Nursing - Communication
What is the best nursing intervention to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination? 1 Distracting the client by asking her preference regarding the infant's sex 2 Assisting the practitioner so the client's examination can be completed quickly 3 Explaining the procedure and maintaining eye contact while touching the client gently 4 Encouraging the client to squeeze the nurse's hand, close her eyes, and hold her breath
Explaining the procedure and maintaining eye contact while touching the client gently
While caring for a client in labor, a nurse notes that during a contraction there is a 15-beat/min acceleration of the fetal heart rate above the baseline. What is the nurse's next action? 1 Call the practitioner to prepare for an imminent birth. 2 Turn the mother on her left side to increase venous return. 3 Record the fetal response to contractions and continue to monitor the heart rate. 4 Document the fetal heart rate abnormality and monitor the fetal heart rate continuously.
Record the fetal response to contractions and continue to monitor the heart rate.
An adolescent is brought to the emergency department after a drug overdose. What is most therapeutic for the nurse to say when assessing the adolescent's suicide potential? 1 "Did you take pills because you wanted to kill yourself?" 2 "Do you know how much harm you can cause by taking these pills?" 3 "Lots of adolescents take too many pills because they want people to pay attention to them." 4 "A few pills aren't very much, but you seem to be asking for someone to pay attention to you.
"Did you take pills because you wanted to kill yourself?"
A nurse sits with a depressed client twice a day, but there is little verbal communication. One afternoon the client asks, "Do you think they'll ever let me out of here?" What is the best reply by the nurse? 1 "We should ask your doctor." 2 "Everyone says you're doing fine." 3 "Do you think you're ready to leave?" 4 "How do you feel about leaving here?"
"How do you feel about leaving here?"
At 40 weeks' gestation a client is admitted to the birthing unit in early labor. She asks the nurse, "Why do you want me to lie on my side?" What response explains the primary purpose of the side-lying position during labor? 1 "Lying on the side prevents fetal hyperactivity." 2 "It makes it less likely that you'll have nausea and vomiting." 3 "Lying on the side encourages the presenting part to descend." 4 "It enhances blood flow to the uterus and makes contractions easier.
"It enhances blood flow to the uterus and makes contractions easier.
The parent of a 7-year-old child wants to improve the child's performance on schoolwork. What advice should the school nurse provide? 1 "Praise your child's accomplishments." 2 "Compare your child's work to that of more successful children." 3 "Allow your child to play more and don't focus too much on academics." 4 "Complete some of the harder tasks until your child gains comprehension.
"Praise your child's accomplishments."
A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. The nurse responds: 1 "Scratching causes lesions to become more contagious." 2 "Scratching spreads dermatitis to other areas of the body." 3 "Scratching results in skin breaks that can lead to infection." 4 "Scratching produces changes that are precursors to skin cancer.
"Scratching results in skin breaks that can lead to infection."
A 34-year-old single woman visiting the clinic for a follow-up examination after a partial mastectomy tells the nurse, "I feel so unattractive!" What is the nurse's most appropriate response? 1 "Have you thought about reconstructive surgery and how it can help?" 2 "Lots of women have mastectomies—it will all work out for you in the long run." 3 "No one will notice if you wear the made-to-order brassiere that we suggested." 4 "Tell me about your concerns about your appearance because of your surgery.
"Tell me about your concerns about your appearance because of your surgery.
A 17-year-old mother is to sign the consent for her son's myringotomy. What should the nurse say to the mother about this procedure? 1 "This procedure may not help." 2 "Tell me what you know about this procedure." 3 "Your son will need to have this done again when he's older." 4 "One of your parents must also sign this because you're too young.
"Tell me what you know about this procedure."
A client is admitted for a biopsy of a tumor in her left breast. The client states, "I know it can't be cancer, because it doesn't hurt." What is the nurse's most therapeutic response? 1 "Let's hope that it isn't malignant." 2 "What do you know about breast cancer?" 3 "Most lumps in the breast are not malignant." 4 "Has your doctor told you that it wasn't cancer?
"What do you know about breast cancer?"
During a period of hyperactivity a client on the psychiatric unit demands to be allowed to go downtown to shop. The client does not currently have privileges. How should the nurse respond? 1 "You can't leave the unit, because you're too sick." 2 "You'll have to ask your doctor for permission to go." 3 "You'll have to wait, because no staff member is available to go with you." 4 "You don't have privileges to leave, but we can look through this new catalog."
"You don't have privileges to leave, but we can look through this new catalog."
The parents of a 20-month-old toddler tell a nurse that they are concerned that bedtime thumbsucking will cause their child's teeth to protrude. What is the best response by the nurse? 1 "You should seek counseling; the thumbsucking could indicate an emotional problem." 2 "You needn't be concerned unless the thumbsucking persists after the permanent teeth have come in." 3 "You should get your child to switch to a pacifier as soon as possible; that will keep the teeth from protruding." 4 "You need to restrain your child from thumbsucking because it makes the baby teeth loose before they should be.
"You needn't be concerned unless the thumbsucking persists after the permanent teeth have come in."
A client has symptoms associated with salmonellosis. The relevant data that the nurse should obtain from the client includes a history of: 1 Any rectal cancer in the family 2 All foods eaten in the past 24 hours 3 Any recent extreme emotional stress 4 An upper respiratory infection in the past 10 days
All foods eaten in the past 24 hours
An older adult resident of a nursing home who has the diagnosis of dementia of the Alzheimer type, frequently talks about the good old days at the ranch. What is the most appropriate action by the nurse? 1 Allowing the resident to reminisce about the past and listening with interest 2 Involving the resident in interesting diversional activities with a small group 3 Reminding the resident that those "good old days" are past and that he should focus on the present 4 Introducing the resident to other residents with the same diagnosis so that they can share their past experiences
Allowing the resident to reminisce about the past and listening with interest
A parent tearfully tells a nurse, "They think our toddler is developmentally delayed. We're investigating a preschool program for cognitively impaired children." What is the most appropriate response by the nurse? 1 Praising the parent for the decision and encouraging the plan 2 Asking for more specific information related to the developmental delays 3 Advising the parent to have the health care provider help choose an appropriate program 4 Explaining that this action may be premature and that the developmental delays could disappear
Asking for more specific information related to the developmental delays
A nurse on the postpartum unit is providing postpartum care instructions to a 21-year-old Hispanic woman who delivered her first baby yesterday without complications. Her husband, mother, and other family members have been with her since delivery. The mother speaks and understands very little English, but her husband and sister speak some English. What is the best way to ensure that the client and her family understand what is being said? 1 Providing the teaching to all family members and the client 2 Asking the client and her family to nod their heads to verify understanding 3 Asking the client and her family members to say yes to verify understanding 4 Asking the client and family members to repeat, in their own words, what they have been told
Asking the client and family members to repeat, in their own words, what they have been told
During a physical in the prenatal clinic the client's vaginal mucosa is noted to have a purplish discoloration. What sign should the nurse document in the client's clinical record? 1 Hegar 2 Goodell 3 Chadwick 4 Braxton Hicks
Chadwick
Which goal specific to a client with impaired verbal communication related to a psychological barrier should be documented in the client's clinical record? 1 Freedom from injury 2 Engaging independently in solitary craft activities 3 Identifying the consequences of acting-out behavior 4 Interacting appropriately with others in the therapeutic milieu
Interacting appropriately with others in the therapeutic milieu
A client has a hypoglycemic reaction to insulin. Which client responses should the nurse document as clinical manifestations of hypoglycemia? Select all that apply. 1 Pallor 2 Tremors 3 Glycosuria 4 Acetonuria 5 Diaphoresis
Pallor Tremors Diaphoresis
Which nursing intervention is indicated for a client with an anxiety disorder? 1 Encouraging suppression of anger by the client 2 Promoting verbalization of feelings by the client 3 Limiting involvement of the client's family during the acute phase 4 Explaining why the client should accept the psychological factors that are precipitating the anxiety
Promoting verbalization of feelings by the client
A pregnant woman tells a nurse, "I think I can feel the baby move now. It feels like butterflies in my stomach. My friend calls it feeling life." What term should the nurse include when discussing fetal movement with the woman? 1 Lightening 2 Quickening 3 Engagement 4 Ballottement
Quickening
Morphine via an epidural catheter is prescribed for a client after abdominal surgery. The client asks the nurse why this medicine is necessary. What primary rationale does the nurse give for the administration of an opioid analgesic after abdominal surgery? 1 Facilitates oxygen use 2 Relieves abdominal pain 3 Decreases anxiety and restlessness 4 Dilates coronary and peripheral blood vessels
Relieves abdominal pain
A client is admitted to the hospital with the diagnosis of severe anxiety. The nurse's plan of care for a client with an anxiety disorder should include: 1 Promoting the suppression of anger by the client 2 Supporting the verbalization of feelings by the client 3 Encouraging the client to limit anxiety-related behaviors 4 Restricting the involvement of the client's family during the acute phase
Supporting the verbalization of feelings by the client
A client with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, "The next time I see the dietitian, I'm going to throw this tray at her!" What is the most appropriate response by the nurse? 1 Suggesting that the client calm down and explaining that sometimes trays get mixed up 2 Informing the client that the behavior is inappropriate and sending the client out of the dining room 3 Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior 4 Informing the client that throwing the tray at the dietitian will make matters worse and may result in his being placed in seclusion
Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietitian is unacceptable behavior
The mother of a 2-year-old child expresses concern to the nurse in the pediatric clinic that her child still takes a bottle of milk to bed at night. How should the nurse explain to the mother that this practice should be stopped? 1 Iron deficiency anemia may occur. 2 Infantile sucking needs are prolonged. 3 The child is at increased risk for dental caries. 4 Milk at bedtime precipitates inner ear infections.
The child is at increased risk for dental caries.
A client in active labor has requested epidural anesthesia for pain management. The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation? 1 It is the policy of the institution to provide 2 bags of lactated Ringer's solution. 2 There is a risk of hypotension, and the large amount of IV fluid reduces the risk. 3 Giving the large amount of IV fluid is a means of hydrating the client when she is unable to drink. 4 The client must be given 500 mL of fluid to ascertain that the line is working so that medication may be administered.
There is a risk of hypotension, and the large amount of IV fluid reduces the risk.
A nurse is caring for a client during the early postoperative period after a modified radical mastectomy. What should the nurse teach her about limiting edema in the affected arm? 1 Turn to the unaffected side every 2 hours. 2 Avoid moving the affected arm for 24 hours. 3 Use pillows to elevate the affected arm above the level of the heart. 4 Maintain the positive pressure drainage bag below the level of the arm
Use pillows to elevate the affected arm above the level of the heart.
A nurse is reviewing medication instructions with the parents of an infant who is receiving digoxin (Lanoxin) and spironolactone (Aldactone). What parental response concerning their infant's care indicates that the instructions have been understood? 1 Activity should be restricted. 2 Orange juice must be offered daily. 3 Vomiting should be reported to the health care provider. 4 Anti-inflammatory drugs will not be given with spironolactone.
Vomiting should be reported to the health care provider.
A client gives birth to a healthy girl. Her husband expresses delight but appears anxious and tends to avoid physical contact with his newborn. Later he says to the nurse, "My wife seems so wrapped up in the baby—I hope she has time for me." How should the nurse respond? 1 "Your parents may be able to help you and your spouse." 2 "You feel that you'll have to fend for yourself. Tell me more about your concerns." 3 "Your concern about future adjustments in your life is valid." 4 "You'll both be so busy that you won't even miss her attention.
"You feel that you'll have to fend for yourself. Tell me more about your concerns."
While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest!" What is the priority nursing action? 1 Call the health care provider. 2 Slow the rate and monitor the vital signs. 3 Ask the client to further describe the feeling. 4 Stop the transfusion and administer normal saline.
Stop the transfusion and administer normal saline.