Foundations exam 1
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? "Was there any cracking of the windshield?" "Were there any fatalities in the other vehicle?" "All of the people got themselves out of the car?" "Did a police officer take a report at the accident scene?"
"All of the people got themselves out of the car?"
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?" "What sorts of things do you do for fun?" "What plans do you have after you are discharged?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"
"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?"
A client expresses worry about upcoming surgery. Which response by the nurse is a cliché? "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."
"Don't worry, everything will be fine."
The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? "I can lower my blood pressure by losing weight." "Osteoarthritis in my knees may be because of my weight." "I can monitor my caloric intake by measuring portions." "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."
"I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."
A client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which statement by the client suggests that the nurse's teaching has resulted in affective learning? "I'm starting to see how my lifestyle has caused me to end up here." "I understand why they're not letting me eat anything for the time being." "My intravenous drip will keep me from getting dehydrated right now." "I can see how things could have been much worse if I hadn't gotten to the hospital when I did."
"I'm starting to see how my lifestyle has caused me to end up here."
Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement? "The rules made by the board of nursing don't reflect my practice." "The board of nursing exists to protect the safety of the public." "The board of nursing is established by state legislation." "Board of nursing rules keep unlicensed people from practicing nursing."
"The rules made by the board of nursing don't reflect my 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: "It sounds as if your surgery is a pretty scary procedure." "You have a great surgeon. You have nothing to worry about." "You shouldn't be nervous. We perform this procedure every day." "The thought of having surgery is keeping you awake."
"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.
The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse? "Let me document that you can walk." "Those physical therapists work wonders. "You have made an amazing recovery." "Are you supposed to be out of the wheelchair?"
"You have made an amazing recovery."
Which is the proper way to document midnight in a client's record? 0000 2401 1200 1201
0000
The parents of an infant with apnea need to be educated on the apnea monitor and cardiopulmonary resuscitation. What should the nurse assess first regarding the parents? Educational levels Home environment Infant bonding Baseline knowledge of these concepts
Baseline knowledge of these concepts
A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching? Blocking 30 minutes of time for skill teaching Using dolls to demonstrate psychomotor skills Ensuring the client's parents are present Giving stickers as a reward for task completion
Blocking 30 minutes of time for skill teaching
Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing? Certification Licensure Accreditation Validation
Certification
A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning? Cognitive Affective Psychomotor Interpersonal
Cognitive
A nurse instructs a client to tell the nurse about the side effects of a medication. What learning domain is the nurse evaluating? Affective Cognitive Psychomotor Emotional
Cognitive
When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall? Cognitive Affective Psychomotor Interpersonal
Cognitive
The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory? Adaptive learning theory Behavioral learning theory Cognitive learning theory Developmental learning theory
Cognitive learning theory
Which is a skill appropriate to use in therapeutic communication? Control the tone of the voice to avoid hidden messages. Avoid the use of periods of silence. Use cliches to enhance a client's understanding of information. Be precise and inflexible regarding the intent of the conversation.
Control the tone of the voice to avoid hidden messages.
A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain? Demonstrating the technique for insulin self-injection Describing the signs and symptoms of low blood sugar Explaining what to do if hypoglycemia occurs Reviewing with the client appropriate foods to eat
Demonstrating the technique for insulin self-injection
A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client? Tell the client how to move the walker as the client ambulates. Explain how the walker supports the client's lower extremities. Fully discuss the rationale for using the walker. Describe how the walker can improve the client's quality of life.
Describe how the walker can improve the client's quality of life.
Which term describes a nurse who is sensitive to the client's feelings, but remains objective enough to help the client achieve positive outcomes? Competent Caring Honest Empathic
Empathic
When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized? Have the clients read material after client education. Be sure that clients are formally engaged. Include educational strategies that encourage clients to be active participants. Administer tests to evaluate learning.
Include educational strategies that encourage clients to be active participants.
A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients? Include the child in the education; ask questions of both the mother and the child. Focus mainly on the mother; ask the child a couple of simple questions. Provide the mother with written materials; teach the child about keeping the cast dry. Separate the mother and the child; teach the mother and then let the mother teach the child.
Include the child in the education; ask questions of both the mother and the child.
Which strategy might a nurse use to increase compliance with education? Include the client and family as partners. Use short, simple sentences for all ages. Provide verbal instruction at all times. Maintain a clear role as the authority.
Include the client and family as partners.
A new nurse is developing a teaching plan for an assigned client who has just started receiving chemotherapy. The nurse plans to teach the client about symptoms to report after chemotherapy. What is the priority action by the nurse? Ask other nurses what should be included in the content. Find out what education has been provided to the client. Refer the client to online resources to learn about this topic. Research information available in journal articles and other authoritative sources.
Research information available in journal articles and other authoritative sources.
The nurse is leading a discussion with a group of adolescents about what to do "if a friend shows you a gun at school in a backpack." The nurse is encouraging the adolescents to explore consequences of their actions for decisions made. What value transmission is the nurse demonstrating? Modeling behavior Laissez-faire approach Rewarding and punishing Responsible choice
Responsible choice
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 stares at the floor and states, "I feel fine." The client smiles at the nurse and states, "I cannot wait to go home." 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."
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 demonstrate self-efficacy and improved body image. The client will have restoration of breast function. The client will be able to perform proper breast self-examination for breast cancer detection and prevention. The client will demonstrate improved coping skills.
The client will be able to perform proper breast self-examination for breast cancer detection and prevention.
A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? Their readiness to learn is often related to a developmental task or social role. Peer group acceptance is a critical issue for this age group. The material presented should focus on future application. Previous experiences have little impact on learning.
Their readiness to learn is often related to a developmental task or social role.
What is the goal of the nurse in a helping relationship with a client? To provide hands-on physical care To ensure safety while caring for the client To assist the client to identify and achieve goals To facilitate the client's interactions with others
To assist the client to identify and achieve goals
Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report? To document everyday occurrences To document the need for disciplinary action To improve quality of care To initiate litigation
To improve quality of care
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: look directly at the client and state, "You are afraid of waking up during surgery." ask the surgeon to come to the bedside to reassure the client. state "everyone is afraid of that." ask why the client thinks the client will wake up during surgery.
ask why the client thinks the client will wake up during surgery.
An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's: critical thinking. emotions or feelings. muscular movements. physical demonstration.
critical thinking Cognitive learning refers to rational thought or critical thinking. Affective learning is influenced by emotions or feelings. Psychomotor learning refers to the muscular movements learned to perform new skills and procedures; for example, when a mother successfully and independently breastfeeds an infant, the mother has physically demonstrated psychomotor learning.
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: plan a meeting where the dominant person cannot attend. pick a team leader who is not the dominant member. have group members confront the dominant member to promote the needed team work. have group members issue a written warning to the dominant member.
have group members confront the dominant member to promote the needed team work.
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. interpretation of data. important information. relevant data.
interpretation of data.
When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using: written material. audio-visual material. demonstration. medical terminology.
medical terminology.
The client being admitted to the oncology unit conveys wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the client that it would be in the client's best interest to obtain which document? A will A living will Proof of health care power of attorney A proxy directive
A living will
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? "Is your name Evelyn?" "Are you in a hospital?" "Is today the first day of the month?" "What day of the week is it?"
"What day of the week is it?"
An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis? Orthopedic surgical history Personal perception of health and aging Floor plan of the client's dwelling Formal religious beliefs
Personal perception of health and aging
A client 36 years of age is able to understand the health education when given the opportunity to put the education into practice. The nurse helps the client to self-administer the medication dosage before the client is discharged from the health care facility. Which domain correctly identifies the client's learning style? Cognitive Affective Psychomotor Interpersonal
Psychomotor
A nurse assisting a new mother in the act of breastfeeding represents which form of learning? Affective Psychomotor Cognitive Simplistic
Psychomotor
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? Cognitive Affective Psychomotor Interpersonal
Psychomotor
An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed? Unintentional tort Invasion of privacy Defamation of character Negligence of duty
Invasion of privacy
Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged? Defamation of character Invasion of privacy Unintentional negligence Intentional negligence
Invasion of privacy
When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed? Slander Assault Invasion of privacy Fraud
Invasion of privacy
When the nurse informs a client's employer of the client's autoimmune deficiency disease, the nurse is committing the tort of: breach of contract. assault. invasion of privacy. battery.
Invasion of privacy
What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women? Role play Lecture/discussion Demonstration Test taking
Lecture/discussion
The daughter of an older adult client asks the nurse why a urine specimen was collected from the client earlier that morning. How can the nurse best respond to the daughter's query? "We want to test the urine to make sure your mother doesn't have a urinary tract infection." "Your mother's physician ordered a urine C&S to rule out a UTI." "We want to do everything we can to get your mother healthy again." "Sometimes sick urine can make the whole person sick, and this might be causing the fever."
"We want to test the urine to make sure your mother doesn't have a urinary tract infection."
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? "Have you ever had chest pain prior to this admission?" "Could you tell me more about how you are feeling right now?" "I have had chest pain before, and it is really scary!" "Did you take any medication when you had the pain?"
"Could you tell me more about how you are feeling right now?"
While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally? "I will call the client and ask for permission to share this infomation with you." "I cannot give you that information due to client confidentiality." "Do you have any identification proving that you are related to the client?" "I'm busy right now but can talk later."
"I cannot give you that information due to client confidentiality."
A nurse pays a house visit to a client who is on parenteral nutrition. The client reports missing enjoying food with the client's family. What is the most appropriate response by the nurse? "Tell me more about how it feels to eat with your family." "You can sit with your family at meal times, even though you don't eat." "In a few weeks you may be allowed to eat a little; you may enjoy it then." "I know that you must be missing your favorite foods."
"Tell me more about how it feels to eat with your family."
A new mother asks the nurse in a pediatric office for information about safety, diet, and immunizations for the baby. What is the best response by the nurse to address the mother's readiness for enhanced coping? "Are you having a difficult time coping with the new baby?" "You don't need to worry about all of these things at once." "I have several pamphlets and online parenting videos that are helpful." "Would you like to talk with a counselor about your depression?"
"I have several pamphlets and online parenting videos that are helpful."
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 nurse confides in a nurse friend, "I never report minor incidents. The charge nurse always wants a variance report filled out and they take so much time." Which responses by the friend are indicated? Select all that apply. "As long as no one is hurt, I don't see a problem with not reporting minor incidences." "I don't blame you, I think the charge nurse is just trying to get us in trouble." "Having documentation might keep you out of trouble someday." "Reporting helps us fix problems that result in danger to clients." "I usually document the problem in the chart, but don't fill out a report."
"Reporting helps us fix problems that result in danger to clients." "Having documentation might keep you out of trouble someday."
A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse? "A living will can only be used in the state in which it was created." "Take it with you. It is recognized universally in the United States." "As long as your family knows your medical wishes, you will not need it." "We have it on file here, so any hospital can call and get a copy."
"Take it with you. It is recognized universally in the United States."
A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client? "Your doctor wants you to take your warfarin every day, go to the clinic every week to have blood drawn, and then wait for any dosage change. Do you understand?" "You have to take your warfarin and go to the clinic every week for a blood draw. It's not the most convenient way to live, but you have to do it." "The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?" "Atrial fibrillation is when your upper heart beats ineffectively and blood clots can go to your brain. Would you like some printed information about this?"
"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"
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? "I will be by your side throughout the procedure; the procedure will be painless if you don't move." "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." "The procedure may take only 2 minutes, so you might get through it by mentally counting up to 120." "You may feel very uncomfortable when the needle goes in, but you should breathe rhythmically."
"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 nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond? "This must be very difficult for you to hear. How do you feel right now?" "Why do you think that the care team has made this recommendation?" "Do you understand that everyone here has your spouse's best interest at heart?" "What would help you accept that this is best for both of you?"
"This must be very difficult for you to hear. How do you feel right now?"
The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response? "After I demonstrate it once, your mother will be able to do it." "When 15 minutes have passed, I will ask your mother to show me how to instill the drops." "We can never be completely sure that your mother understands instructions." "I will have you bring your mother back next week to see how things are going."
"When 15 minutes have passed, I will ask your mother to show me how to instill the drops."
Which is an open-ended question? "Do you take this medication daily?" "Why did the health care provider prescribe this medication for you?" "When was the last time you had your prescription refilled?" "How many tablets do you take at one time?"
"Why did the health care provider prescribe this medication for you?"
During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: "Are you allergic to any medications?" "Can you tell me the medications you take on a daily basis?" "Do you have an advanced directive or a living will?" "Why did your physician send you here to be admitted?"
"Why did your physician send you here to be admitted?"
Which statement describes the person who is likely the most motivated to learn? A 29-year-old male whose significant other is insisting on the client receiving the education A 52-year-old male who has been hired to drive the client home from the clinic A 70-year-old female who is the client's spouse and is learning the care so the client can come home A 25-year-old female who just completed a course of physical therapy
A 70-year-old female who is the client's spouse and is learning the care so the client can come home
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. A nurse is facilitating a family meeting to coordinate a client's discharge planning. A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure. A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke.
A nurse is calling a physician to report a client's new onset of chest pain.
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. A nurse describes a client on Twitter by giving the room number rather than the name of the client. A nurse posts pictures of a client who accomplished a goal of losing 100 lb and later deletes the photo. A nurse describes a client on Twitter by giving the client's diagnosis rather than the client's name.
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 scenario is an example of certification? A nurse who demonstrates advanced expertise in a content area of nursing through special testing A hospital that meets the standards of the Joint Commission An education program that meets the standards of the National League for Nursing A graduate of a nursing education program who passes the NCLEX-RN
A nurse who demonstrates advanced expertise in a content area of nursing through special testing
Which nurse would most likely be the best communicator? An advanced practice nurse A nurse who easily develops a rapport with clients A nurse who is bilingual A nurse who is proficient in sign language
A nurse who easily develops a rapport with clients
A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf? A surrogate decision maker A church-appointed guardian A significant other A best friend
A surrogate decision maker
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? A yes or no question A directing question An open-ended question A reflective question
A yes or no question
A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing? Assault Battery Negligence Defamation
Assault
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 Use facial and hand gestures Contact a person skilled in sign language Provide paper and pencil for written communication
Assess how the client would like to communicate
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? Taught lesson at a school-age developmental level in an authoritarian style while the client was at meal time Taught lesson at an adult developmental level (age 35) using short sentences and assessed motor skills Assessed the client's understanding of health and answered questions on an age-appropriate level while the television was on in the room Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification
Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification
Before starting the education process, the nurse should determine the preferred learning style, age and developmental level, capacity to learn, motivation level, readiness to learn, and learning needs of the client. How does this help the nurse in the client's health education? By implementing effective teaching By fulfilling the client's requirements By assisting the client's learning By reducing chances of any miscommunication
By implementing effective teaching
Which actions should the nurse take to ensure that client information remains confidential? Select all that apply. Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. Exit the client's room when called on the hospital-issued cell phone about another client on the team. Verify the number in the fax machine as correct prior to transmission. Access client information on the portable computer in the hallway where visitors are present. Print client information to a printer shared with another unit.
Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. Exit the client's room when called on the hospital-issued cell phone about another client on the team. Verify the number in the fax machine as correct prior to transmission.
Which are appropriate actions for protecting clients' identities? Select all that apply. Orient computer screens toward the public view. Ensure that clients' names on charts are visible to the public. Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.
Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.
A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? Document the client's claims and the events surrounding the alleged incident. Consult with the hospital's legal department as soon as possible. Consult with practice advisors from the state board of nursing. Enlist support from nursing and nonnursing colleagues from the unit.
Document the client's claims and the events surrounding the alleged incident.
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? Restating Clarification Reflection Encouraging elaboration
Encouraging elaboration
A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase? Make formal introductions Create a contract regarding the relationship Provide assistance to achieve goals Examine goals of the relationship to determine whether they were achieved
Examine goals of the relationship to determine whether they were achieved
A nurse is caring for a client who is visually impaired. Which action is a recommended guideline for communication with this client? Ease into the room without announcing your presence until you can touch the client. Speak in a louder voice to make up for the client's inability to perceive visual cues. Explain the reason for touching the client before doing so. Keep communication simple and concrete.
Explain the reason for touching the client before doing so.
A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability? Administering the medication with the other evening medications Telling the client that the medication will be given the following morning Filling out an occurrence report and notifying the healthcare provider Documenting in the chart a narrative note about the occurrence
Filling out an occurrence report and notifying the healthcare provider
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 Seeking clarification Giving information Encouraging elaboration
Giving false reassurance
A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic? "You should try laser surgery." "Why don't you try laser surgery?" "Have you ever thought of laser surgery?" "My grandfather also benefited from laser surgery."
Have you ever thought of laser surgery?
A nurse caring for an unconscious client knows that communication is important even if the client does not respond. Which nonverbal action by the nurse would communicate caring? Making constant eye contact with the client Waving to the client when entering the room Sighing frequently while providing care Holding the client's hand while talking
Holding the client's hand while talking
A client age 42 years recovering from a myocardial infarction (MI) is having difficulty following the care plan to stop smoking and exercise. What is the nurse's best response to this client? State that the client is not trying hard enough. Warn that the client will have another MI and that it will be the client's own fault. Explain that the client's cigarettes will be taken away if the client smokes again. Ignore the behavior and recommend a behavior modification program.
Ignore the behavior and recommend a behavior modification program.
The family of a client in a burn unit ask the nurse for information. The nurse sits with the family and discusses their concerns. What type of communication is this? Intrapersonal Interpersonal Organizational Focused
Interpersonal
Which action by the nurse would facilitate the nurse-client relationship during the orientation phase? Providing assistance to meet activities of daily living Introducing oneself to the client by name Designing a specific education plan of care Preparing for termination of the relationship
Introducing oneself to the client by name
A nurse gives a speech on nutrition to a group of pregnant women. Within the model of the communication process, what is the speech itself known as? Stimulus Source Message Channel
Message
A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce the client's risk for cancer, improve respiratory status, and enhance the quality of life. The nurse also shares a personal story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client? Motivational Long-term Developmental Situational
Motivational Motivational counseling involves discussing feelings and incentives with the client. Long-term counseling extends over a period of time. Developmental counseling occurs when a client is going through a developmental stage or passage. Situational counseling occurs when a client faces an event or situational crisis.
The nurse gives a change-of-shift report to the oncoming nurse. What vital information should the nurse include in the report? Select all that apply. Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. No new labs have been ordered after surgery. The client has a clean and dry abdominal dressing. The client's hobby is photography, which we had a conversation about. Pain level is currently a 3 following administration of intravenous morphine. The client has two dogs at home; the client's spouse is taking care of the dogs.
Mrs. B. Johnson is in Room 564, admitted postoperatively for an open cholecystectomy. No new labs have been ordered after surgery. The client has a clean and dry abdominal dressing. Pain level is currently a 3 following administration of intravenous morphine.
Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers? Telling the mothers to avoid taking over-the-counter drugs while breastfeeding Showing charts to the mothers that illustrate the types of breast milk Observing a mother expressing the breast milk Advising the mothers to drink plenty of water
Observing a mother expressing the breast milk
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Recording nursing interventions Identifying nursing diagnoses or clients' needs Omitting clients' responses to nursing interventions Documenting clients' health histories and discharge planning
Omitting clients' responses to nursing interventions
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 Working phase Termination phase Evaluation phase
Orientation phase
The nurse makes a contract with the client during which phase of the nurse-client relationship? Intimate phase Orientation phase Working phase Termination phase
Orientation phase
When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship? Intimate phase Orientation phase Working phase Termination phase
Orientation phase
A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress? Reinforcement Motivation Health promotion Positive feedback
Positive feedback
A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss? Preparation Maintenance Precontemplation Contemplation
Preparation
During the admission assessment of a client with a suspected mandibular fracture, the client discloses to the nurse that the injury results from the client's spouse hitting the client. Which action should the nurse prioritize when responding to this disclosure? Reporting the abuse to the appropriate authorities Ensuring that the client's statement is confirmed by another nurse Performing an assessment to confirm the client's statement Informing the client of the client's right to keep this information private
Reporting the abuse to the appropriate authorities
A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client? Written test Oral test Return demonstration Simulation
Return demonstration
The nursing is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? Review the hospital's process for allowing clients to view their health care records. Access the health care record at the bedside and show the client how to navigate the electronic health record. Discuss how the hospital can be fined for allowing clients to view their health care records. Explain that only a paper copy of the health care record can be viewed by the client.
Review the hospital's process for allowing clients to view their health care records.
The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class? Role-playing Role modeling Programmed instruction Panel discussion
Role-playing
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. Ensure that family members are present. Give all of the discharge instructions at once. Have the interpreter write out all of the information listed in the unit brochure.
Speak directly to the client.
A nurse and the facility have been named as defendants in a malpractice lawsuit. In addition to the nurse's attorney, whom else would be appropriate for the nurse to talk with about the case? A colleague The agency's risk manager The plaintiff's lawyer The local press
The agency's risk manager
When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept? The nurse is the expert in the teaching-learning environment. The nurse must be able to handle criticism during the process. The client and the nurse are equal participants. Assimilation and application of psychomotor concepts is essential.
The client and the nurse are equal participants.
A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction? The client is not interested. The client has a short attention span. The client belongs to a different culture. The client is a passive learner.
The client belongs to a different culture.
A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client? The client describes signs and symptoms of hypoglycemia. The client demonstrates proper technique for injecting insulin. The client expresses a desire to improve nutritional intake and lose weight. The client prepares the skin for the administration of an insulin injection.
The client describes signs and symptoms of hypoglycemia.
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 states understanding and passes a written test. The client organizes materials needed and gives return demonstration. The client verbalizes items needed and how to perform the skill. The client nods when asked about process and assists with cleanup.
The client organizes materials needed and gives return demonstration.
A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure? The nurse informs the family about advance directives. The nurse informs the family about the living will. The nurse ensures that the client signs the consent form. The nurse ensures that the client's family signs the consent form.
The nurse ensures that the client's family signs the consent form.
The nurse enters a client's room after receiving a morning report. The nurse rapidly assesses the client's airway, breathing, and circulation and greets the client by saying "Good morning." The client makes no reciprocal response to the nurse. How should the nurse best respond to the client's silence? The nurse should ask appropriate questions to understand the reasons for the client's silence. The nurse should apologize for bothering the client, perform necessary assessments efficiently, and leave the room. The nurse should document the client's withdrawal and diminished mood in the nurse's notes. The nurse should ask the client whether the client feels afraid or angry.
The nurse should ask appropriate questions to understand the reasons for the client's silence.
A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation? The nurse should ask the physician to come back and write the order. The nurse should write the order and implement it. The nurse should inform the client of the change in medication. The nurse should remind the physician later to write the work order.
The nurse should ask the physician to come back and write the order.
A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation? The nurse should have the client restrained and call the physician. The nurse should let the client go because the nurse cannot do anything. The nurse should call and inform the nursing supervisor of the situation. The nurse should warn the client that the client cannot come to the hospital again.
The nurse should call and inform the nursing supervisor of the situation.
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 introduction phase The orientation phase The termination phase
The working phase
A nurse enters the client's room and finds the client lying on the floor experiencing a seizure. After stabilizing the client, the nurse informs the physician. The physician advises the nurse to prepare an incident report. What is the purpose of an incident report? To determine the nurse's fault in the incident To evaluate the quality of care provided and assess the potential risks for injury to the client To provide information to local, state, and federal agencies To evaluate the immediate care provided by the nurse to the client
To evaluate the quality of care provided and assess the potential risks for injury to the client
Nurses are occasionally asked to witness a testator's (person who makes the will) signing of a will. Which guideline is true regarding a nurse's role in witnessing a testator's signature? Witnesses to a signature do not need to read the will. Witnesses do not need to observe the signing of the will and can sign it at a later time. A beneficiary to a will is allowed to act as a witness. A single witness is sufficient for a will.
Witnesses to a signature do not need to read the will
Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? Orientation phase Working phase Termination phase Evaluation phase
Working phase
A nurse touches the client's hand while discussing the client's diagnosis. This action is: a dynamic process. a translation. a communication channel. an auditory channel.
a communication channel.
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. assertive. passive. nurturing.
aggressive.
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. smile at the client and apologize. ignore the statement and empty the urinary catheter. inform the client that the unit was very busy that day.
sit at the bedside and allow the client to explain the statement.
A nurse is overheard in the hospital cafeteria making false, derogatory comments about a client. The nurse is guilty of: slander. libel. invasion of privacy. assault.
slander. Slander is oral defamation of character. Libel is written defamation of character
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: inform the client that several nurses will be needed to care for this wound. tell oneself to "remain calm" and remember that the nurse was trained to perform this skill. tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound. ask the charge nurse to change the assignment.
tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.
