Funds Exam 2

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following action should the nurse take to display empathy towards the client? *What are the examples of non-therapeutic communication* - Tell the client that everything will be just fine - Change the subject while the client is discussing their feelings - Show interest in the client's feelings by acknowledging that they are upset - Tell the client that it is wrong to be crying over the situation

- Tell the client that everything will be just fine (false reassurance not supported by facts) - Change the subject while the client is discussing their feelings( showing a lack of empathy) - Tell the client that it is wrong to be crying over the situation (imposes their own beliefs and client may try to meet nurse's expectations or approval)

The second step of the nursing process is _______. During this step, the nurse uses clinical judgement to identify the client's problems or risks, in order to develop a diagnostic statement.

Analysis

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first? - Assessment - Analysis - Evaluation - Planning

Assessment( during this step the nurse gathers information by performing a physical exam, interviewing the client, and observing the client)

The final step of the nursing process is ________. During this step, the nurse determines if goals were achieved and updates the plan of care as needed.

Evaluation

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing? - Implementation - Evaluation - Analysis - Planning

Implementation (the nurse carriers out the interventions developed in the plan of care, Implementations is when nurse put the plan of care in action)

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment? - Palpation - Percussion - Auscultation - Inspection

Inspect the client's abdomen and assess for symmetry between right and left side of the body

Objective Data Collection (Process)

Inspection Palpation Percussion Auscultation

The nurse should observe the client's overall appearance, hair, skin, and fingernails during ____________?

Inspection ( the client's cleanliness and grooming)

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? - Use the soft end of a cotton swab over the client's abdomen - Auscultate the tender areas of the client's abdomen through clothing -Palpate the tender areas of the client's abdomen last -Use deep palpation when assessing the clients abdomen

Palpate the tender areas of the clients abdomen late ( to avoid client discomfort throughout the rest of the examination) When assessing the abdomens...the nurse should -inspect -auscultate prior to palpation to avoid altering the bowel sounds

A nurse is preparing a assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply) - Doppler - Electrocardiogram monitor - Tongue depressor - Tape measure - Penlight

Penlight - inspect pupils/reflexes Tape measure - measure size of wounds, bruising, or unexpected findings of skin Tongue depressor

The third step of the nursing process is _____. During this step, the nurse sets priorities for client care and develops interventions to meet outcomes.

Planning

A nurse has just received a report on a newly admitted client who speaks a different language than the nurse. Which of the following action should the nurse take to assist with effective communication with the client during the initial assessment process? - Enlist the aid of the client's school-age child to interpret for the nurse and the client - Ask the client's best friend to interpret for the nurse and client - Use jokes and laughter to make the client feel more at ease - Request assistance from a interpreter during the assessment

Request assistant from an interpreter during the assessment ( the nurse should enlist a professional interpreter if the client speaks a different language than the nurse)

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following action should the nurse take to display empathy towards the client? - Tell the client that everything will be just fine - Change the subject while the client is discussing their feelings - Show interest in the client's feelings by acknowledging that they are upset - Tell the client that it is wrong to be crying over the situation

Show interest in the client's feelings by acknowledging that they are upset ( This is a therapeutic communication technique)

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?

Skin temperature, moisture, or unexpected findings

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment? - Tongue depressor - Penlight - Reflex hammer - Stethoscope

Stethoscope to auscultate the sounds of the client's body Tongue depressor is view the uvula and posterior soft palate during the inspection Penlight to make close observations of body cavities for the inspection Reflex hammer to test for deep tendon reflexes during a neurological assessment

A nurse is documenting their assessment and documents that the client states. "I have a dry cough every morning when I wake up". Which of the following types of data is the nurse documenting? - Subjective - Social determinants of health - Objective - Olfactory

Subjective (data includes feelings & concerns from the client's point of view) Subjective date is documented using the client's written in quotation marks

The nurse is completing documentation in a client's medical record. Which of the following entries display proper documentation by the nurse? -The client is feeling better -The client's abdomen is soft and non-distended -The client status is unchanged -The client appears in pain

The client's abdomen is soft and non-distended ( nurse should include factual, accurate, and objective information)

The nurse should listen to the internal sounds the body makes that are created by blood, air, or gastric contents using ___________?

auscultation ( heart sounds, lung sounds and bowel sounds)

Autonomy involves

client's right to make decisions about their care, including refuse treatment (client's freedom)

Olfactory data

data that is collected using the sense of smell

Nonmaleficence means:

do no harm

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? - Close the examination room door but do not pull the curtain in the examination room. -Remain in the client's room while the client is getting undressed - Ask the client if they would like to empty their bladder and bowel before the physical examination begins - do not expose any more of the client's body than required at a time.

do not expose any more of the client's body than required at a time

Justice involes

ethical principle of treating all clients fairly.

Fidelity refer to

faithfulness ( honor promises to the client, the institution, and themselves)

Objective Data Collection

findings that the nurse observes directly, including through seeing, hearing, or touch, or obtains through measurement.

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of nonverbal communication technique by the nurse? - Asking the client to clarify a statement - Asking the client open-ended questions - Maintaining an arm's length between self and client - Stating name and providing credentials upon entering the client's room

nurse should maintain a personal space of about arm's length 46 to 102 cm when communicating with the client. This is a form of nonverbal communication asking to client to clarify a statement - understanding of verbal and therapeutic communication Asking open-ended question is verbal communication introducing themselves - verbal communication

The nurse should use tapping during ____________ to vibrate underlying tissues and organs to assess for unexpected sounds?

percussion (unexpected sounds made by tapping on the client's skin)