NRSG 2200 unit 4 Prep U

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Which client statement from the health history would be a cue to a nursing diagnosis for this problem?

"I get out of breath when I walk a few steps."

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this."

A nurse visits a female victim of sexual assault. During the visit the client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?

"Tell me more about the aspects that make you feel as if it happened yesterday."

When the preoperative client tells the nurse that the client cannot sleep because the client keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is:

"The thought of having surgery is keeping you awake."

Which is an open-ended question?

"Why did the health care provider prescribe this medication for you?"

A nurse takes an adult client's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the nurse do next?

Ask another nurse to take pulse

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

The nurse is caring for the client with pneumonia. An expected client outcome is, "The client will maintain adequate oxygenation by discharge." Which outcome criterion indicates the goal is met?

Client no longer requires supplemental oxygen.

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan.

Which statement about client records and documentation is correct?

Communication is the primary purpose of client records.

A client is diagnosed with diabetes. The client's adult child offers to serve as an interpreter, because the client does not speak the dominant language. Which is the best action for the nurse to take?

Contact a professional interpreter.

The act of analyzing and synthesizing cues requires:

Critical thinking

Which statement regarding the difference between data collected for assessment and data collected for evaluation is correct?

Data collected for assessment identify client health issues, whereas data collected for evaluation determine whether client outcomes are being achieved.

A client, who was recently diagnosed with diabetes, has been coming to the emergency room every day for hyperglycemia. The client reports not being able to self-administer insulin injections. What strategy would best educate the client and improve the client's ability to self-administer insulin?

Demonstrate the proper method and have the client mimic the demonstration.

A nurse is caring for a client who is visually impaired. Which action is a recommended guideline for communication with this client?

Explain the reason for touching the client before doing so.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate?

Explain the reason why information cannot be disclosed.

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be "kept comfortable" and to not continue further treatment. The client's daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time?

Explain to the daughter the wishes of the client.

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

Which is recommended when conducting a client-nurse interview?

Focus full attention on the client.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report

The nurse recognizes that identifying outcomes/goals must include:

Involvement of the client/ family

A nurse touches a client's hand to indicate caring and support. What channel of communication is the nurse using?

Kinesthetic

Which provides the best framework for prioritizing client problems?

Maslow's hierarchy of needs

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12-hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response?

Place a chair next to the bed and encourage the parent to hold the client's hand.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

Soap charting

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which action would be most appropriate for the nurse to do?

Strike out the entry with a single line, place initials next to it, and write the correct entry.

Which is a correctly written client goal?

The client will ambulate 10 ft (3 m) with a walker by October 12.

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

The client will ambulate with assistance by the nurse to a bedside chair.

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation?

The nurse could be fined or even go to jail for violating HIPAA.

A nurse is caring for a client who sustained a spinal cord injury and has paraplegia. The client is frustrated, crying, and tells the nurse, "I just want to die." What is the nurse's best response to the client?

The nurse says, "I can only imagine how hard this is on you. How can I help you?"

Which traits of the nurse are most important for an assessment to be successful?

Trustworthy and Confident

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility.

The nurse is providing education to a client who sometimes has difficulty remembering information. Which form of communication will be most helpful for this client?

Written communication

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

The nurse is beginning an assessment on a nonverbal client. The nurse must first:

establish eye contact prior to assessing, touching, and interacting with the client.

During an annual performance review with an employee, the nurse manager does not maintain eye contact and seems concerned about the time and the next appointment. What type of communication is the manager exhibiting?

nonverbal