Care Management, Communication
A client tells the nurse that he is very worried about his surgery. Which of the following responses by the nurse is a cliché? "Don't worry, everything will be fine." "Tell me what you are worried about." "Have you spoken to your family about your concerns?" "Do you want to cancel your surgery?"
"Don't worry, everything will be fine."
A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? "I am so sorry you are going through this. Can we talk?" "I know this is hard for you. Is there any way I can help?" "Sitting in the dark is not going to cure your cancer. Let's open the curtains." "Can you please tell me why you are crying?"
"I know this is hard for you. Is there any way I can help?"
A client comes into the urgent care center to have sutures removed on an arm. The nurse finds significant crusting along the suture line. The client states not having time to get the sutures removed a week prior, as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls the arm away and tells the nurse, "You are taking too long and it is hurting a little bit. Just pull them out and get it over with." Which statement is an example of appropriate therapeutic response? "It will not hurt if you relax and stop pulling your arm away." "It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them." "I am sorry it is taking so long. Tell me how you hurt your arm?" "I am sorry it is taking so long and I am hurting you; next time do not wait too long to get sutures removed or the same thing will happen"
"It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them." Sharing information about why the removal of the sutures hurts and is taking longer is a teaching moment which helps the client make better decisions about health care. Telling the client not to wait so long for removal is not therapeutic because it diminishes the client's ability to make choices. Changing the subject is not therapeutic and is a way for the nurse to avoid listening and addressing the client's concerns. Telling the client it will not hurt if the client relaxes is an example of false reassurance.
A client says, "Nobody listens to me; even you don't!" Which response is most therapeutic? "It sounds like you're overreacting somewhat." "I listen to you." "It sounds like you're feeling unappreciated." "Why do you say I don't listen to you?"
"It sounds like you're feeling unappreciated."
A nurse is conducting a health history. The client's spouse is answering the interview questions. What question would be appropriate to ask the client before proceeding with the remainder of the interview? "Can you ask your spouse to leave the room?" "Who manages health care-related issues in your family?" "Do you have a hearing impairment preventing you from hearing the questions?" "Why is your spouse answering the questions?"
"Who manages health care-related issues in your family?" In some cultures, the male is considered the head of the family and makes health care decisions and takes the role of answering questions related to health and medical care. It is important to establish who makes those decisions and to be respectful of the client's culture. It is best to take cues from the client. A client that is allowing another family member to answer questions may be doing so based upon the culture and roles in the family; it is important to clarify. Asking the spouse to leave the room or asking why the spouse is answering the questions can be insensitive and unprofessional. While asking about a hearing impairment may be appropriate, determining who makes the decisions is priority.
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."
Phases of the Helping Relationship: Working Phase
-exploring and understanding thoughts and feelings -Facilitating and taking action -Listening and attending skills, empathy, respect, genuineness, concreteness, self-disclosure, and confrontation
4 levels of communication
1. intrapersonal 2. interpersonal 3. public communication 4. mass communication
A client says to the nurse, "I have been so sick for a while with pain in my stomach and nothing seems to work." Which statement by the nurse demonstrates the use of an open-ended question? 1."What you have been doing to manage your illness?" 2."Would you like me to sit with you for a little while?" 3."How long have you been experiencing this pain?" 4."It must be frustrating when nothing works to make you feel better?"
1."What you have been doing to manage your illness?"
■A 12-year-old is transferred from the ED to the pediatric unit. The nurse on the unit reviews the ED summary note, performs an assessment, and interviews the child and the child's mother. What should the nurse do next? 1.Institute the oral rehydration protocol. 2.Continue to monitor the child's vital signs. 3.Formulate a plan of care to meet the child's needs. 4.Analyze data and cluster data that have a significant relationship.
1.Analyze data and cluster data that have a significant relationship.
A nurse is performing a complete physical assessment of a 16-year-old client. What is an important approach to use with this client? 1.Pull the curtain, so that the parents are outside the curtain during the examination. 2.Limit questions from the adolescent until after the examination is completed. 3.Allow the adolescent to keep underwear on during the examination. 4.Have the parents wait outside the room during the examination.
1.Have the parents wait outside the room during the examination.
■Which activity is the nurse engaged in when identifying a nursing diagnosis? 1.Discovering causes of diseases. 2.Documenting desired expected outcomes. 3.Planning care to meet nursing needs of a client. 4.Identifying human responses to actual or potential health problems.
1.Identifying human responses to actual or potential health problems.
The day after surgery, the client says to the nurse, "Since surgery I have been having bloody urine." Which type of data is this information?" 1.Objective 2.Subjective 3.Tertiary 4.Secondary
1.Objective
Which nursing actions are examples of the assessment step of the nursing process? (Select all that apply.) 1.Administering pain medication. 2.Taking a client's blood pressure after ambulating. 3.Obtaining lab results. 4.Taking a client's apical pulse when the radial was irregular. 5. Determining if the client tolerated the change from a soft to regular diet
1.Obtaining lab results. 2.Taking a client's apical pulse when the radial was irregular. 1.Administering pain medication. - implementing 2.Taking a client's blood pressure after ambulating. - evaluating 5.Determining if the client tolerated the change from a soft to regular diet. - evaluating
A client says, "I asked to go to the hospital because I am seeing double and everything is very blurry." Which kind of data is the client describing? 1.Objective 2.Subjective 3.Tertiary 4.Secondary
1.Subjective
A nurse is caring for a client who presents with diarrhea, abdominal cramps, diaphoresis, shortness of breath, and severe anxiety. Which thermometer should the nurse use to obtain this client's temperature? 1.Tympanic 2.Paper strip 3.Rectal 4.Electronic oral
1.Tympanic
Which is most important for the nurse to do when assessing a client's nonverbal expressions? 1.Increase the client's self-awareness. 2.Validate their meaning. 3.Remain observant. 4.Explore feelings
1.Validate their meaning. Rationale: The meaning and significance of behavior must be clarified by the client; otherwise, they are just assumptions by the nurse.
The nurse formulates the following goal/outcome with a client: "The client will ambulate in the hall without experiencing activity intolerance." Which statements below address the status of this goal? (Select all that apply.) It is: 1.not measurable 2.not client-centered 3.missing a parameter 4.missing a target time 5.a correctly written goal/outcome
1.not measurable 3.missing a parameter 4.missing a target time
When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be: Administering pain medication Ambulating the client in the hallway Placing wrist restraints on the client Allowing the family to see a newly admitted client
Administering pain medication
A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client? Arrange for a sign language interpreter when discussing treatment. Use a text-telephone device (TTD) for daily communication. Consult the oncology nurse specialist. Talk with the client's children to determine needs.
Arrange for a sign language interpreter when discussing treatment.
The nurse is caring for a client who does not speak the same language. The UAP (unlicensed assistive personnel) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Mark all that apply. Interview the client as part of the admission assessment. Provide teaching to the client, including discharge instructions. Counsel the client about making adjustments to a new medical condition. Demonstrate and teach new caregiving procedures to the family. Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.
Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.
A nurse has interactions with several clients throughout the day. The nurse would require a formal setting for discussion for which client? A client with difficulty maintaining boundaries A client showing signs of sadness A client that is displaying aggressive behaviors A client that is displaying hearing voices
A client with difficulty maintaining boundaries
A client has recently been diagnosed with cancer. The client says, "What did I do wrong to get such a disease?" Which nonverbal processes, along with the client's statement, would convey a congruent message? Select all that apply. An erect, confident posture A sarcastic tone of voice A fearful tone of voice A cheerful expression A sad facial expression
A sad facial expression A fearful tone of voice
The nurse enters a client's room and observes that the client is hunched over and appears to be breathing rapidly. What type of question should the nurse first ask the client in this interaction? An open-ended question A directing question A yes or no question A reflective question
A yes or no question Sometimes a yes or no question is appropriate. In this case, the nurse may want to ask, "Do you feel short of breath?" or something similar. Directing questions and reflective questions follow up on earlier communication. An open-ended question may elicit the necessary assessment data, but a yes or no question accomplishes this goal more directly.
Prioritizing client care is an ongoing process within the art of nursing. Abraham Maslow proposed five levels of need and grouped them according to significance. Which client need is of primary importance? Being able to keep up with current events while ill Breathing easily Liking one's roommate Being safe from falling
Breathing easily
Which therapeutic communication technique is being utilized when the nurse asks the client, "Is there something you'd like to talk about?" Accepting Exploring Focusing Broad opening
Broad opening This is an example of a broad opening, which allows the client to take the initiative in introducing the topic. Accepting is indicating reception. Exploring is delving further into a subject or idea. Focusing is concentrating on a single point.
During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "Have you been hospitalized this year for your back pain?" This is an example of which type of question? Closed question Reflective question Sequencing question Open-ended question
Closed question
The nurse is attending a patient with chronic renal failure. The patient says that of late, he has lost his appetite and feels like everyday situations have become more stressful. He reports feeling disappointed and frustrated with his condition, and says that he has not been of any help to his family. What is the most important nursing intervention that the nurse needs to carry out at this point? Administer immunosuppressant Offer nutritional counseling Coordinate with resources for client support Administer drug therapy to restore renal functions
Coordinate with resources for client support
Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect? Teacher Counselor Care provision Coordinator of care
Coordinator of care
In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant? Inspect the site for thrombophlebitis. Discontinue the IV solution. Dispose of the disconnected IV set. Check the infusion rate.
Dispose of the disconnected IV set.
An older adult who lives alone is admitted to the hospital for debility and weakness. What is the most important intervention to ensuring cost-effective care is provided for this client? Administer client's regular home medications as prescribed. Request that the health care provider write a prescription for nursing home placement. Ensure case management is actively involved in the client's care to facilitate care coordination. Listen compassionately to the client's concerns about being unable to live independently.
Ensure case management is actively involved in the client's care to facilitate care coordination.
A nurse who provides care on a postsurgical unit is performing discharge teaching as a component of her effort to ensure continuity of care. Which of the following is the primary goal of continuity of care? Minimizing nurses' legal liability during patient transitions between healthcare institutions Ensuring a smooth and safe transition between different healthcare settings Increasing patients' knowledge base and health maintenance behaviors Controlling costs and maximizing patient outcomes after discharge from hospital
Ensuring a smooth and safe transition between different healthcare settings
A client states, "Right before I got here I was doing all right. My job was going well, my spouse and I were happy, and we just moved into a new apartment." The nurse responds, "You said you and your spouse were happy. Tell me more about that." Which therapeutic communication is the nurse using with the client? Exploring General lead Encouraging comparison Restating
Exploring Exploring delves further into a subject or an idea, such as the client's statement about happiness. The nurse has not invited a comparison or restated what the client said. Giving a general lead involves providing permission to speak, not seeking specific elaboration.
An elderly patient is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the patient's frustration? Modify the patient's plan of care to better reflect the commonalities between the different disciplines. Facilitate communication between the different professionals and attempt to coordinate care. Teach the patient about the unique scope and focus of each member of the healthcare team. Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually .
Facilitate communication between the different professionals and attempt to coordinate care.
The nurse fails to assess personal values surrounding a client's gender assignment before caring for a client who is transgender. Which issue is the nurse at most at risk for that may hinder development of the nurse-client relationship? Expressing shock when assessing the client's history Being manipulated by this client Holding a prejudice toward this client Neglecting to include the client's desires in the plan of care
Holding a prejudice toward this client
The nurse is prioritizing the client's nursing diagnoses. Which nursing diagnosis has the highest priority? Constipation related to decreased fluid intake and decreased mobility Self-care Deficit: Bathing related to joint inflammation Ineffective Airway Clearance related to retention of secretions Disturbed Sleep Pattern related to abdominal incisional pain
Ineffective Airway Clearance related to retention of secretions
A nurse responds to a client's statement with silence to achieve which outcome? To demonstrate passive listening To encourage self-reflection by the nurse To allow the nurse to determine an appropriate response To permit the client to gather their thoughts
To permit the client to gather their thoughts
Which of the following nursing actions demonstrates that the nurse understands the nursing process? Obtaining vital signs, documenting nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level Assessing for allergies, administering analgesic, obtaining baseline vital signs, and documenting nursing diagnosis as acute pain Prioritizing patient goals, documenting all health records precisely, conducting the health history, and documenting the nursing diagnosis Reviewing health record, documenting patient goals, identifying etiology of the nursing problem, and evaluating treatment outcome.
Obtaining vital signs, documenting nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level
A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established? Orientation phase Evaluation phase Termination phase Working phase
Orientation phase
Phases of the Helping Relationship
Orientation phase - data gathering/assessment/introductions Working phase - longest/work together to meet patient's needs Termination phase -
The nursing process is integral to the accurate and complete delivery of nursing care. Which of the following activities represent aspects of the nursing process? Select all that apply. Prioritizing activities to improve client comfort Ordering an antidiabetic agent for a client newly diagnosed with diabetes Taking a client's health history Comparing client outcomes against planned goals Selecting interventions to cure the client's medical diagnoses
Prioritizing activities to improve client comfort Taking a client's health history Comparing client outcomes against planned goals
The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurological checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed? Assessment Recommendation Background Situation
Recommendation This information is the recommendation of the nurse regarding the client's condition. It is not discussing background information related to the client, the situation of the client, or any assessment information related to the client.
A nurse in a long-term care facility consistently administers clients' medications 60 to 90 minutes after the scheduled administration time. The nurse also leaves scheduled treatment procedures for nurses to complete on the next shift. Which would be an appropriate strategy for this nurse to pursue? Reschedule treatment procedures for the next shift. Seek input and direction on time management and priority setting. Pre-pour medications for the shift to expedite the process. Ask the nurse manager for a lighter workload.
Seek input and direction on time management and priority setting.
During a therapeutic communication session, the nurse tells the client of a past experience. Which statement best reflects the nurse's use of self-disclosure? It forms the solid foundation for effective communication. Self-disclosure should be used with all clients to some degree. The more the nurse discloses, the more the client will disclose. Self-disclosure on the nurse's part should benefit the client.
Self-disclosure on the nurse's part should benefit the client.
The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client? Leaning back in the chair next to the client with legs crossed at the knees Sitting upright facing the client with both feet on the floor Leaning forward with arms on the table sitting directly across from the client Turned slightly to the side of the client with arms folded across the chest
Sitting upright facing the client with both feet on the floor
The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important? Give all of the discharge instructions at once. Have the interpreter write out all of the information listed in the unit brochure. Ensure that family members are present. Speak directly to the client.
Speak directly to the client.
The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse? The RN identifies outcomes. The RN collects client data. The RN analyzes client data. The RN coordinates care delivery.
The RN coordinates care delivery.
A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation? The client is sitting in a chair and states, "I feel a lot better than I did yesterday. The client smiles at the nurse and states, "I cannot wait to go home." The client stares at the floor and states, "I feel fine." The client looks at the nurse and states, "I am still not feeling my best."
The client stares at the floor and states, "I feel fine." It often helps nurses to understand subtle and hidden meanings in what the client is saying verbally. For example, in the scenario in which the client stares at the floor while claiming to feel fine, the nurse should investigate further because of the incongruence between the client's verbal and nonverbal communication. In the other three scenarios, the nurse-client communication is effective and no further investigation is warranted.
A nurse is taking care of four clients. Which client should the nurse see first? a 17-year-old client 24 hours post appendectomy a 50-year-old client with diverticulitis a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome a 50-year-old client 3 days post-myocardial infarction (MI)
a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome
The nurse cares for a client who is sharing a personal health story. Which behavior(s) demonstrates active listening? Select all that apply. The nurse offers multiple solutions while the client is sharing a personal story. The nurse paraphrases what the client has stated before generating a response. The nurse shares a personal story about experiences with hospitalization. The nurse makes eye contact while the client is sharing a personal story. The nurse observes the nonverbal behavior of the client as the client speaks.
The nurse makes eye contact while the client is sharing a personal story. The nurse observes the nonverbal behavior of the client as the client speaks. The nurse paraphrases what the client has stated before generating a response.
A nurse is preparing for handoff communication for a patient who is being discharged from the hospital to home health care. Which example is not an action performed during this process? The nurse prepares the new room for the patient. The nurse determines who should be involved in the handoff communication The nurse uses the SBAR technique during the handoff. The nurse asks the other health care professionals if they have any questions.
The nurse prepares the new room for the patient.
The nurse is preparing to begin the discharge planning process with a patient whose pulmonary embolism has recently resolved. Which of the following factors should the nurse prioritize during this process? The nurse's knowledge base and experience level The patient's identified needs and goals The NANDA diagnoses relevant to the patient's condition The patient's potential for recurrence
The patient's identified needs and goals
When communicating with a client, the nurse uses reflection for which purpose? To keep the client on the topic of concern To determine the sequence of events in the conversation To have the client elaborate on thoughts and feelings To investigate the situation to help problem solve
To have the client elaborate on thoughts and feelings
A nurse is caring for a client who decides to leave the hospital against medical advice (AMA). The nurse knows that the client must sign a form before leaving. What is the purpose of the AMA form? To release the doctors and the institution from any legal responsibility To let the cafeteria staff know a meal will no longer be required To have relevant information all in one place in case the client is readmitted To ensure the client knows he or she must still pay the bill
To release the doctors and the institution from any legal responsibility
Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? Termination phase Evaluation phase Working phase Orientation phase
Working phase
The parent of a hospitalized toddler tells the nurse, If my child uses the word 'toytoy' a bathroom trip is needed. What action by the nurse best communicates this information about basic care needs for the client? Adding the diagnosis urinary incontinence?to the care plan Writing the information in the plan of care Posting the sign toytoy over the toilet Obtaining written consent for the diagnostic procedure
Writing the information in the plan of care
A nurse is prioritizing care for four new admissions to the inpatient psychiatric unit. Which client should the nurse assess first? a client who periodically burns self with cigarettes when feeling anxious. a client with new-onset confusion and disorientation. a significantly depressed client with decreased energy who was isolated in the bedroom. a client who is anxious and is washing hands excessively.
a client with new-onset confusion and disorientation.
A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech? Therapeutic Nonassertive Aggressive Assertive
assertive
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. verbalize all steps of the nursing assessment when interacting with the client. use various forms of communication when interacting with the client. speak loudly when interacting with the client.
establish eye contact prior to assessing, touching, and interacting with the client.
The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions? clinical coordination delegation networking advocacy
delegation
The exchange of information among the patient, the caregivers, and those responsible for care while the patient is in a care setting and after the patient returns home is key to a successful: community service. discharge planning. guaranteed transfer. proper referral.
discharge planning.
A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan? identifying the potential and actual problems, informing the client about options, and arranging for the client to attend Alcoholics Anonymous informing the client of the extent of damage to the liver and drawing up a contract to start the rehabilitative process identifying nursing goals and explaining the importance of following these goals discussing collaborative goals and involving the client in identifying and prioritizing important interventions
discussing collaborative goals and involving the client in identifying and prioritizing important interventions
What term describes a nurse who is sensitive to the patient's feelings but remains objective enough to help the patient achieve positive outcomes? honest empathic competent caring
empathic
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 open-ended question validating question closed question
open-ended question
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should: ask if the client realizes the infection is a direct result of the drug use. consult with the social worker regarding inpatient drug rehabilitation. ask the client for a urine specimen for urine drug use screening. remain honest, open, and frank.
remain honest, open, and frank.
The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response should the nurse provide to best demonstrate empathy? "I know how you feel. I was the primary caregiver for my father when he was dying." "Just take your time. I am listening." "It is difficult when family members are ill. It helps if you take some time for yourself." "It's okay to cry. Sometimes that helps us to feel better."
"Just take your time. I am listening."
A nurse is transferring a patient from a hospital setting to a long-term care facility. What action is most important to ensure continuity of care for this patient? Carefully moving all the patient's personal items Providing accurate and complete communication to the new facility. Notifying all departments of the room change Asking family members to take home the patient's jewelry, money, or other valuables
Providing accurate and complete communication to the new facility.
In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the patient. This is an example of which step in discharge planning? Making home healthcare referrals Developing goals with the patient Providing patient teaching Assessing the patient's needs and identifying problems
Providing patient teaching
