Communication
A nurse observes a second nurse making social plans with a client and disclosing information of a personal nature, including financial situation. What should the first nurse do in this situation? a) Report the observation to the nurse manager. b) Discuss the observation directly with the nurse. c) Encourage interaction between the client and the nurse. d) Tell the client not to meet with the nurse.
B. Discuss the observation directly with the nurse. Planning to meet a client socially and disclosing personal information could blur the boundaries of the therapeutic relationship, which may result in an unhealthy outcome for the client. The nurse should take the second nurse aside and point out that this behavior is inappropriate and not in the client's best interest. The other options are not correct because they do not address the behavior properly, nor do they protect the best interests of the client.
A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never been this sick before. Which of the following should be the most helpful statement to make to the daughter? a) "We can help you learn how to take care of her after she is discharged." b) "It helps if you avoid arguing when she talks about seeing people who aren't there." c) "The doctor will order tests to find out what is causing her condition." d) "Please don't worry. We will take good care of your mother."
C. "The doctor will order tests to find out what is causing her condition." It is important for the daughter to know that there is an underlying cause for what her mother is experiencing and that it is treatable. Telling her not to worry is a useless cliché and does nothing to inform the daughter. Talking about care after discharge implies that the delirium is irreversible. Delirium is a reversible condition. Although not arguing with hallucinations is valid, this response ignores the daughter's concern.
What are important nursing responsibilities when a referral to other health team members has been made for a client? a) Recommending that each member read the history and nurse's notes to understand the client's progress b) Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living c) Ensuring that the physician reports the level of functioning of the client d) Recommending that each health team member independently completes his or her own assessment and then consults with each other
B. Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.
The mother of a client with schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I don't know what's wrong. I'm worried." Which of the following responses by the nurse is most appropriate? a) "Go over to her apartment and see what's going on." b) "Don't worry about this. It happens sometimes." c) "She may have stopped taking her medications. I'll check on her." d) "Maybe she's just mad at you. Did you have an argument?"
C. "She may have stopped taking her medications. I'll check on her." Noncompliance with medications is common in the client with schizophrenia. The nurse has the responsibility to assess this situation. Asking the mother if they've argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what's going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client's symptoms.
The parent of a preschool-age child tells the nurse that the child is hyperactive and something needs to be done. Which of the following responses by the nurse would be most appropriate initially? a) "What do you think needs to be done ?" b) "Why not wait and see what the doctor says?" c) "How does your child behave normally?" d) "What makes you think your child is hyperactive?"
D. "What makes you think your child is hyperactive?" The best approach by the nurse is to determine why the parent thinks the child is hyperactive. Some children are very active but do not have the necessary defining characteristics of hyperactivity. Asking what the parent thinks needs to be done or how the child behaves normally would be an appropriate follow-up question once more information is gathered from the parent to determine whether the child indeed is hyperactive. Telling the parent to wait for the physician ignores the parent's concern and does not deal with the parent's issue.
A young man makes an appointment to see the psychiatric nurse at the Employee Assistance Program of a large corporation because his female boss is sending him provocative e-mails, and making seductive remarks on his voice mail at home. The nurse informs him about Corporate Workplace Violence Guidelines and he agrees to work with Corporate Security on the issue. What should the nurse do next? a) Report the incident to the client's coworkers who are at risk for similar harassment. b) Suggest the client contact Human Resources to request a job transfer. c) Refer the client to his boss's supervisor to file a report. d) Ask the client about his reactions to this situation.
D. Ask the client about his reactions to this situation. It is important to know the client's reactions in order to plan appropriate interventions. Until the client's reactions are known, it is premature to suggest a job transfer, file a report to his boss' supervisor, or alert his coworkers.
Which of the following activities should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? a) Keeping track of feelings in a journal. b) Reading a magazine. c) Playing a card game with other clients. d) Talking with the nurse.
D. Talking with the nurse Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, reading, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.
A client asks the nurse why the prostate specific antigen (PSA) level is determined before the digital rectal examination. The nurse's best response is which of the following? a) "A prostate examination can possibly increase the PSA." b) "If the PSA is normal, the client will not have to undergo the rectal examination." c) "A prostate examination can possibly decrease the PSA." d) "It is easier for the client."
A. "A prostate examination can possibly increase the PSA." Manipulation of the prostate during the digital rectal examination may falsely increase the PSA levels. The PSA determination and the digital rectal examination are both necessary as screening tools for prostate cancer, and both are recommended for all men older than age 50. Prostate cancer is the most common cancer in men and the second leading killer from cancer among men in the United States and Canada. Incidence increases sharply with age, and the disease is predominant in the 60- to 70-year-old age-group.
A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information? a) 1 bottle of glucose. b) 1 Unit of glucose. c) 1U of glucose. d) One U of glucose.
B. 1 Unit of glucose. The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the Joint Commission "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit," instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dl (16.65 mmol/l). The nurse should: a) Administer the insulin dose dictated by the sliding scale. b) Withhold all medications as ordered. c) Call the physician for specific orders based on the glucose level. d) Notify the surgery department.
C. Call the physician for specific orders based on the glucose level The nurse should notify the physician directly for specific orders based on the client's glucose level. The nurse cannot ignore the elevated glucose level. The surgical experience is stressful and the client needs specific insulin coverage during the perioperative period. The nurse should not administer the insulin without checking with the surgeon because there are specific orders to withhold all medications. It is not necessary to notify the surgery department unless the physician cancels the surgery.
A nurse is preparing a health promotion program for teenagers focusing on lifestyle choices. Which of the following methods used by the nurse will best ensure the success of the program? a) Disclosing and explaining personal lifestyle choices b) Reviewing data about common teenage lifestyle choices c) Creating a safe environment for sharing information d) Validating the current lifestyle choices of the teenagers
C. Creating a safe environment for sharing information Creating an environment where the teenagers feel safe to share their information leads to therapeutic communication that is client focused. This helps to establish trust, which facilitates a more successful program. The other options block the ability of the teenagers to share their thoughts and feelings openly.
A pregnant client is seeking information from the nurse about a home birth with registered midwives. Which of the following statements lets the nurse know that the client has considered the risks and benefits of using a midwife? Select all that apply. a) "I realize that I may need to be transferred to a hospital if complications develop." b) "I am safer having a home birth with a physician." c) "I will look for an obstetrician because it's hard to find a general practitioner who provides maternity services." d) "I understand the complications that could occur in a home birth setting." e) "I will develop a list of questions to use in interviewing potential midwives."
A. "I realize that I may need to be transferred to a hospital if complications develop." D. "I understand the complications that could occur in a home birth setting." E. "I will develop a list of questions to use in interviewing potential midwives." Developing a list of questions, understanding the complications that could occur with a home birth, and realizing that a transfer to a hospital might be necessary all demonstrate that the client has researched a home birth and is aware of the positive and negative factors that could occur. These choices show that the client is approaching the situation in a realistic and educated manner. Looking for an obstetrician and stating that a home birth is safer with a physician are not appropriate answers.
A charge nurse is making shift assignments when a staff nurse requests to not be assigned to a particular child because of the quantity of time the child requires. The charge nurse knows that the child and family have bonded with the staff nurse. What should the charge nurse do next? a) Talk with the staff nurse about the assignment and the concerns voiced. b) Promise the unit nurse additional help. c) Assign the child's care to the staff nurse anyway. d) Acknowledge the staff nurse's request and assign the child's care to another nurse.
A. Talk with the staff nurse about the assignment and the concerns voiced It is the charge nurse's responsibility to make clinical assignments based on safety and client needs. Talking about the reasons for not wanting to care for the child may enable the unit nurse to recognize her duty to the child and to the unit. Continuity of care is in the child's best interest. A nurse should never promise to perform a duty or action; negative feelings will result if the nurse can't keep the promise. Unless there is a valid reason to assign the child's care to another nurse, the charge nurse should talk with the unit nurse before making the assignment.
A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which of the following is the best action for the first nurse to take? a) Encourage the interaction with the client after discharge. b) Discuss the conversation directly with the other nurse. c) Tell the client not to meet the nurse socially. d) Report the conversation to the nurse manager.
B. Discuss the conversation directly with the other nurse Planning to meet a client for a social event while the client is still hospitalized could blur the boundaries of the therapeutic relationship. This could result in an unhealthy outcome for the client. The nurse should take the second nurse aside and point out that the behavior is inappropriate and not in the client's best interest. The other options do not demonstrate behavior that is consistent with the therapeutic nurse-client relationship.
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? a) Focus charting. b) Narrative notes. c) SOAP notes. d) Charting by exception.
B. Narrative notes. One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.
An adult is dying from metastatic lung cancer, and all treatments have been discontinued. The client's breathing pattern is labored, with gurgling sounds. The client's spouse asks the nurse, "Can't you do something to help with the breathing?" Which of the following is the nurse's best response in this situation? a) Suction the client so that the client's wife knows all interventions were performed. b) Reposition the client, elevate the head of the bed, and provide a cool compress. c) Direct the unlicensed personnel to assess the client's vital signs and provide oral care. d) Explain to the spouse that it is standard practice not to suction clients when treatments have been discontinued.
B. Reposition the client, elevate the head of the bed, and provide a cool compress. Repositioning the client, elevating the head of the bed, and providing a cool compress are comfort interventions consistent with the concept of palliative care of the dying. Directing the unlicensed personnel to assess vital signs focuses on the dying process, not the client. Suctioning may not benefit the client and is considered invasive and uncomfortable. Telling the spouse an intervention is not needed discounts the spouse's judgment and concerns.
A nurse observes a second nurse documenting a peripheral blood glucose level that the second nurse did not actually collect from a client with diabetes. What is the priority action by the nurse observing this situation? a) Strike through the entry that the nurse documented. b) Document the nurse's behavior on the client's chart. c) Do the blood glucose level on the client for the other nurse. d) Discuss the observation with the other nurse.
D. Discuss the observation with the other nurse. The first action the nurse should take is to discuss what was witnessed with the other nurse and express concern that this behavior is unethical, unprofessional, and illegal. The nurse manager should be notified in order to follow up with the nurse. Documenting assessments that were not actually done on a legal document is illegal and constitutes professional misconduct. The other options do not reflect safe and competent care, nor do they protect the client.
A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation? a) "Your verbal threats to the client are legally considered assault." b) "I think you need to review therapeutic communication techniques." c) "Could you clarify for me whether you were joking with the client?" d) "I will have to report you for unprofessional behavior toward a client."
A. "Your verbal threats to the client are legally considered assault." Assault is conduct that makes a person fearful and produces a reasonable apprehension of harm. The nurse's behavior in legal terms is assault.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a) A graphic sheet. b) 24-hour fluid balance record. c) Medication record. d) Acuity charting forms.
A. A graphic sheet. A graphic sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to their conditions and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.
The nurse is caring for an 8-year-old child with a life-threatening illness. The parents do not speak the native language and want the child discharged so they can pursue alternative therapies that they believe will be less expensive. What is the most important action by the nurse to help the family and the child? a) Arrange to have a translator present when talking with the parents. b) Notify the physician that treatment will no longer be necessary. c) Contact a priest to administer last rites to the child. d) Have a social worker help the family with the financial burden.
A. Arrange to have a translator present when talking with the parents. A translator is an immediate priority. No effective health teaching or social intervention will be effective until there is an established means of communication with the family.
The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse? a) Ask the family to identify a spokesperson to be the communicator with the team. b) Inform team members that only the parents should receive information. c) Review policies to see who should be informed of the child's treatment plans. d) Ask team members to share information with the nurse instead of the family.
A. Ask the family to identify a spokesperson to be the communicator with the team. In situations with large extended families where frequent updates are required or the state of the child is critical, it is imperative that a spokesperson be identified for receiving information and for disseminating the information to the extended family members.
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By supplying a magic slate or similar device b) By suctioning the client frequently c) By providing a tracheostomy plug to use for verbal communication d) By placing the call button under the client's pillow
A. By supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.
A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a) Gauging the nurse's professional performance over time. b) Following up the incident with other members of the care team. c) Identifying risks and ensuring future safety for clients. d) Protecting the nurse and the hospital from litigation.
C. Identifying risks and ensuring future safety for clients Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.
The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse? a) Seek to promote homogeneity and common views rather than focus on differences. b) Seek input from all groups and strive for consensus on what would benefit most or all of these people. c) Support the implementation of the ideas of the majority. d) Make decisions based on findings from the community assessment.
B. Seek input from all groups and strive for consensus on what would benefit most or all of these people The responsibility is to conduct the community assessment and to identify the key needs. All members need to have representation in this process. It is best to strive for consensus on what the key issues are and to implement programs that would benefit most of the people, rather than responding to one interest group. Listening to the majority viewpoint or helping everyone to change their views and have homogeneity would not be effective. Decisions based on the community alone are also not an appropriate answer.
A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 101.1 F (38.4° C); pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive: a) Promethazine IM. b) Meperidine IM. c) Hydromorphone IV. d) Diltiazem PO.
C. Hydromorphone IV. Hydromorphone should be considered for pain management. It should be administered intravenously for rapid action to address the severe pain the client is experiencing. Intramuscular injections are painful and slower acting. Since meperidine's toxic metabolite can cause seizures, it is no longer the treatment choice for pain. Diltiazem, a calcium channel blocker, is not indicated. Elevation of heart rate and blood pressure are likely due to pain and fever. Promethazine is used to treat nausea.
A 7-year-old child is brought to the clinic by a parent for a school physical. When the child is prepared for examination, which of the following interventions should the nurse provide to ensure the the child's comfort? a) Distract the child with bright colors b) Have the child take off all of their clothing and put on a client gown c) Offer the option of the parent staying or remaining in the waiting room d) Explain the purpose of the equipment being used during the examination
D. Explain the purpose of the equipment being used during the examination At this age in the early school-age years, the child is still comfortable with a parent's presence in the examination room and is not generally given the option. It is important for the child's comfort and to decrease anxiety to explain the use of each piece of equipment prior to using it. During the school-age years, the child should be allowed to keep their underpants on along with the gown. Gaining distraction with bright objects would be used for an infant.
A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response? a) Ask the client if calling the family would be helpful. b) Assure the client that everything will work out fine. c) Approach the client and ask if there are questions about the condition. d) Explain that the condition is complicated and ask a physician to come speak with the client.
C. Approach the client and ask if there are questions about the condition. This is the best therapeutic response that is client focused. The other answers do not demonstrate therapeutic response: nurses should not offer false assurances, and calling the family is not addressing the problem between nurse and client.
A nurse working in a community clinic is discussing lifestyle modifications with a client. The client has been advised to lose weight because of a BMI greater than 25. Which of the following statements by the nurse would be most therapeutic in helping the client? a) "Just skipping your between-meal snacking is the solution." b) "I can offer you some information outlining a variety of ways to lose weight." c) "There are herbal preparations for weight loss that are very effective." d) "I know it is hard. I needed to lose weight last year, too."
B. "I can offer you some information outlining a variety of ways to lose weight." The therapeutic response should put the client in the position to make an individual choice. The nurse should offer options to allow for choice. The other options are incorrect because they either place the emphasis back on the nurse rather than on the client or they provide a solution that the nurse feels is best without allowing the client to make the choice.
A client needs to be transferred to the oncology unit for further care. Which of the following information is necessary to include in the transfer report? a) Results of laboratory tests. b) Current client assessment. c) Client's admission number. d) Nursing treatment initiated.
B. Current client assessment The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report.
The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next? a) Ask the pharmacist for a list of preoperative medications for the client. b) Contact the surgeon for clarification because this is not a complete order. c) Obtain new orders for the client from the physician on call. d) Transcribe the preoperative medication orders the surgeon has ordered.
B. Contact the surgeon for clarification because this is not a complete order After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.
A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation? a) Notify security that the visitor viewed confidential client information. b) Inform the other nurse that the viewed screen resulted in a breach of confidentiality. c) Validate the relationship of the visitor to the client before discussing the client's status. d) Confirm that the client is on the unit but offer no further details.
B. Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Nurses must protect the privacy of all client information, and this includes information on an electronic medical record. The computer screen at the nurses' station should not be in view of anyone other than the person accessing the record. The other answers are incorrect because they breach client confidentiality.
When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, she realizes the client doesn't fully understand the surgery. She approaches the physician, who curtly says, "I've told him all about it. Just get the consent." The nurse should: a) ask the charge nurse to talk with the physician. b) explain the procedure more fully to the client and obtain his signature. c) tell the physician he didn't give the client enough information. d) tell the physician the client isn't comfortable consenting to surgery at this point.
D. tell the physician the client isn't comfortable consenting to surgery at this point The nurse has evaluated the client's knowledge concerning the surgery and determined that he doesn't have enough information to give informed consent. Even though the physician might want to move ahead, the nurse should advocate for the client by telling the physician the client isn't ready for the surgery. Telling the physician that he hasn't given the client enough information would be rude. The nurse shouldn't ask the charge nurse to talk with the physician unless the physician refuses to accept the nurse's professional opinion. Explaining surgery for the purpose of obtaining consent is beyond the nurse's scope of practice.
Despite education and role-play practice of restraint procedures, a staff member is injured when actually restraining a client. When helping the uninjured staff deal with the incident, the nurse should address which of the following about the injured member? a) Legal action against the client will take time and energy. b) The member must debrief with the assaultive client before returning. c) The member is likely to resign after experiencing such an injury. d) The emotional responses may be similar to those of other crime victims.
D. The emotional responses may be similar to those of other crime victims Being injured by a client can result in emotional responses similar to those of other crime victims. A resignation after being injured is relatively rare. Legal action against the client is sometimes discussed but rarely initiated. Debriefing with the client may be inappropriate or unnecessary to resolve the situation.
A nurse hears a staff member giving incorrect information to the family of a client newly diagnosed with diabetes mellitus who is being discharged to home. The nurse wants to make sure the family has the proper information before the client is discharged. What should she do? a) Have the nurse step outside of the room and tell her she's giving wrong information to the family. b) Go into the room, introduce herself to the family, and complete the discharge teaching. c) Have the nurse step outside of the room, discuss the situation, and use it as a learning opportunity. d) Go into the room and correct the nurse so the family will be safe in providing home care.
C. Have the nurse step outside of the room, discuss the situation, and use it as a learning opportunity The nurse should use this situation as a learning opportunity for her colleague by asking her to step outside of the room to discuss the situation. Telling the nurse that she's providing incorrect information is too blunt and corrective. Going into the room to correct the teaching would undermine the nurse doing the teaching.
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message: "You are not authorized to view this information." What is the reason for this message? a) The laboratory assistant does not have the correct access number. b) The laboratory assistant is trying to view archived data. c) The laboratory assistant does not have the correct password. d) The laboratory assistant can retrieve medical records but cannot view the details.
D. The laboratory assistant can retrieve medical records but cannot view the details It is important to block the type of information that personnel in various departments can retrieve. Laboratory assistants can retrieve information from the medical records, but they cannot view information in the client's personal history. Even if the laboratory assistant had the correct access number and the password or was trying to view archived data, he or she would not have been able to access a client's personal history.
