Saunders Communication and Documentation
The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic?
"Do you recall needing to be hospitalized because you stopped your medication?
The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching?
"I am the nurse and, as such, I'll have you know that all information is kept confidential."
A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?
"Perhaps you could just enjoy the music without singing."
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?
"Tell me more about what causes you to feel like the rape just occurred."
The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?
"What aspects of this situation are the most difficult for you?"
A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?
"You are concerned that you don't feel any better after surgery?"
A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client?
"You have concerns about skeletal versus skin traction for your type of fracture?"
The nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. The nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization?
Associated with poor comprehension
A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure?
Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."
The nurse knows when preparing the Filipino-American client for a surgical procedure it is important to assess for which culturally relevant influences? Select all that apply
Familial hierarchy Cultural practices Reactions to surgery Pain management plans
The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip
Maternal vital signs
The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply.
Medical tubes, devices, or lines left in the body 5.Name of primary health care provider certifying death Time and date of death 2.Time of body transfer and destination
The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area?
Midway between the symphysis pubis and the umbilicus
A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client? Select all that apply.
Repeating what the client said to verify the message Using a communication board when necessary Asking yes and no questions when able Listening attentively
The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?
Sometimes people hear things or voices others can't hear."
The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?
Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."
A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?
Tell me what you know about complementary therapies."
The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be appropriate? Select all that apply.
You feel like there's nothing else you can do to cure your acne." "You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."
A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which therapeutic response to the client?
"It must be frightening to you. Has something made you feel that your food is poisoned?"
A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house ready to plan our activities for the day." Which is the therapeutic nursing response?
"It must be hard to accept that she has passed away."
The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?
"Let me know if you change your mind, and I'll get you something to eat."
A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?
"You understand that people fear for their children, but you're feeling unfairly treated?"
The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern?
150 beats per minute, moderate variability
The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.
Adequacy of circulation in the body area that is restrained 4.Type of restraint and body area where the restraint was applied 5.Communication with client and family member about need for restraint 6.The alternative measures that were attempted before restraints were applied
The nurse is caring for a child who returned from tonsillectomy surgery 30 minutes ago and enters the room for routine monitoring to see the child repeatedly and rapidly swallowing. Using the SBAR (Situation, Background, Assessment, Recommendation) technique, which statements and/or questions should the nurse include in the conversation with the primary health care provider? Select all that apply.
Could you please come assess the child as soon as possible?" 4."I am concerned that the child is bleeding from the surgical sites." 5."Two minutes ago, I entered the child's room for routine monitoring and observed that she was swallowing repeatedly and rapidly." 6."Hello, this is Maria on the third floor. I am the nurse caring for Ella Smith, the 6-year-old child in room 342 who returned 30 minutes ago from a tonsillectomy."
The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors?
Have the client express the feelings in writing.
The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?
I cannot discuss any client situation with you."
A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response?
I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?
The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?
Kussmaul's respirations
The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? Select all that apply.
Speaking slowly and clearly 3.Standing directly in front of the client while speaking Turning down the volume on the radio or TV when talking
A client at 32 weeks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic?
Tell me about your concerns."
A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client
Tell me about your difficulty sleeping.
A 10-year-old child in remission from leukemia is upset over the appearance of cushingoid characteristics from long-term use of corticosteroids that are currently being administered every other day. Which therapeutic statements should the nurse make to the child about the cushingoid appearance? Select all that apply.
The signs/symptoms are lessened by taking the prednisone every other day instead of daily." 5."The cushingoid appearance will gradually disappear once the steroids are tapered and discontinued." "I am sure it will be all right; they hardly look unusual." 2."Which manifestations of this condition do you find most troublesome?"
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
Use a picture or word board.
The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement?
What do you find difficult about this situation?"
A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate?
What do you mean by that?"
A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time?
What is causing you to become agitated?"
A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response?
You are concerned about losing your leg?"
A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?
You feel you are having difficulty fulfilling your role as a wife."
The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse would be therapeutic?
You haven't had an appetite at all?"
A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which response by the nurse would be therapeutic?
You seem very discouraged. Can you think of anything recently that went as you planned?"
A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. After the nurse provides information about this procedure, the client states, "I can't urinate in front of other people. I have a 'bashful' kidney." What is the nurse's best response?
You will be screened and given as much privacy as possible."
he nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time?
"You sound very unhappy. Are you thinking of harming yourself?"
The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking in which manner?
In a normal tone while facing the client
The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?
"It seems as if you or your daughter feel regret?"
A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear?
This aching and cramping are normal and temporary and will subside."
The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness skin loss and the formation of a blister. The nurse should document the pressure injury as which category?
Stage II
The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?
I can see that you are upset. I'll be back in a few minutes to see how you are doing."
Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement?
Are you fearful and think that others may want to hurt you?"
A female client with myasthenia gravis comes to the primary health care provider's office for a scheduled office visit. The client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. Which is the appropriate nursing response?
Have you thought about sharing your feelings with your husband?
