Exam 1

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 is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?"

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:

"Were you tired and depressed before starting the new medication?"

In which situation would the SBAR technique of communication be most appropriate?

A nurse is calling a physician to report a client's new onset of chest pain.

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

Which example of client care is not the responsibility of the nurse?

Confirming a medical diagnosis

The nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist?

Interpersonal

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

Orientation phase

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis?

Risk for falls

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with this diagnosis that the client's general appearance can nonverbally communicate to the nurse include:

easy wrinkling of the skin and sunken eyes.

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using:

medical terminology

A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response?

"Share with me the advantages and disadvantages of your options as you see them."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

"What day of the week is it?"

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?

"You're worried about how you will tolerate the pain associated with labor."

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?

- Be silent and allow the client to continue speaking when ready.

Which action exemplifies the purpose of evaluation in the nursing process?

Decide whether to continue, modify, or terminate client care.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

Disturbed sleep pattern

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

Empathy

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?

Encouraging elaboration

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

Pain -Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?

"All of the people got themselves out of the car?"

A client has just been given a diagnosis of cirrhosis of the liver. Which statements by the nurse should be avoided because they could impede communication? Select all that apply.

"Cheer up. Tomorrow is another day." "Your doctor knows best." "Don't worry. You will be just fine in another day or two." "Everything will be all right."

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?"

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 know this is hard for you. Is there any way I can help?"

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this follow-up with the client, the nurse is in which step of the nursing process?

Evaluation

Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?

Evidence-based practice -as defined by Quality and Safety Education for Nurses (QSEN) indicates the need to value evidence-based practice findings to ensure that the best clinical practice is provided for clients. When health care institutions change their policies based on research, this reflects the significance of this QSEN competency. Informatics is the use of techonology to gather and use data to improve client health. Person-centered care is a model of patient care based on holistic roots in which the nurse or other caregiver uses every clinical encounter to assess how the person is doing and to communicate respect, compassion, and care. Teamwork and collaboration are values in nursing that emphasize the benefits of health care team members working together to meet clients' needs rather than just individually.

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

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

Facial expressions

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

The purpose of obtaining a nursing history is to:

Identify actual and potential health problems

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. -If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding- The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a newborn. Although the infant does demonstrate an impaired sleep pattern and impaired comfort, these are not as important as the infant's inability to gain weight. There is no evidence that the mother is at risk for impaired parenting.

A client is brought to the emergency room in respiratory arrest and is immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client?

Ineffective spontaneous ventilation

Which are examples of objective data? Select all that apply.

Laboratory test results Breath sounds on auscultation A client's temperature

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?

Prioritize the nursing diagnoses.

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting -A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent.

A client is admitted for removal of a cancerous tumor of the lung. The client expresses concern to the nurse about how the cancer and the treatment will affect the client's family. The client explains that the client's spouse has never worked outside the home and that the client is concerned that their financial situation will be compromised by this illness. Which would be the best nursing diagnosis for this client?

Risk for Interrupted Family Processes

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

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?

Speak directly to the client.

The clinical nurse manager is evaluating a new nurse who has been employed for 3 months. What type of knowledge does the manager evaluate that is required for competent clinical reasoning? Select all that apply.

The nurse is committed to the organization's mission and values. The nurse is able to organize and manage time efficiently. The nurse understands nursing and medical terminology.

The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis?

The nurse observes unsafe conditions in the client's home.

Which technique would a nurse employ when using listening skills appropriately when interviewing a client?

The nurse would listen to the themes in the client's comments.

The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of:

etiology

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

have group members confront the dominant member to promote the needed team work. -Effective groups have members who are mutually respectful. If a group member dominates or thwarts the group process, then the leader or other group members must confront the member to promote the needed collegial relationship

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:

involve the child's stuffed animal in the educational session.

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 mother is at the bedside in tears. The mother states, "I just want him to know I am here with him." To address the needs of the mother and the client, the nurse should:

place a chair next to the bed and encourage the mother to hold the son's hand. -Despite its individuality, touch is viewed as one of the most effective nonverbal ways to express feelings of comfort, love, affection, security, anger, frustration, aggression, excitement, and many others.

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:

remain honest, open, and frank.

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the client to explain the statement.

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?

"I will start an IV that will add fluids directly to the blood stream."

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"Why did your physician send you here to be admitted?"

patient centered care

-concept to improve work efficiency by changing the way that patient care is delivered -providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

Which statement is true regarding addressing a priority problem?

A priority problem requires a nursing intervention before another problem is addressed.

Put the phases of the nursing process in the correct order.

ADPIE

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

Actual nursing diagnosis

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?

Assertive

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

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

What must the nurse do to identify actual or potential health problems?

Gather data from sources- The nursing process includes: assessment, diagnosis, planning, implementation, and evaluation. The first phase, assessment, is the collection of data to identify actual or potential health problems for nursing interventions. Aside from evaluation, which is the final phase of the nursing process and involves assessing the client's progress toward meeting goals established in the plan of care

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

The nurse notices during an assessment interview that the client cannot stay focused and jumps from one topic to another. The client also is speaking very rapidly and at times incoherently. What should the nurse suspect is the main cause of this behavior?

High anxiety

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders.

Which are ciriticisms that have been made of the use of nursing diagnoses in nursing practice? Select all that apply.

Nursing diagnoses apply limits to nursing practice. Nursing diagnoses discourage innovative thinking. Nursing diagnoses focus on negative client factors. Nursing diagnoses promote a paternalistic attitude in health care providers.

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?

Objective

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

A nurse enters the client's room and states, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." The nurse then gives the client a printed card with this information. In the helping relationship, which phase does this represent?

Orientation phase

The nurse makes a contract with the client during which phase of the nurse-client relationship?

Orientation phase

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

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 stares at the floor and states, "I feel fine."

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly.

When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?

The client's tone of voice

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?

The working phase

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

Therapeutic communication

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

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

Trustworthy and confident

A nurse is performing an admission assessment with a non-English speaking client. Which actions can the nurse take to enhance communication? (Select all that apply.)

Use an electronic translator. Contact a telephone-based medical interpreter. Request assistance from an agency interpreter.

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

Working phase

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to priortitize

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses.

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.

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:

allow the client to set the pace.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

an audiologist.

Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice?

analysis

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 afraid of waking up during surgery. The best response by the nurse is to:

ask why the client thinks the client will wake up during surgery.

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by:

asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate.

Each of the following facilitates a therapeutic nurse-client relationship except:

closed-ended questions.

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"

The child of a client who just died in a hospice unit arrives and asks, "May I please stay and sit at the bedside? I really wanted to be here so my dad would not die alone." Which statement made by the nurse best demonstrates the use of empathy

"I will close the door so you can spend some quiet time at the bedside."

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?

-"What hobbies do you enjoy?" - "Why did the health care provider prescribe this medication for you?"

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

-The nurse maintains eye contact with the client. -The nurse shows patience with the client and gives the client time to respond. -The nurse keeps communication simple and concrete.

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:

eliminate as many distractions as possible.

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview.

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

Analyze the data and create an individualized nursing diagnosis.

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficient data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse.

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?

Consult with another nurse for that colleague's description of the assessment or observations.

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills?

Ensuring the client's privacy during dressing changes and providing an explanation during the procedure

In a helping relationship, the nurse would most likely perform what action?

Establish communication that is continuous and reciprocal.

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.