Fundies- Unit 1

The nurse who uses appropriate therapeutic listening skills will display which behaviors? Select all that apply. A. Absorb both the content and the feeling the client is conveying B. Presume an understanding of the client needs C. Adopt an open professional posture D. React quickly to the message E. Reassure the client that everything will be fine

A. Absorb both the content and the feeling the client is conveying C. Adopt an open professional posture

The case management model using critical pathways would be appropriate for a client with which diagnosis? A. Myocardial infarction (heart attack) B. Diabetes, hypertension C. Myocardial infarction, diabetes, hypertension D. Diabetes, hypertension, an infected foot ulcer, senile dementia

A. Myocardial infarction (heart attack) --Critical pathways work best for patients with one diagnosis

The client's VS are WNL. He has BRP and he receives his pain pill PRN. His nutrition is DAT. Interpret the commonly used abbreviations: A. NKA B. BRP C. PRN D. DAT

A. No Known Allergies B. Bathroom privileges C. When necessary D. Diet as tolerated

A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse represents effective nursing practice? Select all that apply. A. Provides the medical diagnosis or reason for admission B. States the time the client last received pain medication C. Speaks loudly when giving report D. States priorities of care that are due shortly after the report E. Reports on number of visitors for each client

A. Provides the medical diagnosis or reason for admission B. States the time the client last received pain medication D. States priorities of care that are due shortly after the report

The nurse asks the client, "What do you fear most about your surgery tomorrow?" This is an example of which communication technique? A. Providing general leads B. Seeking clarification C. Presenting reality D. Summarizing

A. Providing general leads

A nurse tells a client who is struggling with cancer pain, "It is normal to feel frustrated about the discomfort." Which is most representative of the skills associated with the working phase of the helping relationship? A. Respect B. Genuineness C. Concreteness D. Confrontation

A. Respect

A 74-year old female is brought to the ER c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client's inner thighs. Which of the following is the most appropriate documentation? A. Six round skin lesions partially healed, on the inner thighs bilaterally B. Several burned areas on both of the client's inner thighs C. Multiple lesions on inner thighs possible related to elder abuse D. Several lesions on inner thighs similar to cigarette burns

A. Six round skin lesions partially healed, on the inner thighs bilaterally

Which charting rule(s) will keep the nurse legally safe? Select all that apply A. Use military time B. Document worries or concerns expressed by the client C. Perform most of the charting at the end of the shift D. Record only information that pertains to the client's health problems

A. Use military time B. Document worries or concerns expressed by the client D. Record only information that pertains to the client's health problems

The nurse demonstrates active listening by: A. assuming a relaxed posture and leaning toward the client B. agreeing with the client C. repeating everything the client says D. smiling and nodding continuously throughout the interaction

A. assuming a relaxed posture and leaning toward the client

The nurse replies to a client's statement by saying, "If I were you, I would put your mother in a nursing home." The nurse is using the non-therapeutic communication technique of: A. giving a personal opinion B. asking a personal question C. changing the subject D. false resassurance

A. giving a personal opinion

The nurse is communicating with a primary care provider about medical interventions prescribed for a client. Which statement is most representative of a collaborative relationship? A. "That new medication you prescribed for Mr. Black is ineffective." B. "I am worried about Mr. Black's blood pressure. It is not decreasing even with the new antihypertensive medication." C. "Can we talk about Mr. Black?" D. "Excuse me doctor, I think we need to talk about Mr. Black's blood pressure."

B. "I am worried about Mr. Black's blood pressure. It is not decreasing even with the new antihypertensive medication."

The patient says "I need to tell you something, but you have to promise not to tell anyone else." Which of the following responses would be most appropriate? A. "A secret? You can trust me. I'd never tell anyone." B. "I will listen, but I may need to share this information if it endangers life or health." C. "I don't think you should tell me, I'll definitely have to tell the staff." D. "According to the law and the code of ethics, I cannot share with anyone what you tell me."

B. "I will listen, but I may need to share this information if it endangers life or health."

After being admitted for emergency surgery, an 80-year old client has just returned to the room from the PAR (postanestethesia room). Which nursing interventions are most likely to facilitate effective communication with this client? Select all that apply A. Ask the client, "Do you know where you are?" B. Ask the client or support person about visual or learning problems C. Inform the client and support person about events likely to occur during the next 2 hours D. Provide the client with instructions about discharge E. Tell the client, "You will feel better soon."

B. Ask the client or support person about visual or learning problems C. Inform the client and support person about events likely to occur during the next 2 hours.

When the nurse replies to a client, "I'm not sure I understand what you mean when you say, 'sicker than usual.'' The nurse is using the therapeutic communication technique: A. paraphrasing B. clarifying C. providing information D. focusing

B. Clarifying

Which charting entries are written correctly? Select all that apply A. MS 5 gr given IV for c/o abdominal pain B. Lanoxin 0.25 mg given orally per Dr. Smith's STAT order C. KCl 15 mL given orally for K+ level of 2.9 D. Regular insulin 10.0 u given SQ for capillary blood glucose of 180 E. Ambien 5 mg given orally at bedtime per request

B. Lanoxin 0.25 mg given orally per Dr. Smith's STAT order C. KCl 15 mL given orally for K+ level of 2.9 E. Ambien 5 mg given orally at bedtime per request

Which of the following nursing documentation entries reflects a potential legal risk? A. Skin, pink, warm, dry over bilateral extremities. B. Patient smelled like urine and is really dirty. C. Patient verbalized he is "happy to be going home." D. Ambulated in hallway 3 times for 100 feet with one assist.

B. Patient smelled like urine and is really dirty.

A depressed client who has not bathed or dressed in clean clothes today is reading the lunch menu but is unable to make a decision. Which would be the most appropriate nursing diagnosis for this client? A. Anxiety B. Powerlessness C. Chronic Low Self-Esteem D. Social Isolation

B. Powerlessness

During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client's blood pressure seems high. What is the next step? A. Ask the client about past blood pressure ranges B. Review the graphic record on the client's record C. Examine the medication record for antihypertensive medications D. Review the progress notes included in the client's records

B. Review the graphic record on the client's record

The nurse is employed by an institution using a problem-oriented record system. The patient states, "I have a sore throat, feel awful, and I think I have a temperature of 102F." This data would be classified as: A. objective B. subjective C. factual D. assessment

B. Subjective

The nurse caring for a 74-year-old man has not charted since the beginning of the shift, five hours ago. The patient begins to complain of chest pain and shortness of breath, and is diaphoretic. Following the administration of emergency medication, the patient is transferred to the intensive care unit. The nurse is now responsible for charting all of the relevant patient information. What might occur regarding documentation? A. The nurse will document all information with regard to time and care provided B. The nurse is at risk of missing information based on the changes in the patient's condition. C. The information the nurse has compiled will be easily documented prior to transfer of the patient D. During the patient's transfer the nurse will need a coworker to help with the charting.

B. The nurse is at risk of missing information based on the changes in the patient's condition.

Place the following descriptions of the helping relationship phases in the correct sequence A. After introductions, the nurse asks, "What plans do you have for the upcoming holiday weekend?" B. The nurse states, "It sounds like you are concerned about the possible complications of having diabetes. What would be the most helpful for you at this time?" C. The nurse reads in the medical history that the client was diagnosed with diabetes 1 week ago. D. The nurse states, "When we met, you knew very little about diabetes and now you are able to use your new information and apply it to your own personal situations."

C, A, B, D

The nurse is communication with a well-oriented older adult client in a long-term care setting. Which statement best reflects respectful and caring communication? A. "Are we ready for our shower?" B. It's time to go to the dining room, honey." C. "Are you comfortable, Mrs. Smith?" D. "You would rather wear the slacks, wouldn't you?"

C. "Are you comfortable, Mrs. Smith?"

A patient says to her husband in a matter-of-fact tone of voice, "I am angry with you because you were late again." This demonstrates which type of communication behavior by the patient? A. passive B. passive-aggressive C. assertive D. aggressive

C. Assertive

When communicating with an unconscious client, which of the following facts should be considered? A. Hearing is the first sense to be lost; therefore, it is most likely that the client cannot hear the nurse. B. An unconscious client needs to be spoken to in a clear, louder-than-normal voice. C. Environmental noise should be controlled so that the client may hear the communicator. D. An unconscious client should not be subjected to the use of touch because it is ineffective and may be detrimental to the client.

C. Environmental noise should be controlled so that the client may hear the communicator.

A student nurse is caring for a 72-year old client with Alzheimer's disease who is very confused. Which is the most appropriate communication strategy to be used by the student nurse? A. Written directions for bathing B. Speaking very loudly C. Gentle touch while providing ADLs D. Flat facial expression

C. Gentle touch while providing ADLs

Which action by a nurse ensures confidentiality of a client's computer record? A. The nurse logs on to the client's file and leaves the computer to answer the client's call light. B. The nurses shares her computer password C. The nurse closes a client's computer file and logs off. D. The nurse leaves client computer worksheets at the computer workstation

C. The nurse closes a client's computer file and logs off.

The statement that best identifies the "Body" or the "Development" stage of the interview process would be: A. The purpose of this part of the interview is to allow the nurse time to explain how the information from the interview will be used. B. The purpose of this part of the interview is to establish rapport and orient the interviewee (patient). C. The purpose of this part of the interview is to have the client communicate what he or she thinks, feels, knows, and perceives in response to questions from the interviewer (nurse). D. The purpose of this part of the interview is to allow the nurse time for physical assessments/examining.

C. The purpose of this part of the interview is to have the client communicate what he or she thinks, feels, knows, and perceives in response to questions from the interviewer (nurse).

While taking an admission history from the mother of an 18-month-old being admitted for surgery, the nurse notes that the mother is twisting her rings, running her hands through her hair, and moving about restlessly. When the nurse asks the mother about any problems or concerns, she replies, "Everything is just fine." The mother's behavior is an example of: A. inappropriate communication B. inadequate language skills C. incongruence of communication. D. violation of personal space.

C. incongruence of communication.

A nurse caring for a dying client sees the client's life partner crying. In order to facilitate the discussion of feelings, the best comment she could make to this partner would be: A. "How are you feeling today?" B. "You seem upset. Is your friend worse today?" C. "Crying is good for you. Things will look brighter tomorrow." D. "I see you have been crying. Would you like to talk about it?"

D. "I see you have been crying. Would you like to talk about it?"

The client amde the following statement to the nurse, "My doctor just told me that he cannot save my leg and that I need to have an above-the-knee amputation." Which response by the nurse is most appropriate? A. "Dr. Jones is an excellent surgeon." B. "Are you in pain?" C. "If I were you, I'd get a second opinion." D. "Tell me more......"

D. "Tell me more...."

After charting your nurses' notes following those of the previous shift, you discover you have made an error. How should you correct it? A. Blot or use "white-out" on the incorrect entry. B. Recopy that page of nurses' notes. C. Be sure to scribble out the entry so no one else misreads the documentation D. Draw a line through the error and write "Error" and your initials above it.

D. Draw a line through the error and write "Error" and your initials above it.

After making a documentation error, which action should the nurse take? A. Use correcting liquid to cover the mistake and make a new entry B. Draw a line through it and write error above the entry C. Draw a line through the mistake and write mistaken entry above it D. Draw a line through the mistake and write mistaken entry with initials above it

D. Draw a line through the mistake and write mistaken entry with initials above it

While talking with a patient, you observe her body posture, facial expressions, and gestures. These behaviors make up what kind of communication? A. verbal B. perceptual C. cultural D. nonverbal

D. Nonverbal

Which charting entry would be the most defensible in court? A. client fell out of bed B. Client drunk on admission C. Large bruise on left thigh D. Notified Dr. Jones of BP of 90/40

D. Notified Dr. Jones of BP of 90/40

During the termination stage of a helping relationship, the nurse and the patient should: A. establish mutually agreed on goals B. cooperate with one another in goal-related activities C. explore the patient's prognosis and the future healthcare needs D. identify progress toward mutually established goals

D. identify progress toward mutually established goals