The nurse manager is preparing an annual performance appraisal for Alisha, a staff nurse who has worked on a medical-surgical care area for two years. The manager determines that Alisha's level of proficiency is competent. What did the manager observe Alisha perform to make this decision? 1. Referred to the procedure manual to change an intravenous site dressing 2. Focused on a specific client problem when planning care 3. Determined how a new medication would impact a client's other health problems 4. Waited for direction from charge nurse before providing care
2. Focused on a specific client problem when planning care
The nursing instructor assigns Carol, a senior nursing student, to create a concept map for a client recently assigned during clinical. The concept map is going to be showcased during the School of Nursing's scheduled open house for nursing student candidates in a week. What should be a priority for Carol when preparing this concept map? 1. Include the rationales for each nursing intervention 2. Follow the sequence of the nursing process 3. Highlight medical treatments provided by other providers 4. Individualize the care by using checklists and blank lines
2. Follow the sequence of the nursing process
The nurse is caring for a neonate, Sally, who requires nasogastric tube feedings due to prematurity. Sally's nasogastric tube frequently slips out of position and the nurse tries different approaches to prevent this from happening. Which critical thinking skill is the nurse demonstrating? 1. Reflection 2. Inquiry 3. Intellect 4. Reasoning
2. Inquiry
Mitchell Asplund, a clinical nursing instructor, is assigned to serve as a student faculty advisor. Mitchell's responsibilities include determining which stage of commitment to nursing his students are experiencing. He is evaluating nursing student Don Rowlands, who is a junior in nursing school. During his evaluation, Don states, "I want to join the National Student Nurses Association. I'm also volunteering to participate in the student health fair. I know I'm really busy, but my schedule will be crazy when I'm working as a nurse, too. It's worth it to me." Mitchell recognizes that Don is in which stage of making a professional commitment to nursing? 1. Exploratory 2. Passionate 3. Integrated 4. Testing
2. Passionate
The nurse is a member of a nursing journal club. What interpersonal perspectives would be demonstrated by the group members? (Select all that apply.) 1. Provides source of collegiality and support 2. Promotes a feeling of goodwill among members 3. Provides a context for setting priorities 4. Empowers group members to promote change 5. Provides socialization toward growth and development
2. Promotes a feeling of goodwill among members 3. Provides a context for setting priorities 5. Provides socialization toward growth and development
Jasmine Riddle is a novice nurse in the telemetry unit of a large hospital. While assessing her client, 72-year-old Albert Griswald, Jasmine notes that his pulse feels irregular. When she calls the telemetry monitoring station, the monitoring technician, Miguel, tells Jasmine that Mr. Griswald just developed atrial fibrillation. The technician praises Jasmine for catching the change in Mr. Griswald's cardiac rhythm so quicklylong dash—even before the telemetry technician recognized it. In her response, which action would reflect Jasmine's nursing integrity? 1. Advising the telemetry technician to focus on his job and monitor clients' heart rhythms more closely 2. Thanking the telemetry technician for praising her and for being part of the client's care team 3. Notifying the telemetry technician's supervisor of his failure to recognize the change in cardiac rhythm 4. Telling the telemetry technician that noticing the client's change in cardiac rhythm was "pure luck"
2. Thanking the telemetry technician for praising her and for being part of the client's care team
What would be an appropriate goal when caring for a client with impaired communication? 1. The client will review discharge instructions at home. 2. The client will effectively communicate needs. 3. The client will call for help before getting out of bed. 4. The client will state ways to reduce communication deficits.
2. The client will effectively communicate needs.
The nurse educator asks the nursing students to describe the stage of commitment development during which the student discovers negative aspects of a chosen profession. Which student's response is accurate? 1. The passionate stage. 2. The testing stage. 3. The integrated stage. 4. The quiet-and-bored stage.
2. The testing stage.
The nurse is providing care to several clients on a medical-surgical unit. The nurse needs to prioritize care for the assigned clients. Which action is a common pitfall when prioritizing client care? 1. Being cognizant of time when completing tasks 2. Involving the client during the care plan process 3. Administering medications based on vital signs at admission 4. Completing tasks based on level of difficulty
3 A common pitfall when prioritizing care is prioritizing care without completing an assessment. Administering medications based vital signs obtained at admission is failing to assess the client, as the client's condition may have changed since admission. Involving the client during the care plan process, completing tasks based on level of difficulty, and being cognizant of time when completing tasks are not pitfalls related to prioritizing care.
A novice nurse is working independently on a maternal-newborn unit after 12 weeks of orientation with a preceptor. The nurse is assigned several newborns to care for during the shift. Based on the clinical pathway for a mother and baby of a vaginal birth, which intervention by the nurse is appropriate? 1. Administering vitamin K to the mother within 24 hours of delivery 2. Ensuring the newborn is breastfed 6 times per day at 48 hours of life 3. Scheduling bottle feedings for the newborn of 15 to 30 mL every 4 hours at 24 hours of life 4. Administering erythromycin ointment to the newborn's eyes at 48 hours of life
3 Based on the clinical pathway for the mother and newborn after a vaginal delivery, the most appropriate intervention is to schedule bottle feedings for the infant every 4 hours (6 times per day) at 24 hours of life. These feedings should consist of 15 to 30 mL of infant formula. Vitamin K is administered to the newborn, not the mother, within 24 hours of delivery. Erythromycin ointment is administered to the newborn's eyes within 24 hours of delivery. Newborns who are breastfed should be offered the breast 8 times per day at 48 hours of life, not 6 times per day.
A nurse is caring for a client who is scheduled to have a chest x-ray at 0900 and will be off the unit. The client is also due to have medication at 0900. Which action by the nurse is most appropriate? 1. Administer the medication after the client returns from x-ray 2. Administer the client's medication at the start of shift 3. Administer the client's medication at 0845 4. Wait to administer the medication at the next dosage time
3 By administering the scheduled medication 15 minutes early, the nurse is using clinical decision making to ensure the client receives all necessary care despite the apparent scheduling conflict. Because there is no way to tell how long the client might be at x-ray, it might jeopardize the client's dosing schedule to wait to administer the client's medication. Administering medication at the start of shift may be inappropriate depending on the dosing schedule. Waiting until it is time for the next dose will result in the client missing a dose, which is not an option.
An adolescent client is sitting in a chair waiting for the nurse to complete a health history. After entering the room, where should the nurse sit to conduct the history with the client? 1. Against the wall near the door 2. About 4 to 12 feet from the client 3. Between 1 ½ to 4 feet from the client 4. One foot away from the client
3 Communication is influenced by personal space. Personal distance is 1½ to 4 feet, and much of the communication between nurses and clients takes place at personal distance. Social distance is 4 - 12 feet, which is too far for most communication between nurses and clients. One foot away is within intimate distance. Intimate distance is used by nurses when treating clients, but not for taking a health history. Against the wall near the door would be described as public distance, which would not be useful for taking a health history.
The clinical nursing instructor is evaluating the student's developmental stage of professional commitment. The student has settled into the nursing program's routine and reports experiencing decreased performance anxiety. Which stage of professional commitment is most appropriate for the clinical nursing instructor to use when describing the student's current level of development? 1. The testing stage 2. The integrated stage 3. The quiet-and-bored stage 4. The exploratory stage
3 Development begins with the exploratory stage, which begins when individuals explore the positive aspects of their profession. Examples include the excitement nursing students experience when first wearing their new uniforms or when purchasing their first stethoscope. The second stage is the testing stage, during which students discover the positive and negative aspects of the nursing profession. During the third stage, which is the passionate stage, students are willing to commit to their profession and to contribute to its well-being. Examples of student behaviors that are reflective of this stage include serving as a class officer and becoming involved in student nursing associations. During the fourth stage, which is the quiet-and-bored stage, students settle into the nursing program's routines, grow more comfortable in their role, and experience decreased performance anxiety. The integrated stage, which is the fifth stage, manifests through the student's demonstration of commitment as a matter of habit. This stage usually begins in the final phases of the nursing program, with students beginning to see themselves as nurses, and growing eager to take the NCLEX-RN® and to begin working.
The nurse is formulating a plan of care for a client who is pregnant. Which goal is appropriate for the nursing diagnosis dealing with a knowledge deficit related to pregnancy? 1. Client will attend medication management classes within four weeks. 2. Nurse will facilitate learning readiness. 3. Client will attend prenatal classes through the course of the pregnancy. 4. Nurse will teach client about prescribed exercise regimen for pregnancy at next appointment.
3 Goals are created from the client's nursing diagnoses, specifically from the diagnostic label. Each nursing diagnosis has one goal. An appropriate goal statement to address the client's insufficient knowledge about pregnancy is that the client will attend prenatal classes. Medication management classes will not be sufficient to assist the client with learning about other aspects of pregnancy. Client goal statements are always written to capture actions or changes of the client, not the nurse.
The charge nurse is reviewing e-mails and sees a message from the laboratory containing results for a client's blood work. What is the priority action by the nurse regarding this information? 1. Delete the message 2. Forward the message to the client 3. Print the message and place it in the client's medical record 4. Phone the healthcare provider and verbally provide the results
3 Information sent through e-mail is considered a part of the client's medical record. A copy of each e-mail message is to be placed in the client's chart. Deleting the message may alter the client's medical record. Sending laboratory results by e-mail is inappropriate as it denies the client the opportunity to ask questions. The nurse can phone the healthcare provider and verbally provide the results; however, the nurse still needs to print the message and place it in the client's medical record. The healthcare provider can see the results when reviewing the chart.
TThe nurse is providing care to several clients in the emergency department: A client who arrived by ambulance with stroke symptoms; a client with a fractured femur; a client complaining of sharp, continuous pain radiating from the kidney area; and a young child with a possible fractured arm whose mother is with him. Using the urgency factor, which client will the nurse prioritize for care? 1. The young child with the possible arm fracture 2. The client with sharp, continuous pain radiating from the kidney area 3. The client with stroke symptoms 4. The client with a fractured femur
3 Prioritizing client care can be approached by various methods. Criteria that impact the urgency factor include changes in the client's condition, deterioration of client status, or complexity of the client's condition. Imminent death is the highest urgency factor where interventions need to be addressed immediately in order to save a client's life. The client with stroke symptoms is at risk of imminent death or substantive impairment and must be seen immediately. The client experiencing kidney pain is considered medium-high urgency because the condition may become life threatening if not assessed and addressed quickly. Sprains and fractures are less urgent.
The nurse unit manager is giving an in-service about sexual harassment in the workplace. When discussing what constitutes sexual harassment, which statement is most appropriate for the nurse unit manager to include in the in-service? 1. Behaviors must include unwelcome advances of a sexual nature that are demonstrated through the perpetrator's physical conduct. 2. Submitting to requests for sexual behaviors must be explicitly considered a condition of an individual's employment. 3. Sexual harassment must be considered both a form of discrimination and a violation of an individual's rights.. 4. The sexual behaviors must interfere with the victim's work performance and prevent fulfillment of work functions.
3 Sexual harassment is a form of discrimination, as well as a violation of an individual's rights. The Equal Employment Opportunity Commission (EEOC) defines sexual harassment as open double quote"unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual natureclose double quote" occurring when submitting to such requests or behavior is considered, either explicitly or implicitly, a condition of an individual's employment; when submission to or rejection of such requests or behavior is used as the basis for employment decisions affecting the individual (e.g., promotion); or when such conduct interferes with an individual's work performance or creates an "intimidating, hostile, offensive working environment.close double quote
A nurse working in the ICU has decided to attend a professional critical care conference. What critical thinking attitude is exemplified by this nurse's actions? 1. Independence 2. Integrity 3. Awareness of self-limits 4. Confidence
3 The nurse is demonstrating awareness of self-limits by seeking new knowledge or skills. Nurses exhibit independence when they think on their own. Confidence is exemplified by self-assurance. Integrity is displayed when the nurse chooses the right option, even if it is not the popular option.
A nurse is caring for a pediatric client who is recovering from a recent open appendectomy surgery. The nurse states to the client, open double quote"I saw that you walked up and down the hallway twice today already. Good job!close double quote" Which therapeutic communication technique is the nurse using to establish rapport with the client? 1. Listening actively 2. Validating perceptions 3. Giving recognition 4. Offering self
3 The nurse is giving recognition by observing the client's behavior and showing an interest in the child. Offering self, which the nurse might do by sitting with the child or walking with the child down the hall, shows that the nurse is accessible and willing to listen to the child. Validating perceptions provides an opportunity for the client to reflect on the explanations that the nurse has made. Active listening involves being present with the client in a discussion and encouraging the client to share thoughts and feelings.
While transferring a client back into bed after a procedure, the client says that it wasn't very nice for the nurse to say that the "cow" was coming down the hall. Which response by the nurse is most appropriate in this situation? 1. "You must have misunderstood what I said." 2. "I didn't mean to call someone a cow!" 3. "The term 'cow' is used for computer on wheels." 4. "I was just joking with that person!"
3 The nurse should avoid using jargon when communicating with clients. The client did not understand the acronym "C.O.W." as meaning a computer on wheels. The nurse needs to explain the term in language the client understands. The nurse should not become argumentative and deny using the term. The client did not misunderstand the nurse. Saying that the nurse was joking with another person supports the client's claim that the nurse called someone a "cow."
The nurse is providing care to a 1-year-old pediatric client who is admitted to the emergency department with SaO2% of 93% on room air, respiratory rate of 50 breaths per minute, with moderate wheezing. Based on the pediatric clinical pathway for asthma, what intervention does the nurse anticipate for this client? 1. Systemic magnesium sulfate 2. Continuous anticholinergic medication administration 3. Nebulizer treatment of albuterol 4. IV corticosteroids
3 The pediatric client is experiencing a mild asthma attack. Based on the clinical pathway, the nurse anticipates the client will be given a nebulizer treatment of a beta adrenergic medication, such as albuterol. Systemic magnesium sulfate, IV corticosteroids, and continuous administration of anticholinergic medications are not appropriate for a pediatric client experiencing a mild asthma attack, per the clinical pathway.
A nurse is interviewing for a staff position on a medical-surgical unit. Which portion of the hiring process best represents the hospital's efforts to evaluate the nurse's commitment to the profession? 1. Offering the candidate the option of completing a four-week unit orientation and preceptorship 2. Requiring the candidate to provide official copies of college transcripts 3. Exploring the candidate's desire to maintain membership in the profession 4. Inviting current staff nurses to serve as members of the candidate's interview committee
3 The candidate's desire to maintain membership in the nursing profession is reflective of professional commitment. The requirement to provide official college transcripts is not directly related to the candidate's commitment to the nursing profession. Inviting current staff nurses to serve as interview committee members and offering a unit orientation and preceptorship are not direct methods of evaluating the candidate's professional commitment to nursing.
The manager schedules a nursing assistant to attend a basic communication program after observing the assistant provide client care. Which actions would result in this type of referral? (Select all that apply.) 1. Talking with a newly admitted client about his grandchildren 2. Referring to a 75-year-old male client as "Mr. Dan" 3. Asking a 65-year-old client, "Are we ready to get out of bed?" 4. Calling an 80-year-old client "Sweetie" 5. Referring to a 70-year-old client's abdominal wound as a "boo-boo"
3, 4, 5 Elderspeak is a demeaning way of speaking with an older adult client. Use of inappropriate terms of endearment, such as sweetie, inappropriate use of the first person plural ?we? when referring to getting out of bed, and using baby talk by referring to a wound as a boo-boo are all examples of elderspeak. Using a formal title as Mr. and following it with the client's first name is appropriate if the client has asked to be called in this manner. Discussing grandchildren with the client does not demonstrate elderspeak.
A healthcare provider yells at a novice nurse for not knowing a client's latest laboratory values. Which responses by the novice nurse would demonstrate assertive communication? (Select all that apply.) 1. "You can look them up on the computer." 2. "I'm sorry. I'll see where those results are." 3. "I will locate the values and get them to you." 4. "I can't do anything right for you." 5. "The lab has not phoned in the results yet."
3, 5 Assertive communication is demonstrated by using "I" statements such as "I will locate those values and get them to you." Fogging is another technique that causes both parties to focus on something that is agreed. In this case, the statement "the lab has not phoned in the results yet" takes the focus off of the healthcare provider's anger towards the nurse and places it on the issue that the values are not yet available. Saying "I can't do anything right for you" and "I'm sorry" are both passive responses. Saying "you can look them up on the computer" is an aggressive response.
The nursing student is experiencing the integrated stage of commitment development. When developing professional commitment, which behavior would the nursing student be most likely to demonstrate during the integrated stage? 1. Considering switching to a major other than nursing 2. Learning about positive aspects of the nursing profession 3. Being eager to take the NCLEX-RN® examination 4. Becoming involved in a student nursing association
3. Being eager to take the NCLEX-RN® examination
Esther Wulfman, an 83-year-old client with a hearing deficit, is admitted for exacerbation of heart failure. What should Marta, the nurse, do to support Esther's communication needs during the assessment process? 1. Shout into the client's good ear when talking 2. Ask if a family member is available to complete the assessment 3. Close the door to the room when conducting the assessment 4. Sit beside the client during the assessment
3. Close the door to the room when conducting the assessment
The leader of a group of staff nurses is encouraging all members to work towards achievement of a common goal. Which behavior is the leader demonstrating? 1. Monopolizing 2. Commitment 3. Power 4. Brainstorming
3. Power
Gordon Sullivan, a 58-year-old client with acute pain and bleeding from prostate cancer, rates his pelvic pain as an 8 on a pain rating scale from 1 to 10. He is considering surgery to remove the prostate before beginning chemotherapy and radiation. When writing a three-part nursing diagnosis for Gordon, what should the nurse use as the etiology? 1. Surgery 2. Acute Pain 3. Prostate cancer 4. Bleeding
3. Prostate cancer
Which are characteristics of a primary group? (Select all that apply.) 1. Impersonal communication 2. Task oriented 3. Spontaneity 4. Face-to-face communication 5. Unity
3. Spontaneity 4. Face-to-face communication 5. Unity
In an annual evaluation, the nurse unit leader describes the staff nurse as "skilled at analyzing a complex situation and able to pick out the most important aspects of a clinical scenario." According to Patricia Benner's model of nursing development, which developmental stage best matches the nurse unit leader's evaluation of the staff nurse? 1. Expert 2. Novice 3. Competent 4. Proficient
4 According to Benner's model, the novice nurse has no experience and relies only on guidelines, policies, and theories. The advanced beginner is starting to gain experience, with a focus on tasks and guidelines as the nurse at this stage does not have the experience to consider complexities. The competent nurse has begun to master some tasks, but does not yet possess the speed and flexibility of the proficient nurse. The proficient nurse is able to view the complexities of a situation, looking at the whole and determining which are the most important aspects. The expert nurse possesses an intuitive understanding of most situations and is able to quickly determine a course of action without much problem solving.
The nurse leader is evaluating the charge nurse's type of commitment to the nursing profession. Which behavior by the charge nurse is most reflective of affective commitment to nursing? 1. Expressing a sense of obligation to remain in the nursing profession 2. Choosing to stay in nursing due to personal experiences with illness 3. Remaining in the nursing profession to avoid loss of income 4. Joining professional nursing organizations and engaging in nursing service activities
4 Affective commitment develops when professional involvement produces a satisfying experience. Manifestations of affective commitment include engaging in profession-specific organizations and service activities. Normative commitment manifests as a feeling of obligation to continue in one's profession and it develops in response to benefits or positive experiences gained by way of engagement in one's profession. For example, the nurse whose desire to enter nursing stems from personal or family experiences with illness is reflective of normative commitment. Continuance commitment develops when negative consequences of leaving, such as loss of income, are viewed as reasons to stay.
The nurse is assessing an 8-year-old client whose parent brought him to the walk-in clinic. The parent reports that the child is tired and has been coughing for 2 days. Which assessment findings may be clustered as significant cues suggesting that the child has influenza? 1. The child's oxygen saturation is 98%. 2. The child's lungs are clear on auscultation. 3. The child's vital signs are BP 95/62 mmHg, RR 23, P 90, T 98.8degrees°F 4. The child's vital signs are BP 90/60 mmHg, RR 22, P 80, T 101.5degrees°F.
4 After collecting data, the nurse attempts to identify significant cues that form a pattern to generate a tentative hypothesis as to what is occurring with the client. In this scenario, significant cues suggesting influenza include the cough, malaise, and vital signs that show an elevated temperature of 101.5degrees°F. A normal temperature does not indicate the flu. Clear lungs and an oxygen saturation of 98% do not indicate influenza.
The nurse educator is teaching a class about professional development in nursing. When describing an area of nursing competence, which component is most appropriate for the nurse educator to include in the teaching? 1. Recognizing the nurse's responsibility to remain strictly in a client-centered role 2. Understanding that client populations tend to demonstrate the same personal needs 3. Knowing and demonstrating adherence to the ethics of primary care providers 4. Understanding the culture of the client population and the healthcare institution
4 Areas of nursing competence include understanding the culture of the client and the institution; knowing and demonstrating adherence to the ethics of the nursing profession; acknowledging the client's need for individualized care; and assuming multiple nursing responsibilities, including legal, professional, ethical, and client-centered roles.
The nurse is caring for a client who is recovering from abdominal surgery. During the morning assessment, the client complains of pain and rates the pain at 7 out of 10. The nurse tells the client that she will prepare pain medication and return in 10 minutes to administer it. Which characteristic of verbal communication is the nurse using? 1. Pace 2. Humor 3. Intonation 4. Credibility
4 By assessing the client's pain and stating a return time to administer needed pain medication, the nurse is relaying credibility. She is being trustworthy and reliable in responding to the client's report of postoperative pain. Pace and intonation are often used when communicating with a client who is anxious, but this scenario does not indicate that the client has anxiety. There is no indication that the nurse is using humor while communicating with this client.
The nurses on a care area are uncharacteristically quiet. There is no friendly chatter, and nurses are staying in clients' rooms to document until the end of the shift. Which incident might cause the nurses to demonstrate this behavior? 1. The director is identifying staff for promotion. 2. The nurse manager is working on the annual budget. 3. The medical director is making client rounds. 4. The charge nurse called everyone incompetent during report.
4 By calling the nursing staff incompetent, the charge nurse's aggressive behavior influenced all of the staff during the shift as they tried to avoid another similar encounter. The behavior of the nurse manager, director, and medical director did not cause the nurses to be afraid to leave clients' rooms.
During a meeting to discuss the implementation of a new computerized documentation system, one staff nurse asks about the ease of use, preloaded templates, and online nursing resources. What behavior is the staff nurse demonstrating? 1. Opinion giver 2. Information giver 3. Opinion seeker 4. Information seeker
4 Each member of the group is responsible for individual behavior and participation. Roles that members assume include information giver, information seeker, and opinion giver. The nurse asking questions is seeking information. Providing information to another is functioning in the role of information giver. Explaining personal views about an issue would be characteristic of an opinion giver. Opinion seeker is not an identified role behavior when working in groups.
A staff nurse is overhead counseling a newly hired nurse about limiting suggestions to improve the functioning of the unit because the manager open double quote"does not like suggestionsclose double quote" and will open double quote"put you down.close double quote" Which characteristic of an ineffective group is the manager influencing? 1. Goal setting 2. Cohesion 3. Problem solving 4. Creativity
4 In an ineffective group, creativity is discouraged and members fear appearing foolish if they put forth a creative thought. In an ineffective group, problem solving is low and criticism may be destructive, taking the form of either overt or covert personal attacks. In an ineffective group cohesion is either ignored or used as a means of controlling members and promoting rigid conformity. In an ineffective group, goal setting is unclear, misunderstood, or imposed goals may be accepted by members. The goals are competitively structured.
Several nurse managers are having lunch after attending a shared governance committee meeting. Which manager statement indicates that the committee is ineffective? 1. "Who knew we had such a nice conference room!" 2. "I think the goals are tough but appropriate in the circumstances." 3. "I could have prepared better before today's meeting." 4. "I am not sure why the chairperson made all of the decisions."
4 In an ineffective group, decision making is made by the individual with the most authority in the group, with minimal involvement by members. In an effective group, goals are clarified so that all group members commit to completing them. In an effective group, self-evaluation of group members occurs often. The atmosphere in an effective group is comfortable and relaxed. The comment about the nice conference room indicates the group members feel comfortable commenting on the accommodations.
The nurse educator is explaining the significance of punctuality and attendance in the nursing profession to a class of nursing students. Which statement is most appropriate for the nurse educator to include in the discussion? 1. "Nurses must be flexible about helping colleagues who routinely need to miss work." 2. "During a nursing shortage, hospital attendance requirements usually are less strict." 3. "The most severe consequence of excessive tardiness for the professional nurse is suspension." 4. "Chronic tardiness and frequent absenteeism among nurses can compromise client care."
4 In nursing practice, chronic tardiness and frequent absenteeism place a greater burden on colleagues, compromise client care, and can cause conflict among staff. Just as excessive tardiness to clinicals can lead to severe repercussions, even during a nursing shortage, professional nurses who demonstrate excessive tardiness or absences may face disciplinary actions including suspension and termination.
The nursing student is designing a poster that describes how to recognize burnout among nurses. Which recommendation for identifying manifestations of burnout should be included on the poster? 1. Understand that emotional depletion is a natural response to the demands of employment 2. Recognize that outbursts of anger are normal signs of professional frustration 3. Acknowledge feelings of helplessness as signs of inexperience or professional inadequacy 4. Interpret that smoking and an increase in coffee consumption may be potential warning signs
4 Manifestations of burnout include physical and emotional depletion, negative attitude and self-concept, and feelings of helplessness and hopelessness. Danger signs that may precede the development of burnout include increased coffee consumption and smoking.
Which evaluation statement by the nurse is appropriate and indicates a goal has been met for a client diagnosed with a stroke? 1. 04/03/2015, 1830: Goal partially met: Client demonstrates use of home oxygen machine. 2. 1750: Goal met: Client voices understanding of treatment therapy. 3. 04/03/2015: Goal not met: Client does not demonstrate use of incentive spirometer. 4. 04/03/2015, 1800: Goal met: Client demonstrates self-injection of Lovenox prior to discharge.
4 Once the nurse determines if a goal has been met, the nurse writes an evaluation statement on the care plan. Evaluation statements must contain the date and time of evaluation, and they must state whether the goal was met, partially met, or not met.
The nurse is preparing to discharge a client after a hospital stay. What should the nurse take into consideration when evaluating the client's health status at discharge? 1. Modification of implemented interventions 2. Impact of the evaluation 3. Opportunities to correct intervention deficiencies 4. Identification of the client's self-care abilities
4 Outcomes are evaluated to determine if the client's goals have been met and for the effectiveness of the care plan. Based on the evaluation, the plan of care is continued, modified, or terminated. Three situations in which nursing care should be evaluated are during or immediately after an intervention in order to continue or modify; at time-specific intervals in order to measure progress and correct or modify deficiencies as necessary; and at discharge to identify the client's self-care abilities and determine the need for follow-up care.
The manager is concerned that a novice nurse is being made a scapegoat for an event that occurred on the care area. Which observation supports this manager's concern? 1. The novice nurse volunteers to work with other staff on a quality improvement study. 2. The charge nurse meets with the oncoming shift to review clients who could be discharged later in the day. 3. Nursing assistants are discussing work assignments and suggesting ways to help each other. 4. Staff nurses suggest that the novice nurse is responsible for missing narcotics during a shift when the nurse was not at work.
4 Scapegoating occurs when an individual or group forces blame on an individual who is not at fault. People and groups who use this approach focus on others' weaknesses. Volunteering to work with other staff, discussing work assignments, and meeting to discuss possible discharges are all positive actions that do not indicate scapegoating.
The nurse leader is preparing a webinar about how to prevent burnout in nursing. To accurately describe strategies for preventing burnout, which activity should the nurse educator include in the webinar? 1. Develop acceptance and recognize that the limitations of any situation can be changed 2. Study assertiveness and learn to take on added responsibilities even when feeling overwhelmed 3. Learn to depend on oneself and to avoid expressions of emotions toward colleagues 4. Actively engage in efforts to produce constructive change if organizational policies create stress
4 Strategies for preventing burnout in nursing include involvement, studying assertiveness techniques, expressing compassion, and developing acceptance. Involvement includes being active in efforts to produce constructive change if organizational policies cause stress. Studying assertiveness techniques, which can help with overcoming feelings of powerlessness in relationships, includes learning to say no. Compassion includes learning to ask for help and expressing emotions toward colleagues. Acceptance includes recognizing the limitations associated with each situation and accepting what cannot be changed.
A nurse educator chooses to implement scenario-based simulations for educating a group of student nurses regarding clinical judgment. Which approach is the educator using? 1. Benner's skill acquisition model 2. Tanner's clinical judgment model 3. Maslow's hierarchy of needs 4. Lasater's assessment rubric
4 The Lasater clinical judgment rubric is designed to allow for student reflection on the level of observed development of decision making and clinical judgment skills. This is exemplified with the use of simulation in a nursing lab. Tanner's clinical judgment model emphasizes the importance of elements the nurse uses in cognitive processing, including book knowledge, past experiences, and previous knowledge. Benner's skill acquisition model is based on the idea that the ability to make clinical judgments progresses as nurses gain experience and build their skills. Maslow's hierarchy of needs is a model nurses can use to inform how they prioritize care for a client.
The nurse is caring for an adolescent client who is alert but intubated following a C7-T1 spinal cord injury. Which communication strategy is the most developmentally appropriate for the nurse to use with this intubated client? 1. Hand signals 2. Grease pencil and white board 3. Flash cards 4. Text messages
4 The client is an adolescent and has a spinal cord injury that most likely has kept his arm and hand function intact. Text messaging, popular among adolescents, would be the best communication method for this client. Flash cards, hand signals, and grease pencil with a white board might work as a method of communication to some extent; however, these may or may not support the client's physical and developmental needs. With text messaging the client will be able to communicate needs to healthcare staff as well as communicate with friends and family.
The nurse has been determining a method of communicating with a client recovering from a stroke. Which client observation indicates that an effective communication method has been established? 1. Slapping the nurse's hand to refuse an action 2. Groaning to get the nurse's attention 3. Holding a pen to write on paper 4. Spelling words on a bedside table using tiled letters
4 The client using letters to spell words on a bedside table demonstrates that an effective communication method has been established. Groaning and slapping hands are not effective communication methods. Trying to use a paper and pen to write might be premature for this client and does not indicate that an effective communication method has been established.
A nurse is caring for a client with a history of a heart dysrhythmia. The nurse notifies the client's healthcare provider after noticing a decreasing trend in the client's serum potassium level, client muscle spasms, and changes in ECG pattern. Which critical thinking concept is the nurse using? 1. Seeking new knowledge 2. Approaching situations objectively 3. Differentiating fact from fiction 4. Recognizing salient cues
4 The nurse has recognized salient cues, pieces of clinical information that provide the nurse with a larger overall clinical picture of the client. Differentiating fact from fiction and approaching situations objectively are aspects of intellect, not critical thinking as used by the nurse in this scenario. The nurse is not seeking new knowledge, but rather is recognizing a trend in the client
During a health history interview, the client denies having any health problems but then crosses her arms and looks away. What does this behavior indicate to the nurse? 1. The nurse is taking too long, and the client is uncomfortable sitting in a chair. 2. The client is bored with the nurse asking too many questions. 3. The nurse is rushing the client to complete the health history. 4. The client's verbal communication and nonverbal communication are not congruent.
4 The nurse is interpreting both verbal and nonverbal messages from the client. A client who denies having any problems while crossing her arms and looking the other way is sending incongruent messages. There is no way to confirm that the client is bored, that the nurse is rushing the client, or that the nurse is taking too long. Crossing the arms and looking away does not usually indicate an uncomfortable body position.
A nurse is caring for a client, with a right femur fracture, who complains of pain in the right leg. The nurse asks the client, open double quote"Please tell me how you would rate your pain on a scale of zero to ten.close double quote" Which method of therapeutic communication is the nurse using with this client? 1. Seeking clarification 2. Giving information 3. Providing general leads 4. Being specific
4 The nurse is using the therapeutic communication technique of being specific when the nurse makes statements that are specific rather than general. Providing general leads is using statements or questions that encourage the client to verbalize feelings and encourages further conversation. Seeking clarification occurs when the nurse restates the client's message to make it more understandable. Giving information is when the nurse provides the client specific factual information.
A nurse is caring for a client who will undergo a cholecystectomy surgery in two hours. To assess that the client has informed consent, the nurse asks the client, open double quote"Can you tell me what your surgery will involve?close double quote" Which method of therapeutic communication is the nurse using with this client? 1. Giving information 2. Seeking clarification 3. Paraphrasing 4. Open-ended questioning
4 The nurse is using open-ended questioning. With this technique, the nurse invites the client to elaborate and use answers that are longer than one or two words. Paraphrasing is when the nurse repeats the client's basic message using the nurse's own words. Seeking clarification occurs when the nurse restates the client's message to make it more understandable. Giving information occurs when the nurse provides the client specific factual information.
A nurse is caring for a client who has been diagnosed with liver cancer but has not shared this diagnosis with family members. The client tells the nurse, open double quote"I can't tell my family that I have cancer.close double quote" The nurse replies, open double quote"What do you think would be best?close double quote" Which method of therapeutic communication is the nurse using with this client? 1. Presenting reality 2. Focusing 3. Acknowledging 4. Reflecting
4 The nurse is using reflecting, a technique that leads the client's feelings back to the client to assist the client in discovering his or her own ideas. Focusing is used when the nurse helps the client expand on and develop a topic of importance, which is often an emotion disguised behind words. Presenting reality helps the client distinguish the real from the unreal. Acknowledging is used when the nurse gives nonjudgmental recognition to the client for a client effort or change in behavior.
A nurse is caring for a pediatric client with possible pneumonia who is about to go for an X-ray. The nurse states, open double quote"The doctor needs to X-ray your chest so she can get a picture of what's happening in your lungs. Let me tell you what's going to happen.close double quote" Which therapeutic communication technique is the nurse using to develop a therapeutic relationship with the client? 1. Clarifying time 2. Acknowledging 3. Focusing 4. Giving information
4 The nurse is utilizing the technique of giving information to provide the client with specific, accurate information. The technique of clarifying time is used to clarify an event in relationship to time. Focusing is used when the nurse supports the client to expand on and advance a topic of importance, which is often an emotion disguised behind words. Acknowledging is used when the nurse gives broadminded recognition to the client for a client effort or change in behavior.
A nursing assistant is overheard telling a client, open double quote"I don't have all day. Let me put those shoes on you.close double quote" What type of communication style is the assistant demonstrating? 1. Assertive 2. Passive 3. Passive-aggressive 4. Aggressive
4 The nursing assistant is displaying aggressive communication; she is focusing on her needs and has become impatient with the client. Passive communication involves a person focused on the needs, demands, and requests of others without regard to his or her own feelings and needs. Assertive communication conveys concern for the needs of others. Passive-aggressive communication combines the attributes of focusing on the needs of others and then lashing out and being impatient when personal needs are not met.
The nurse is preparing to explain the insertion of an intravenous catheter into the arm of a client who has never been hospitalized. Which explanation by the nurse is the most appropriate for this procedure? 1. "An angiocath is inserted in a vein and fluids are administered." 2. "An intracath is placed in a vein, and the IV is set to administer 100 ccs an hour." 3. "A needle is inserted in a vein so that this bag of fluid is pushed into your body." 4. "A small tube is put in a blood vessel, and liquid is dripped into your body."
4 When communicating with a client regarding a procedure, the nurse should avoid the use of slang, buzz words, or medical jargon to prevent any potential misunderstanding. The statement "a small tube is put in a blood vessel and liquid is dripped into your body" is the simplest way to describe an IV infusion, using words with few syllables and no medical jargon. The phrases with "angiocath" and "intracath" use medical jargon. Saying "a needle is inserted in a vein" so "fluid is pushed" can be frightening to a client who has never been hospitalized.
The nurse prioritizing care for a client with diabetes mellitus utilizes Maslow's hierarchy of needs. Which need is priority for this client? 1. The nurse teaches the client proper home safety techniques to prevent diabetic wounds. 2. The client attends classes to deal with body image after amputation of right leg. 3. The client joins the local American Diabetes Association support group. 4. The nurse teaches the client how to properly change dressings on right leg amputation site.
4 When prioritizing care based on Maslow's hierarchy of needs, physiological needs will come before safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with body image issues addresses an esteem need. Teaching the client about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.
A nurse working in the emergency department uses a clinical decision tree to determine the best course of action for a client who presents with signs and symptoms of a myocardial infarction (MI). Which statements are true regarding this clinical decision tool? (Select all that apply.) 1. It cannot be implemented by all nurses. 2. It requires higher-level decision making. 3. It requires no decision making. 4. It can assist in decision making. 5. It requires standardization of care.
4, 5 Clinical decision trees and protocols can assist in decision making, especially for nurses who do not have enough nursing experience, or nursing knowledge, to make decisions. This tool can assist in standardizing care because the tool can be used for all clients who present with similar symptoms. Because the tool has steps of decisions presented, it does not require higher-level decision making. However, the tool still requires some decision making by the nurse to ensure interventions are appropriate for the client.
A nurse educator asks the student nurse to describe chronic obstructive pulmonary disease (COPD) and nursing interventions used to treat the condition. The student nurse states, "COPD is a chronic pulmonary disease, and the nurse should place the client in high Fowler position." Which clinical reasoning concepts is the student nurse using in this statement (Select all that apply.) 1. Judgment 2. Inference 3. Inquiry 4. Fact 5. Opinion
4, 5 The nurse is using both fact and opinion in the statement. Facts can be confirmed by research-COPD is a chronic pulmonary disease. Opinions may be based on fact and are beliefs made over time, including nursing interventions such as placing the client with COPD in high Fowler position. Judgment is an evaluation of facts that reveal values; e.g., place the client with COPD in high Fowler when the sPO2 is <92%. Inference is going beyond the facts to make a statement about something not currently known. Inquiry is a search for knowledge.
During hospital orientation, the human resources specialist is defining and explaining sexual harassment. Which statement should be included in the human resource specialist's discussion of sexual harassment? 1. "Physical contact is required for a behavior to be considered sexual harassment." 2. "Discrimination is one type of sexual harassment." 3. "Sexual harassment requires the victim and violator to be of different genders." 4. "Sexual harassment interferes with performance in the workplace."
4. "Sexual harassment interferes with performance in the workplace."
Rosario, the manager of a 20-bed unit, is evaluating the success of assertiveness training classes that staff nurses attended to improve communicating with physicians. Which behavior by Yvonne, a staff nurse, indicates she needs more training? 1. Focusing on the situation before speaking and requesting help 2. Using a neutral voice when discussing a client's abnormal laboratory values 3. Stating "I would like some help" when planning care with other team members 4. Apologizing to the neurosurgeon for "bothering him" with a question 5. Identifying an area where both the nurse and client agree
4. Apologizing to the neurosurgeon for "bothering him" with a question
When communicating discharge instructions to a client, the nurse states exactly what needs to be done using the fewest number of words. Which characteristics of verbal communication is the nurse using? (Select all that apply.) 1. Intonation 2. Pace 3. Simplicity 4. Brevity 5. Clarity
4. Brevity 5. Clarity
The nurse is a member of a work group in which the members like and trust each other and provide each other with support. Which characteristic is this group demonstrating? 1. Atmosphere 2. Creativity 3. Power 4. Cohesion
4. Cohesion
The nurse is assessing Julia McMichael, an 82-year-old client with pneumonia. Mrs. McMichael is experiencing dyspnea, has a pulse oximeter reading of 90, and lung assessment reveals rales. Which nursing intervention is the most appropriate for Mrs. McMichael at this time? 1. Keep the head of Mrs. McMichael's bed flat 2. Use a face mask for oxygen even though a request for nasal cannula was made 3. Empty fluid from the oxygen humidifier 4. Explain that the oxygen will help Mrs. McMichael breath better
4. Explain that the oxygen will help Mrs. McMichael breath better
Linda is a member of a nursing journal club that meets every 2 weeks. Linda does not agree with most of the group members' opinions about proposed changes that would expand the membership of the group, but she does not speak up. Which behavior is Linda demonstrating at this time? 1. Monopolizing 2. Scapegoating 3. Apathy 4. Groupthink
4. Groupthink
William is a nurse working on the pediatric cancer unit at a large urban hospital. One of his clients, Angela, is a 16-year-old who is recovering from surgery. Her mother, Carlotta, has been by her side almost constantly, but Angela's father has not been to visit since she was transferred to the unit. Angela is frequently rude to William, and it often takes him several attempts to get her to participate in interventions when William is on duty. The nurse from the night shift, who is female, shared that she does not have any difficulty with Angela. William recognizes that Angela's hostility toward him is most likely due to which factor? 1. Apathy 2. Countertransference 3. Scapegoating 4. Transference
4. Transference
Dena, the nurse at a local clinic, is determining the best way to communicate test results to a client who has requested all communication go to his e-mail address. The test results showed some abnormalities. Which is the best option for Dena in this situation? 1. E-mail the test results directly to the client 2. Ask the healthcare provider to e-mail the test results to the client 3. Send the test results by regular mail 4. E-mail the client with a request to call the office
4. E-mail the client with a request to call the office
A healthcare organization is adopting the use of a three-column nursing care plan. What information will be documented in these columns? (Select all that apply.) 1. Assessment 2. Evaluation 3. Goals/desired outcomes 4. Nursing interventions 5. Nursing diagnoses
3. Goals/desired outcomes 4. Nursing interventions 5. Nursing diagnoses
Colleen is assessing Janie, a 6-year-old girl who was hit by a car while riding her bicycle. When Colleen sits down to look in Janie's eyes, she says, "Promise you won't do anything that hurts." Janie's mother looks at Colleen with pleading eyes. Which response by Colleen is the most appropriate? 1. "Nothing can feel worse than how you hurt right now." 2. "There's no way that I can make that promise to you." 3. "I promise that I won't let anyone hurt you." 4. "Sometimes things hurt just for a second so that you can get better faster."
4. "Sometimes things hurt just for a second so that you can get better faster."