Exam 3 Foundations
A nurse caring for a client who was recently diagnosed with metastatic lung cancer finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy?
"I see you are upset. Would you like to talk?" Nurses use empathy, an intuitive awareness of what a client is experiencing, to perceive the client's emotional state and need for support. Empathy helps nurses become effective at providing for the client's needs while remaining compassionately detached.
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?" The use of the clarifying question or comment allows the nurse to gain an understanding of a client's comment.
An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate? You Selected:
"It combines nursing science with information management and analytical sciences." The ANA defines nursing informatics (NI) as "the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice."
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." Reflection means repeating or paraphrasing the client's own statement back to the client to verify that the nurse understands what the client is saying. identifying the main emotional themes.
An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.
"This system fits nicely into how we work." "We've noticed that this system really helps to save us valuable time." "Using the system is highly intuitive."
While the nurse is caring for a hearing impaired client, and a family member of the client states, "What do you think is the best way to communicate?" What is the best response by the nurse?
"Use flash cards and writing pads." Using flash cards and writing pads to communicate is a good substitute for verbal instructions for persons with hearing impairment.
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." Reflecting or paraphrasing confirms that the nurse is following the conversation and demonstrates listening, thus allowing the client to elaborate further.
When performing fall risk assessments, which client does the nurse determine is most at risk for falls?
A 70-year-old female with postural hypotension who wears eyeglasses, but has no history of falls Risk factors for falls include age older than 65 years, documented history of falls; impaired vision or sense of balance; altered gait or posture; a medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics; postural hypotension; slowed reaction time; confusion or disorientation; impaired mobility; weakness and physical frailty; and/or an unfamiliar environment. The 70-year-old client with postural hypotension who wears eyeglasses, but has no history of falls, has three of these risk factors.
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. The SBAR technique of communication has numerous applications, including nurse-physician communication surrounding acute client developments.
Which guideline is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults?
Allow ample time for psychomotor skills. Older adults need more time to learn psychomotor skills. Sessions of 2 to 3 hours are too long; short-term rather than long-term memory loss affects older adults; and information can be structured or nonstructured, depending on the content.
The nurse is caring for a 70-year-old client with a fractured wrist. Which is the best method to determine whether the client has retained the information taught?
Ask the client to recall after approximately 15 minutes. Asking a client to recall what has been discussed after approximately 15 minutes helps determine what information the client has actually retained.
When preparing client teaching materials, how does the nurse best assess a client's preferred learning style?
Ask the client, "Do you learn best by observing, valuing, or doing?" One way to determine the client's preferred learning style is to ask the client about the client's personal learning preference--whether cognitive, affective, or psychomotor.
The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?
Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification
A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client?
Assessing importance Using the 0 to 10 scale is a key aspect of assessing importance with motivational interviewing. It helps the nurse to understand the client's feelings toward the recommended activity and can help start a conversation about why the client chose that rating number—and what the nurse could do to increase the number.
What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household?
Avoid stuffed animals and blankets in the crib. Suffocation is a hazard for infants, especially before the age of 4 months.
The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which is the most appropriate method for the nurse to use in teaching this client?
Begin the session with a reference to the client's actual experience. Beginning the session with a reference to the client's actual experience will help provide a link to which the new learning can connect.
An informatics nurse specialist is using technology to collect health care-related data from multiple sources in an attempt to transform that data to answer questions. The nurse plans to use this data to assist with the management of clients regardless of the setting. The nurse is using which area of analytics?
Big Data Big Data comprises the accumulation of health care-related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. (ANA)
Which learning domain is the focus for instruction when the nurse educates a new mother about the breast and its role in milk production for feeding the newborn?
Cognitive Educating a new mother about the physiology of the breast and its role in milk production is an example of cognitive learning, which involves the client's critical thinking and reason.
A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin." Which domains of learning does the nurse identify for this client as having been successfully addressed by education?
Cognitive, affective, and psychomotor
The parents of a school-age child are meeting with the nurse for health promotional education for their child. The child has the following assessment data: a 7-year-old male with diabetes mellitus type 1 with a hemoglobin A1C level of 8.3%, a body mass index (BMI) of 31.7, and a BMI percentile of 99. What are the most appropriate learning diagnoses for this first session?
Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance. The data present for the nurse to use for planning the educational session do not give enough information to determine the parents' concepts of their child's health. Before making judgments on their readiness to learn, the nurse must assess them. There are not enough data to support sedentary lifestyle. When making a diagnosis, do not address actual problems as risks.
The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan?
Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique. Documentation of teaching must include who was taught, the topic taught, and some indication of the success of the learning plan beyond a simple verbal statement by the client.
As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?
Have the client rate pain level, and reschedule the teaching session.
An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency?
Health teaching and health promotion
The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request?
Identify and recommend some credible websites appropriate to the spouse's learning needs. Web-based resources can be a useful tool in client education, but suitability and accuracy need to be carefully considered.
An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?
Identify clients at risk for infection
The nurse is conducting a teaching session regarding HIV/AIDS for hotel workers in the community. Which nursing actions are appropriate for providing this type of adult learning? Select all that apply.
Identifying the length of the session Beginning with basic concepts about HIV/AIDS Providing adequate lighting and comfortable temperature Identifying the time, place, and content for the next teaching session The nurse should identify the length of the session, because it prepares the participants for the demand on their time and attention. The nurse should begin with basic concepts about HIV/AIDS, as this allows for the participants to learn from the simple to the complex. The nurse should providing adequate lighting and comfortable temperature, as these will promote an environment for learning. The nurse should identify the time, place, and content for the next teaching session, because it allows participants to plan ahead and prepare for the next session.
The nurse is preparing discharge teaching for a client with diabetes. Which information should the nurse include? Select all that apply.
Meal planning Community resources Appropriate use of a glucometer Instructions to follow up with the health care provider The nurse should teach the client with diabetes about meal planning, community resources, appropriate use of a glucometer, and instructions for follow-up care.
A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?
Most people who die in house fires die of smoke inhalation rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.
When a client says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate?
Motivational counseling The most appropriate counseling for the situation at hand would be motivational counseling. With motivational counseling, the nurse would discuss feelings and incentives with the client.
Validating question or comment
Nurse: At home, have you been taking both a water pill and a blood pressure pill every day? Did you take them both today? Patient: Yes, I took one of each with my breakfast. Validates what the nurse believes he or she has heard or observed
Closed questions or comment
Nurse: What medicine have you been taking at home? Patient: My doctor gave me a water pill and a blood pressure pill. The questions related to medication use, allergies, and an advanced directive are examples of closed communication, in which only one or a few words are required for an answer. Two- word answer, a "yes" or "no," or a forced choice.
Sequencing question or comment
Patien't: I don't feel like myself anymore. I've been taking my blood medicine. I'm tired and don't have energy. Nurse: Your tiredness began after you started taking medicine? used to place events in a chronological order or to investigate a possible cause and effect relationship
Clarifying question
Patient: I have never needed to take medicine before. Nurse: Is this the first health problem you have ever had? Patient: Yes, I have always been healthy. Allows the nurse to gain an understanding
Reflective question or comment
Patient: I've been really upset about my blood pressure Nurse: You've been upset..... Patient: I guess I am worried about what could happen involves repeating what the person has said or describing the person's feelings
A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching?
Preventing illness
What is the primary role of the nurse in the care of clients who experience domestic violence?
Providing prompt recognition of the potential or actual threat to safety The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.
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 neurolgoical checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed?
Recommendation This information is the recommendation of the nurse regarding the client's condition.
The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?
Risk for Poisoning related to poor eyesight and the inability to read medication labels Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of the multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance use in this client.
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. When utilizing an interpreter, speak clearly in a conversational tone and directly address the client.
The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?
Take the restraints off, stay with her, and talk gently to her. Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death.
When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?
Talk with animation and vocal inflection to stimulate the client aurally.
A client is reluctant to learn to do finger sticks for home international normalized ratio (INR) monitoring. What is the best statement by the nurse?
Tell me what you know about these tests. Saying something to encourage the client to openly discuss personal issues is the best option.
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 keeps communication simple and concrete. The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. There are several nursing actions that would be appropriate to facilitate. The nurse would maintain eye contact with the client. The nurse shows patience and gives the client time to respond. The nurse keeps communication simple and concrete.
A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.
The nurse uses medical jargon frequently when discussing the teaching plan. The nurse fails to accept that clients have the right to change their minds. The nurse ignores the restrictions of the client's environment. The nurse does negotiate goals with the client. The nurse would evaluate what the client had learned. The nurse would review educational media when planning learner objectives.
A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school?
The students will demonstrate proper use of safety equipment while playing sports. Educating school-age children about safety when playing sports and other physical activities is an important responsibility of school nurses.
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 The scenario defines characteristics of the working phase, during which the nurse and client work together to meet the client's physical and psychosocial needs.
For which purposes would observing silence be appropriate? Select all that apply.
To allow the client time to reflect on the client's thoughts To allow the client time to reflect on communication that has occurred To allow the client time to formulate an answer after asking the client a question To allow the client time to compose oneself when the client is upset
A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to:
ask to speak to the physician in private and address the disrespectful remark. When disruptive physician behavior occurs, it is best to respond assertively and confront the physician directly.
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. Both ferrous sulfate and bismuth subsalicylate can cause darkening of the stool, and either may be the causative agent in this case.
A client shares with the nurse how much the client appreciates understanding the physiology of breastfeeding. The client states, "I felt very comfortable with what you explained to me, and I feel I will be successful at breastfeeding." In affective learning, this represents the nurse:
creating an atmosphere for discussion of feelings When working with clients to change beliefs, values, and attitudes (i.e., affective learning), the nurse creates an atmosphere in which clients can honestly and freely discuss their feelings and emotions.
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. Factors that distort the quality of a message can interfere with communication at any point in the process. These distractors might be from the television, or from pain or discomfort experienced by the client.
The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:
polypharmacy and use of multiple extension cords. Older adults have significant risk of falls at home due to aging changes such as diminished cognition, vision, hearing, and balance. Multiple medications, especially those altering level of consciousness, and household objects that challenge safe mobility, are common dangers. fffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff
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. One key factor to effective communication is to be open, accepting, frank, respectful, and without prejudice.
The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When should the nurse begin client teaching?
During the admission process
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?" Using an open-ended question is the most effective way to elicit further conversation and information.
The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?
"Tell me about what signs of infection you will report to the health care provider."
A registered nurse (RN) is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate for the RN to delegate to the LPN/LVN? Select all that apply.
-Administer oral aspirin and lisinopril to the client with hypertension -Insert a nasogastric tube in a client with absent bowel sounds -Reinforce a postsurgical abdominal dressing Administration of oral medication, insertion of nasogastric tubes, and dressing changes are all within the scope of practice for a LPN/LVN.
Which actions should the nurse take when preparing for and conducting a teaching session for clients with visual impairment? Select all that apply.
-Avoiding the use of materials printed on glossy paper -Using a lamp that shines over the clients' shoulders -Ensuring that the clients are wearing prescription eyeglasses The nurse should avoid using materials printed on glossy paper, because glossy paper reflects light, causing a glare that makes reading uncomfortable. The usage of a lamp that shines over the clients' shoulders concentrates light on a small area where the clients need to focus. Ensuring the clients are wearing prescription eyeglasses will maximize their ability to perceive sensory stimuli.
Which is a skill appropriate to use in therapeutic communication?
Control the tone of the voice to avoid hidden messages. Conversation skills used in therapeutic communication include controlling the tone of one's voice so that exactly what is intended is conveyed and not any hidden message.
The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When should the nurse begin client teaching?
During the admission process The client should be educated during the process of admission regarding what to expect, patient rights, etc. The client should be educated prior to diagnostic testing.
A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting?
Empathy An empathic nurse is sensitive to the client's feelings and problems but remains objective enough to help the client work to attain positive outcomes.
During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:
Nurse: "Why did your physician send you here to be admitted?" Patient: He told me that my blood pressure is high and I need testing. When obtaining a nursing history, use the open-ended question technique to allow the client a wide range of possible responses.
When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?
Psychomotor Because the client learns better by practicing the self-administration of the insulin injection alone, the client's learning style falls in the psychomotor domain.
The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill?
The client organizes materials needed and gives return demonstration. Being able to gather all equipment needed for a skill and then perform it demonstrates proficiency.
The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education?
The client will be able to perform proper breast self-examination for breast cancer detection and prevention. This client education is focused on teaching the client a psychomotor skill for the prupose of early detection of breast cancer. Therefore, an appropriate learning outcome would be that the client is able to perform the skill properly.
