Unit 4 PrepU quiz Foundations

a nurse is calling a physician to communicate a change in the client's condition. according to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?

"My name is Sue Smith, RN, and I am calling regards Mrs. Jones in room 356 at Jefferson Hospital."

a hospital utilizes the SOAP method of charting. within this model, which of the nurses statements would appear at the beginning of a charting entry?

"client is reporting that her abdominal pain is rated at 8/10"

the health care provider tells the client, "you are experiencing an MI," and leaves the room. the client asks the nurse what an MI stands for. what response by the nurse is most accurate?

"myocardial infarction"

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"

the health care provider has recommended the client have a surgical procedure performed. the surgery would allow the clients problem to resolve quicker. without surgery, healing would be delayed. the client states "I do not want the surgery done" what is the appropriate response by the nurse?

"tell me the reason you do not want the surgery"

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"

the nurse must use appropriate interviewing techniques to elicit accurate and complete health information. which statement is an example of an open-ended question or comment?

"what brought you to the hospital this morning?"

a client scheduled to have hip replacement surgery states, "I am so scared of the surgery and of the anesthetic." what is the best response by the nurse?

"what questions do you have about the surgery?"

which is an open-ended question?

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

the nurse is collecting health data and avoids using closed-ended questions. which examples of closed-ended questions? select all that apply

- do you smoke cigarettes? - are you ready to get out of bed? - is there any chance you might be pregnant?

the nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. which technique would be most appropriate for the nurse to use when communicating with the health care provider?

ISBAR

a client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. which action is the best defense against allegations of negligence?

accurately documenting client care on the client record

an evening shift nurse is caring for a client scheduled for a colon resection in the morning. the client tells the nurse that the client is nervous about the surgery. the best response by the nurse is to:

ask the client "can you tell me more about what is worrying you?"

a client aged 83 years who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. the nurse communicates the clients wish to the family and health care team. this is an example of what ethical principle?

autonomy

a nurse is caring for a client who is a celebrity in the area. a person claiming to be a family member inquires about the medical details of the client. the nurse reveals the information but later comes to find out that the person was not a family member. the nurse has violated:

confidentiality

a nurse is sitting with friends in a coffee shop while working on a plan of care for a client. the clients name is written at the top of the plan. which ethical responsibility is the nurse violating?

confidentiality

a nurse is most likely to experience ethical distress in which client situation?

continuing IV fluids for a client who wants to die

a nurse is discharging a client and thus terminating the nurse-client relationship. which action should the nurse perform in this phase?

examine goals of the relationship to determine whether they were achieved

the client is an 18 month-old in the pediatric intensive care unit. the client is scheduled to have a subgaleal shunt placed tomorrow, and the clients mother is quite nervous about the procedure. the nurse tells the clients mother, "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

a client rings the call bell to request pain medication. on performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. after a few moments, the nurse returns with the pain medication. the nurses returning with the pain medication is an example of which principle of bioethics?

fidelity

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 is calling a health care provider to give an update on a clients condition. the nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." what is the most appropriate action by the nurse?

inform the provider, to ensure safety for the client, it must be read back

which flow sheet provides the health care provider with information on an ongoing record of fluid loss?

intake and output graphic sheet

in the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. the nurse is most clearly demonstrating which professional value?

integrity

a nurse touches a clients hand to indicate caring and support. what channel of communication is the nurse using?

kinesthetic

a nurse using the principle-based approach to client care seeks to avoid causing harm to clients in all situations. what is the principle known as?

nonmaleficence

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

a nurse shows client advocacy by:

offering a hospice consultation to a client who is terminally ill

in SBAR, what does R stand for?

recommendations

a nurse has a duty of nonmaleficence. which action would be considered a contraindication to that duty?

refusing to administer pain medication as prescribed

several nurses on the same hospital unit communicate on the same social networking site. a nurse posts the following statement to the social networking page, "the lady in room 34 with heart failure was a train wreck!' in which manner has the nurse failed to apply the principles of confidentiality?

sharing information about a client beyond the area of client care is unacceptable and breaches the client's confidentiality rights

nurses must maintain the privacy of clients. which example is a breach in privacy and would pose an ethical problem?

taking a picture of a client with the nurses cell phone

the principle of autonomy by a client is applied in which situation?

the client has decided to stop chemotherapy treatments

which action by the nurse demonstrates respect for the client as an individual?

the nurse is administering medication to a client she addressed as "Mrs. Taylor."

what situation would permit the nurse to disclose information without the clients approval?

the nurse suspecting that a client is being abused or neglected

A nurse in a physicians office has noted on several occasions that one of the physicians frequently obtains forms for writing prescriptions for controlled substances. the physician reports that the physicians spouse has chronic back pain and requires pain medication. one day the nurse enters the physicians office and sees the physician take a pill out of a bottle. the physician mentions having migraines and that the spouses pain medication alleviates the pain. what type of nurse-physician ethical situation is illustrated in this scenario?

unprofessional, incompetent, unethical, or illegal physician practice

the nurse is preparing a SOAP note. which assessment findings are consistent with objective client data?

urine output 100 ml

a nurse tells a client, "are you going to get out of bed, or are you just going to sleep all day and night?" this is an example of which barrier to communication?

using judgmental or belittling language

a nurse is documenting care in a source-oriented record. what action by the nurse is most appropriate?

write a narrative note in the designated nursing section

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