chpt 20

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

"Can you tell me why your physician sent you here to be admitted?"

A nurse is discussing cataract treatment with a client. Which of the following statements by the nurse would be most therapeutic?

"Have you ever thought of laser surgery?"

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

"I know that you are anxious, but removal will be painless and the IV location needs to be changed."

A nurse is asking a colleague about a situation. Which of the following statements demonstrates assertive communication?

"I think there is a better way to handle this."

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

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

A nurse is calling a physician to communicate a change in the client's condition. According to the I-SBAR-R format for hand-off communication among healthcare personnel, which is the most appropriate way to begin the conversation?

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

When the preoperative client tells the nurse that he cannot sleep because he keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is what?

"The thought of having surgery is keeping you awake."

A nurse is examining a child age 3 years with conjunctivitis. During the examination, the child starts crying and refuses to sit still. What statement by the nurse is most appropriate?

"Would you like to see my flashlight?"

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective.

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

Empathy

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

A nurse is caring for a client in a semi-private room. The nurse is preparing to discuss the medical treatment plan with the client. To best ensure privacy the nurse should do what?

Pull the curtain dividing the two beds, maintain eye contact, and speak in a low, audible voice.

A nurse is attempting to communicate with a patient who speaks a different language and does not understand what is being communicated. Which nursing action would best facilitate the communication process?

Speaking slowly and distinctly, but not loudly

A nurse has been caring for a client who suffered a myocardial infarction two days ago. During the morning assessment, the nurse asks the client how he or she feels. Which of the following scenarios warrants further investigation?

The client stares at the floor and states, "I feel fine."

A nurse who "unblocks" and "clears" congested areas of energy in a patient's body to promote comfort is applying the phenomenon known as:

Therapeutic Touch

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

The nurse will be sensitive to the patient's emotional barriers.

Which of the following factors is most important in the development of rapport between nurse and patient?

Trust

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:

aggressive.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

an audiologist.

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

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

A nurse is performing a wet to dry dressing change on a client's abdomen. During this intervention the nurse is communicating with the client in the:

intimate zone.

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:

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

A nurse gives a speech on nutrition to a group of pregnant women. What is the speech itself known as?

message

A nurse is caring for a client who presents with a skin infection. While obtaining the patient's medical history, it is determined that the client is an intravenous drug abuser. To foster effective communication, the nurse should:

remain honest, open, and frank.

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a client's room to empty his or her urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the patient to explain the statement.

A nurse enters a client's room to complete an admission history. The nurse will convey interest in the client's story if the nurse:

sits at the client's bedside and faces the patient.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:

tell herself to "remain calm" and remember that she was trained to perform this skill.

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the teaching session, the nurse should:

turn off the television in the room.

A nurse has developed strong rapport with the wife of a client who has been receiving rehabilitation following a debilitating stroke. The wife has just been informed that her husband will be unlikely to return home and will require care that can only be provided in a facility with constant nursing care. The client's wife tells the nurse, "I can't believe it's come to this." How should the nurse best respond?

"This must be very difficult for you to hear. How do you feel right now?"

A client with a cardiac dysrhythmia was recently prescribed metoprolol (Lopressor) and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:

"Were you tired and depressed before starting the new medication?"

A dialysis nurse is educating a client on caring for the dialysis access that was inserted in the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. What phase of the working relationship is best described in this scenario?

The working phase

Social media use is a form of communication that, if used incorrectly, can result in Health Insurance Portability and Accountability Act (HIPAA) violations and be both ethically and legally problematic for nurses. Which of the following is an appropriate use of social media for professional nurses?

To connect with other nursing professionals and gain insight into new educational information and share ideas

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

swaddling the child and gently stroking its head.

The nurse-client relationship is dependent on communication. Effective communication between the nurse and the patient includes. Select all that apply.

• Spoken words • Sight • touch

A nurse is communicating the plan of care to a patient who is cognitively impaired. Which nursing actions facilitate this process? (Select all that apply.)

• The nurse maintains eye contact with the patient. • The nurse keeps communication simple and concrete. • The nurse is patient and gives the patient time to respond

A 70-year-old female client had a cholecystectomy four days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask in order to assess the client's orientation?

"What day of the week is it?"