Foundations Exam 1 Chapter 20 PrepU
A nurse touches the client's hand while discussing his diagnosis. This action is a(an): dynamic process. translation. communication channel. auditory channel.
communication channel.
Paramedics arrive in the emergency department with a victim of a motor vehicle collision. The paramedic reports the driver was restrained, the car was traveling about 30 miles per hour (48 Km/hour) , and the air bags were not deployed. The paramedic continues to report the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic? "Were there any fatalities in the other vehicle?" "All of the victims got themselves out of the car?" "Did a police officer take a report at the accident scene?" "Was there any cracking of the windshield?"
"All of the victims got themselves out of the car?"
A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic? "Why don't you try laser surgery?" "Have you ever thought of laser surgery?" "You should try laser surgery." "My grandfather also benefited from laser surgery."
"Have you ever thought of laser surgery?"
A nurse caring for a client who was recently diagnosed with metastatic lung cancer finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy? "I see you are upset. Would you like to talk?" "I am sorry to hear you have cancer." "Don't worry, I have seen lots of people with cancer do fine." "Do you want me to call someone for you?"
"I see you are upset. Would you like to talk?"
A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication? "Why are you treating me this way?" "I think there is a better way to handle this." "You always act like this." "What is your problem with me?"
"I think there is a better way to handle this."
A graduate nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the graduate nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to: call hospital security and ask them to take a report. ask to speak to the night shift nurse in private and explain how the comment made her feel. ignore the comment and begin her shift. approach the night shift nurse and tell her that she is "out of line."
"I understand you have four kids; how many times have you actually been pregnant?"
A client is reluctant to undergo surgery and is discussing it with the nurse. Which response by the nurse would reflect an authoritarian approach? "Surgery is your only option. You need this operation." "If you don't have the surgery you may not live. Your family needs you." "It's your choice about the surgery. What do you understand about the situation?" "Your grandchildren would be very upset if they lost their grandfather."
"Surgery is your only option. You need this operation."
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client? "I will be by your side throughout the procedure; the procedure will be painless if you don't move." "The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position." "You may feel very uncomfortable when the needle goes in, but you should breathe rhythmically." "The procedure may take only 2 minutes, so you might get through it by mentally counting up to 120."
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."
The nurse faculty is observing a student nurse gather data from a client. Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions? "Why did the health care provider prescribe this medication for you?" "When was the last time you had your prescription refilled?" "How many tablets do you take at one time?" "How often do you take this medication?"
"Why did the health care provider prescribe this medication for you?"
A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse? "Don't worry about labor, I have been through it and it is not so bad." "There are many good medications to decrease the pain; it will not be so bad." "I would recommend keeping a positive attitude." "You're worried about how you will tolerate the pain associated with labor."
"You're worried about how you will tolerate the pain associated with labor."
In which of the following situations would the SBAR technique of communication be most appropriate? A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure. A nurse is calling a physician to report a client's new onset of chest pain. A nurse is facilitating a family meeting in order to coordinate a client's discharge planning. A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke.
A nurse is calling a physician to report a client's new onset of chest pain.
Which of the following nurses most likely is the best communicator? A nurse who is proficient in sign language. An advanced practice nurse. A nurse who easily developed a rapport with clients. A nurse who is bilingual.
A nurse who easily developed a rapport with clients.
A nurse is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate to delegate to the LPN/LVN? (Select all that apply.) Reinforce a post-surgical abdominal dressing. Change an intravenous catheter for a client with an infiltrated IV. Teach a client with diabetes how to administer insulin/ Administer oral aspirin and lisinopril to the client with hypertension. Insert a nasogastric tube in a client with absent bowel sounds.
Administer oral aspirin and lisinopril to the client with hypertension. Insert a nasogastric tube in a client with absent bowel sounds. Reinforce a post-surgical abdominal dressing.
The nurse interviews a client during which step of the nursing process? Planning Evaluation Assessment Diagnosing
Assessment
A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response? Nod and say, "I agree. If I were you, I would get a new doctor." Smile and say, "Don't worry, I am sure the physician is doing a good job." Be silent and allow the client to continue speaking when ready. Stand and say, "I can see this interview is making you uncomfortable, so we can continue later."
Be silent and allow the client to continue speaking when ready.
A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply. "That's a lot of information to take in. Would you like to talk about it?" "Everything will be all right." "Cheer up. Tomorrow is another day." "Don't worry. You will be just fine in another day or two." "Your doctor knows best."
Cheer up. Tomorrow is another day." "Your doctor knows best." "Don't worry. You will be just fine in another day or two." "Everything will be all right."
A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation? Sympathy Pity Empathy Indifference
Empathy
Which qualities in a nurse help the nurse to become effective in providing for a client's needs while remaining compassionately detached? Sympathy Commiseration Empathy Kindness
Empathy
The nurse is visiting a hospice client in his home. He is explaining the difficulties he is having with his home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is utilizing which therapeutic nurse-client communication technique? Restating Reflection Clarification Encouraging elaboration
Encouraging elaboration
Which example would be considered nonverbal communication? Select all that apply. SBAR Brochure Facial expression Eye contact Tone of voice
Eye contact Facial expression Tone of voice
When assessing a client's nonverbal communication, the nurse will assess which characteristic as the most expressive part of the body? Facial expressions Posture Eye contact Hand gestures
Facial expressions
A nurse gives a speech on nutrition to a group of pregnant women. What is the speech itself known as? Channel Message Source Stimulus
Message
A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques? Reflective question Validating question Closed question Open-ended question
Open-ended question
A nurse enters the client's room and introduces himself stating, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and I will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." He then gives the client a printed card with this information. In the helping relationship, what does this represent? Orientation phase Working phase Termination phase Intimate phase
Orientation phase
The nursing instructor is discussing communication with a student. The student identifies that a contract is made with the client during which phase of the nurse-client relationship? Working phase Intimate phase Termination phase Orientation phase
Orientation phase
A nurse working with an experienced licensed practical/vocational nurse (LPN/LVN) delegates the task of administering oral medications to a team of clients. The nurse observes the LPN/LVN document a client's medication administration before entering the client's room. What is the most appropriate action of the nurse? Continue to supervise the LPN/LVN as medications are being administered. Contact the nurse manager to discuss the actions of the LPN/LVN. Check all client's medication records to make sure the appropriate drugs were given. Stop the LPN/LVN immediately and discuss the possible consequences of this action.
Stop the LPN/LVN immediately and discuss the possible consequences of this action.
A nurse who is caring for newborn infants delivers care by utilizing the sense that is most highly developed at birth. Which example of nursing care achieves this goal? The nurse wears colorful clothing to stimulate the infant. The nurse plays "peek-a-boo" with the infant. The nurse speaks to the infant in a loud voice to get attention. The nurse gently strokes the baby's cheek to facilitate breastfeeding.
The nurse gently strokes the baby's cheek to facilitate breastfeeding.
A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. The nurse gives lengthy explanations of the care that will be given. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete. The nurse maintains eye contact with the client. The nurse communicates in a busy environment to hold the client's attention. If there is no response, the nurse does not repeat what is said and takes a break.
The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.
Which factor is most important in the development of rapport between nurse and client? Happiness Skill Kindness Trust
Trust
Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? Orientation phase Evaluation phase Termination phase Working phase
Working phase
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. assertive. nurturing. passive.
aggressive.
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: direct the client in the other bed to walk in the hallway. ask all visitors to leave the room. pull the curtain dividing the two beds, maintain eye contact, and speak in a low, audible voice. bring the client into the hallway to discuss the treatment plan.
aggressive.
Each of the following facilitates a therapeutic nurse-client relationship except: reflection. closed-ended questions. rephrasing. active listening.
closed-ended questions.
An experienced nurse is orienting a new nurse to the unit. The experienced nurse tells the new nurse that to be an effective caregiver, the new nurse needs to: attempt to obtain a specialty certification. read client medical records thoroughly. spend as much time as possible with clients. develop good communication skills.
develop good communication skills.
A pregnant female client presents to the emergency department with vaginal bleeding. A transvaginal ultrasound is performed and the health care provider informs the client that there are normal fetal heart tones noted on the study. When the nurse observes the client's facial expression, she is: implementing the plan of care. gathering information necessary to treat the client. evaluating the client's nonverbal response to the findings. identifying desired outcomes and a plan to meet them.
evaluating the client's nonverbal response to the findings.
The client is an 18-month-old in the pediatric intensive care unit. He is scheduled to have a subgaleal shunt placed tomorrow, and his mother is quite nervous about the procedure. The nurse feels for the mother and tells her that the surgeon "has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication? false reassurance rescue feelings being moralistic giving advice
false reassurance
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 information giving false reassurance seeking clarification encouraging elaboration
giving false reassurance
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: pick a team leader who is not the dominant member. have group members issue a written warning to the dominant member. plan a meeting where the dominant person cannot attend. have group members confront the dominant member to promote the needed team work.
have group members confront the dominant member to promote the needed team work.
A nurse communicating with a client states, "I will be changing your dressing, but we have plenty of time to talk first." She is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying a (an) functional focus. incongruent relationship. congruent relationship. therapeutic relationship.
incongruent relationship.
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: provide both verbal and written information to the child. involve the child's stuffed animal in the educational session. show the child the intravenous catheter and explain how it works. ask the child's parents to leave the room while the nurse and child talk.
involve the child's stuffed animal in the educational session.
A nurse is caring for a client who suffered a head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's mother is at the bedside in tears. The mother states, "I just want him to know I am here with him." To address the needs of the mother and the client, the nurse should: place his hand on the mother's shoulder and reassure the mother that things will be fine. encourage the mother to bring in pictures of the family that can be displayed in the room. place a chair next to the bed and encourage the mother to hold the son's hand. leave the room and allow the mother to grieve.
place a chair next to the bed and encourage the mother to hold the son's hand.
A nurse is caring for a client who suffered a spinal cord injury and has paraplegia. The client is frustrated, crying, and tells the nurse, "I just want to die." The nurse best displays empathy when she: places a warm blanket over the client's legs. says, "I am so sorry this happened to you." leaves the room quietly and silently. says, "I can only imagine how hard this is on you. How can I help you?"
says, "I can only imagine how hard this is on you. How can I help you?"
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 client. holds the medical record while sitting at the bedside and crossing the legs. asks all visitors to leave the room. stands at the foot of the bed and maintains constant eye contact.
sits at the client's bedside and faces the client.
A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: softly humming a song near the neonate. swaddling the child and gently stroking its head. staring into the neonate's eyes and smiling. offering the neonate infant formula.
swaddling the child and gently stroking its head.
What quality do clients most value in nurses? Trustworthiness Efficiency Educational level Technical skill
trustworthiness
The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? (Select all that apply.) "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "What sorts of things do you do for fun?" "Are you ready to get out of bed?" "Does it hurt when I touch you here?" "What plans do you have after you are discharged?"
"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"
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? "You should relax and take deep breaths; the procedure is very minimal and will be over soon." "It will be a painless procedure and there is nothing to worry about; many clients experience this." "I know that you are anxious, but removal will be painless and the IV location needs to be changed." "The infiltration is causing you pain and you will be relieved when I remove the IV line."
"I know that you are anxious, but removal will be painless and the IV location needs to be
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? "Were these term births?" "How old are your children?" "All right, you have four children, is that correct?" "I understand you have four kids; how many times have you actually been pregnant?"
"I understand you have four kids; how many times have you actually been pregnant?"
A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack. What should be the nurse's reply? "The physician wants to monitor you and control your pain." "Yes, you had a heart attack; this is why you are here with us." "Yes, you had a heart attack, but the damage is very minimal." "No; we can assure you that you will not have a heart attack."
"The physician wants to monitor you and control your pain."
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: "Sounds as if your surgery is a pretty scary procedure." "You have a great surgeon. You have nothing to worry about." "You shouldn't be nervous. We perform this procedure every day." "The thought of having surgery is keeping you awake."
"The thought of having surgery is keeping you awake."
A client with a cardiac dysrhythmia was recently prescribed metoprolol 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?" "Do you check your blood pressure and pulse before you take your medication?" "Have you tried exercising at all in the last week or two?" "Tell me about the foods you are eating."
"Were you tired and depressed before starting the new medication?"
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?" "Is your name Evelyn?" "Is today the first day of the month?" "Are you in a hospital?"
"What day of the week is it?"
A client has just learned that she has Stage 2 breast cancer. She appears distant and withdrawn. Her shoulders are slumped. She explains "I just never thought this could happen to me." Which answer best describes the client's response? Incongruent communication Nonverbal communication Verbal communication Congruent communication
Congruent communication
Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. What is an example of the proper use of social media by a nurse? A nurse describes a patient on Twitter by giving the patient's diagnosis rather than the patient's name. A nurse posts pictures of a patient who accomplished a goal of losing 100 pounds and later deletes the photo. A nurse uses a disclaimer to verify that any views expressed on Facebook are his or hers alone and not the employer's. A nurse describes a patient on Twitter by giving the room number rather than the name of the patient.
A nurse uses a disclaimer to verify that any views expressed on Facebook are his or hers alone and not the employer's.
A nurse is performing an admission assessment with a non-English speaking client. Which actions can the nurse take to enhance communication? (Select all that apply.) Use an electronic translator. Ask the client's teenage daughter to interpret. Request assistance from an agency interpreter. Contact a telephone-based medical interpreter. Use gestures and pictures to convey information.
Use an electronic translator. Contact a telephone-based medical interpreter. Request assistance from an agency interpreter.
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 does not actively listen to the client. The nurse will tell the patient that teaching is not important. The nurse will be sensitive to the patient's emotional barriers. The nurse is not concerned with the patient's pain.
The nurse will be sensitive to the patient's emotional barriers.
A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should: ask questions as quickly as possible. tell the client to rest and allow a family member to answer. allow the client to set the pace. use only open-ended questions.
allow the client to set the pace.
A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult: an ophthamologist. an audiologist. a clinical psychologist. an optometrist.
an audiologist.
A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's 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 client to explain the statement. smile at the client and apologize. ignore the statement and empty the urinary catheter. inform the client that the unit was very busy that day.
sit at the bedside and allow the client to explain the statement.
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?" "Do you have and advanced directive or a living will?" "Are you allergic to any medications?" "Can you tell me the medications you take on a daily basis?"
"Can you tell me why your physician sent you here to be admitted?"
A nurse is caring for an older adult client who has just died in a hospice unit. The child of the client arrives and asks, "Can I please stay and sit at the bedside? I really wanted to be here so they did not die alone." Which statement made by the nurse best demonstrates the use of empathy? "I tried to contact you earlier, but you did not answer your phone." "I will close the door so you can spend some quiet time at the bedside." "You are too late for that, but you can stay for a while if you would like." "I understand, I lost my dad last year and he died alone."
"I will close the door so you can spend some quiet time at the bedside."
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? "Why do you think that the care team has made this recommendation?" "Do you understand that everyone here has your husband's best interest at heart?" "This must be very difficult for you to hear. How do you feel right now?" "What would help you accept that this is best for both of you?"
"This must be very difficult for you to hear. How do you feel right now?"
The nurse is conducting an assessment on a client and identifies a need for an interpreter. Which of the following is the best choice for an interpreter?" A family member A friend who speaks both languages A fellow nurse who knows a few words of Spanish A professional interpreter
A professional interpreter
Mrs. Miller is a 60-year-old woman status post a hip replacement. She has had multiple complications following surgery including a skin infection and a blood clot. As a result, she has been a client on the unit for 6 weeks. The nurse has just returned from vacation and this is her first day caring for Mrs. Miller. A colleagues looks at the nurse and describes Mrs. Miller as "quite difficult to deal with." The nurse knows that all of the following can contribute to difficult behaviors except:
A quiet room
A nurse is planning care for an adult client with severe hearing impairment and a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care? Consult the oncology nurse specialist. Use text-telephone device (TTD) for daily communication. Arrange for an interpreter when discussing treatment. Talk with the client's children to determine needs.
Arrange for an interpreter when discussing treatment.
A student nurse is attempting to improve her communication skills. Which therapeutic communication skill is appropriate? Be precise and inflexible regarding the intent of the conversation. Use cliches to enhance a client's understanding of information. Avoid the use of periods of silence. Control the tone of the voice to avoid hidden messages.
Control the tone of the voice to avoid hidden messages.
The nurse is visiting a hospice client in his home. He is explaining the difficulties he is having with his home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is utilizing which therapeutic nurse-client communication technique? Restating Encouraging elaboration Clarification Reflection
Encouraging elaboration
A nurse is engaged in a nurse-client relationship. Which communication techniques would be important for the nurse to avoid? Select all that apply. Summarizing Silence Exploring False reassurance Giving advice
False reassurance Giving advice
A dialysis nurse is educating a client on caring for the dialysis access that was inserted into 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. Which phase of the working relationship is best described in this scenario? The introduction phase The orientation phase The termination phase The working phase
The working phase
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: ask the charge nurse to change her assignment. tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound. tell herself to "remain calm" and remember that she was trained to perform this skill. inform the client that several nurses will be needed to care for this wound.
tell herself to "remain calm" and remember that she was trained to perform this skill.