Communication and caring Nclex

The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse determines the UAP understands the information provided if the UAP identifies which situation portrays ageism?

Advising older adults to forgo aggressive treatment

The nurse should plan which to encourage autonomy in the client who is a resident in a long-term care facility?

Allowing the client to choose social activities

A client receiving chemotherapy asks the nurse, "What will I do when my hair starts to fall out?" Which action by the nurse is therapeutic?

Assist her to express feelings.

A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should best respond by taking which action?

Assist the client in expressing feelings.

The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization?

Associated with poor comprehension

The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding?

Encourage her to hold the infant even when the infant is crying.

A 24-year-old Chinese-American who delivered her baby yesterday is breastfeeding her infant girl. The client's mother asked the nurse not to include cold foods on her daughter's tray because they are not good for the baby. The nurse responds by telling the client that she can have what she wants; it is not up to her mother. This response of the nurse demonstrates which cultural characteristic?

Ethnocentrism

A client has just been told by the primary health care provider about her diagnosis of breast cancer. The client responds, "Oh no, does this mean I'm going to die?" The nurse interprets which response as the client's initial reaction?

Fear

The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs?

Providing the mother with pamphlets and booklets to read about the pregnancy

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response?

Request to hold the infant following delivery

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which action should the nurse take?

Seek an interpreter from the hospital's interpreter services.

The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client?

Smiling continuously during conversation

The nurse documents that the client has a stage 2 pressure injury on the decubitus area. Which describes a stage 2 pressure injury?

The ulcer is superficial and characterizes an abrasion.

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?

Use a picture or word board.

The nurse observes an outburst by a client with a history of schizophrenia, during which the client uses extreme foul language. Which appropriate documentation should the nurse make for this occurrence?

Use quotation marks, exact words, and additional objective information about affect and nonverbal behavior.

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house ready to plan our activities for the day." Which is the therapeutic nursing response?

"It must be hard to accept that she has passed away."

A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?

"Tell me what concerns you have."

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response?

"You don't think you can ever do anything right?"

A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client?

"You have concerns about skeletal versus skin traction for your type of fracture?"

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

3.Encourage expression of feelings, concerns, and fears. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse.

The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has which type of cast?

A hip spica cast

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns?

Ask the client to discuss information known about the planned surgery.

A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which nursing intervention would be most appropriate to alleviate the child's fears and the mother's anxiety?

Ask the mother if she would like to stay overnight with the child.

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically?

Collect data regarding how the client perceived the event.

The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate?

Gather data from the client and spouse about the perception of the event.

The nurse should implement which activity to promote reminiscence among older clients?

Having storytelling hours

The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner?

In a normal tone while facing the client

A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How should the nurse be most therapeutic in this situation?

Provide support to the mother.

The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication?

Speak in a normal tone.

The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness skin loss and the formation of a blister. The nurse should document the pressure injury as which category?

Stage II

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially?

Stand in front of the client.

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely?

The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

A client receives meperidine by the intramuscular route. Thirty minutes after receiving the medication, the client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client and contacts the registered nurse, who then contacts the primary health care provider. The nurse completes an incident report and accurately documents which?

Thirty minutes after receiving meperidine, the temperature is 101° F, skin is warm and flushed, and a rash is noted on the chest and back; the primary health care provider was notified.

A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response best supports the client?

"Better blood glucose control means fewer effects; let's review your plan of care."

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, which is the best response by the nurse?

"Can you tell me more about what you are eating?"

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic?

"Do you recall needing to be hospitalized because you stopped your medication?"

During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't stop myself from wondering if he killed her, but the police have ruled him out as a suspect." Which statement reflects a therapeutic nursing response?

"Have you shared your concerns with the police?"

The nurse is caring for a client who has undergone pelvic exenteration. In addressing psychosocial issues related to the surgery, which statement by the nurse should be therapeutic?

"How do you feel about this surgery?"

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response?

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"

The nurse manager asks a licensed practical nurse to work on her day off because of a short-staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. Which response by the licensed practical nurse to the nurse manager is assertive?

"I have planned to take the day off and will not be able to work on that day."

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement?

"In most cases, medication and diet will control fluid retention."

A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?

"Let me go over your prescribed medications with you again."

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home with family caregivers. Which nursing response would be appropriate at this time?

"Tell me more about your concerns with your feedings after going home."

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?

"Tell me what you know about complementary therapies."

A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?

"Would you like to hold your baby?"

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time?

"You sound very unhappy. Are you thinking of harming yourself?"

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

1."I notice you are wearing a blue shirt." 2."Do you have any plans of harming yourself?" 4."I will sit here with you even if you choose not to talk with me."

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

1.Change the password for entering computer files at least monthly. 2.Shred the printout of the nurse's flowchart at the end of the nurse's shift. 3.Use own user name and password when logging into the computer system.

The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply.

1.Time and date of death 2.Time of body transfer and destination 4.Medical tubes, devices, or lines left in the body 5.Name of primary health care provider certifying death

An Appalachian family has brought a toddler to the emergency department with a fractured arm. The nurse knows that nonverbal communication is important to evaluate with assessing the family. Which factors are involved in nonverbal communication? Select all that apply.

1.Touch 3.Body posture 4.Use of space 5.Eye behavior 6.Facial expressions

The nurse is working with a 21-year-old client who has a family history of Huntington's disease and asks for information about the advantages of genetic testing. Which responses by the nurse are best? Select all that apply.

2."Genetic testing will help you make decisions about having children." 3."Retirement issues might be easier to plan if you know the results of the test." 4."Planning for the future might be affected if you know the results of the test".

The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.

3.Adequacy of circulation in the body area that is restrained 4.Type of restraint and body area where the restraint was applied 5.Communication with client and family member about need for restraint 6.The alternative measures that were attempted before restraints were applied

A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?

"Perhaps you could just enjoy the music without singing."

While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic?

"So you're saying that you want to talk to your health care provider?"

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response best supports the client?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply.

2.Speaking slowly and clearly 3.Standing directly in front of the client while speaking Turning down the volume on the radio or TV when talking

A client with carcinoma of the breast is admitted to the hospital for treatment with intravenous vincristine. The client tells the nurse that she has been told by her friends that she is going to lose all her hair. After offering an open-ended question in reply, the client expresses how she feels. The nurse then gives the client information. The nurse makes which appropriate response to the client?

"Hair loss may occur, and it will grow back, but it may have a different color or texture."

The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

"I cannot discuss any client situation with you."

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

"It's okay to grieve and be angry with your daughter and anyone else for a time."

A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's husband?

"It's seems that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

"Let me know if you change your mind, and I'll get you something to eat."

Which guidelines should the nurse follow when performing narrative documentation? Select all that apply.

1.Date and time entries. 2.Sign and title each entry. 3.Avoid judgmental and evaluative statements. 5.Do not leave blank spaces on documentation forms.

Which identifies accurate nursing documentation notations? Select all that apply.

1.The client slept through the night. 2.Abdominal wound dressing is dry and intact without drainage. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Why should the nurse who is focusing on facilitating positive outcomes regarding health care services become familiar with the cultural beliefs and practices of a childbearing woman?

A culturally diverse woman may have beliefs that impact the delivery of health care services.

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?

Keep the client and her family members informed of her progress.

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?

Kussmaul's respirations

A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, consistently crying, and tries to climb out of the tent. Which is the appropriate nursing action?

Let the mother hold the child and direct a cool mist over the child's face.

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?

The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands.

The nurse is caring for an older adult and knows that an ethical dilemma is most likely to occur in this population because of which issues? Select all that apply.

1.Limited vision 2.Chronic illness 5.Lack of assertiveness

The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse should perform which?

Lower the voice pitch and face the client when speaking.

The nurse is aware that the Americans with Disabilities Act provides which rights? Select all that apply.

1.Labels asymptomatic HIV as a disability 2.Protects the privacy of individuals with HIV 4.Prohibits discrimination in employment and public services

The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the primary health care provider regarding this client's condition? Select all that apply.

1."I am concerned this client has Kawasaki's disease. Can you please come assess this client?" 2."This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days. 4."I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." 5."I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? Select all that apply.

1.Character of drainage 2.Presence of blood clots 3.Amount of drainage emptied 4.Client complaint of pain/spasms 5.Type and amount of irrigation fluid used

The nurse is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply.

1.Pink-tinged frothy sputum 2.Increase in respiratory rate 5.Auscultation of crackles throughout the lungs

The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply.

1.Receiving assurance 2.Receiving information 3.Having support available 4.Remaining near the client

After reviewing the psychosocial implications following a disaster, the nurse is assigned to care for a client who has just witnessed a mass shooting. Upon obtaining subjective information from the client, which actions should the nurse take? Select all that apply.

1.Remain calm and reassuring. 3.Convey caring behaviors towards the client. 4.Establish rapport and actively listen to the client.

A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.

1.Sit by client's bed holding his or her hand. 2.Reminisce with the client and share a humorous story that the client enjoys. 3.The nurse asks: "What can I do, that might make you feel more comfortable today?" 5.The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" 6.The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain."

A 10-year-old child in remission from leukemia is upset over the appearance of cushingoid characteristics from long-term use of corticosteroids that are currently being administered every other day. Which therapeutic statements should the nurse make to the child about the cushingoid appearance? Select all that apply.

2."Which manifestations of this condition do you find most troublesome?" 4. "The signs/symptoms are lessened by taking the prednisone every other day instead of daily." 5. "The cushingoid appearance will gradually disappear once the steroids are tapered and discontinued."

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.

250 mL

The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be appropriate? Select all that apply.

3."You feel like there's nothing else you can do to cure your acne." 5."You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. After the nurse provides information about this procedure, the client states, "I can't urinate in front of other people. I have a 'bashful' kidney." What is the nurse's best response?

"You will be screened and given as much privacy as possible."

A client is experiencing impotence after taking an antihypertensive medication. The client states, "I would sooner have a stroke than keep living with the side effects of this medication." The nurse should make which appropriate response to the client?

"You are concerned about the side effects of your medication?"

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?

"You are concerned that you don't feel any better after surgery?"

A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?

"You feel you are having difficulty fulfilling your role as a wife."

A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which response by the nurse is appropriate?

"You have concerns about the surgical treatment for your condition?"

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue?

The feelings of guilt that is often associated with grief

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?

Encourage the client to discuss her concerns and desires regarding anesthesia options.

The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority?

Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. Which intervention would be appropriate to decrease the client's anxiety?

Convey empathy, trust, and respect toward the client.

In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

Establish a therapeutic relationship between the nurse and pregnant client.

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium. After appropriately charting in the medication administration record, which action should the nurse take?

Make a notation regarding the client's refusal in the nurse's notes.

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?

Maternal vital signs

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area?

Midway between the symphysis pubis and the umbilicus

A client is admitted to the hospital with a diagnosed bowel obstruction secondary to a recurrent diagnosed malignancy. The primary health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which action should the nurse determine is best?

Remain with the client and be silent.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

Support the mother in her reaction to the newborn.

The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement provides the best encouragement?

"Tell me about the delivery of your baby."

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement?

"What do you find difficult about this situation?"

The nurse finds a client tensing while lying in bed staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!" Which is the nurse's best response?

"Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?"

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response?

"You are concerned about losing your leg?"

The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern?

150 beats per minute, moderate variability

A client at 32 weeks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic?

"Tell me about your concerns."

The nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client?

"Tell me more about what happened that causes you to feel like the rape just occurred."

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?

"Tell me what you mean when you say that your baby has moved."

A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate?

"The flowers from your garden are beautiful, but they should not be placed in the child's room at this time."

A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear?

"This aching and cramping are normal and temporary and will subside."

A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which response by the nurse is appropriate?

"Usually, these physical changes slowly improve following treatment."

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

3.Encourage expression of feelings, concerns, and fears. 5.Extend touch, and hold the client or family member's hand if appropriate. 6.Be honest and truthful, and let the client and family know that you will not abandon them.

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?

Encourage the parents to touch their newborn.

When caring for clients, the nurse knows that which ethical philosophies focus on understanding relationships and the use of personal narratives? Select all that apply.

3.Ethics of care 4.Feminist ethics

A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic?

"You're feeling angry that your family is hoping for a cure?"

The nurse knows when preparing the Filipino-American client for a surgical procedure it is important to assess for which culturally relevant influences? Select all that apply.

1.Familial hierarchy 2.Cultural practices 3.Reactions to surgery 4.Pain management plans

The nurse is caring for a new immigrant from the Philippines who is in labor. The client is 4 cm dilated and 30% effaced. This is her first child. The mother is grimacing. Her pulse, respiratory rate, and blood pressure are elevated. The nurse offers to check on a prescription for an epidural. The mother declines. The nurse hypothesizes the client may be declining the epidural for which reasons? Select all that apply.

1.Filipino mothers fear drug addiction. 5.Filipino mothers believe pain is a form of spiritual atonement for one's past deeds.

The nurse is aware that the ethical philosophy of deontology is composed of which "right-making characteristics"? Select all that apply.

1.Justice 3.Truthfulness 5.Fidelity to promises

The nurse is caring for a child who returned from tonsillectomy surgery 30 minutes ago and enters the room for routine monitoring to see the child repeatedly and rapidly swallowing. Using the SBAR (Situation, Background, Assessment, Recommendation) technique, which statements and/or questions should the nurse include in the conversation with the primary health care provider? Select all that apply.

3."Could you please come assess the child as soon as possible?" 4."I am concerned that the child is bleeding from the surgical sites." 5."Two minutes ago, I entered the child's room for routine monitoring and observed that she was swallowing repeatedly and rapidly." 6."Hello, this is Maria on the third floor. I am the nurse caring for Ella Smith, the 6-year-old child in room 342 who returned 30 minutes ago from a tonsillectomy."

Which actions should be performed when communicating with a client with presbycusis? Select all that apply.

2.Speak slowly and distinctly. 3.Face client when speaking 5.Use short sentences and phrases.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?

"You're feeling angry that your family continues to hope for you to be 'cured'?"