Unit 4: Communication

Which strategy can help make the nurse a more effective teacher?

including the client in the discussion An effective teacher always involves the client in the discussion. Using technical terms and providing detailed explanations usually confuse the client and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from teaching goals.

Which of these involves charting information about the client and client care in chronological order?

narrative charting Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain?

Ask the child to point to a face drawing that indicates pain intensity. In this age group, it would be most appropriate to use a nonverbal manner of pain assessment. The pain intensity rating scale consists of six faces with expressions ranging from happy and smiling to sad and tearful. It is highly reliable in children of this age-group. Observing the child for pain behaviors such as crying and restlessness is most appropriate for pain assessment in infants. Asking a child of this age to describe the way the pain feels may give inconsistent data. The numeric pain scale is most reliable in children older than age 8.

The young sister of a young adult client with leukemia asks, "Can you check my blood? When my sister got pneumonia, so did I. And I think I have this, too." Which of the following by the nurse would be inappropriate?

Ask the client's health care provider to take a sample of the sister's blood. Taking a blood sample is an unnecessary, invasive procedure that would not directly address the sister's fear. Leukemia is not considered a communicable disease. Providing an explanation and alerting the parents to the sibling's concern and the resources available to assist siblings to deal with the terminal illness are all appropriate interventions.

The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse?

Ask the family to identify a spokesperson to be the communicator with the team. In situations with large extended families where frequent updates are required or the state of the child is critical, it is imperative that a spokesperson be identified for receiving information and for disseminating the information to the extended family members.

A preadolescent client diagnosed with oppositional defiant disorder is verbally lashing out at other clients and threatening violence. What intervention should the nurse include when planning the care for a child?

Assist the client to find ways to deal with their anger. Assisting the client in dealing with feelings is a behavior modification technique that is quite effective for children and adolescents with defiance and oppositional behaviors. By assisting the client to find ways to deal with anger, the nurse sets limits on the child's behavior and emphasizes appropriate behavior. Taking away privileges and secluding the client misses the opportunity to help the client learn ways to manage their anger. It is not the role of the nurse to go between this client and the other clients and mediate issues.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order. After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse?

Contact the surgeon to answer the client's question. If a client verbalizes questions regarding a surgery, then informed consent cannot be given. To have informed consent, the surgeon performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. The surgeon is responsible for ensuring that informed consent is obtained. The nurse would contact the surgeon to answer the client's questions prior to the start of the procedure, not answer the client's questions. Informed consent would be obtained prior to the client being transported to the operating room; therefore, having the circulating nurse convey the information is inappropriate. Although it may be necessary to delay the surgery, it would be most appropriate to contact the surgeon to answer the client's question.

The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse?

Document the adolescent's choice and offer to discuss feelings about the medication. The client has the right to choose whether to take the medication. The nurse should try to determine the reason for the adolescent not wanting the medication other than choice (e.g., side effects, fear of falling asleep and not waking). The other options do not support the autonomy of the adolescent to make an informed decision.

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?

Face the client and establish eye contact. When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. Enunciating each word is unnecessary. The nurse should allow the client at least 30 seconds to respond to questions or follow a command. Clients with aphasia may need more time to process and understand information. Nurses should use short, simple sentences and avoid frequently changing topics. It is unnecessary to speak in a louder or softer voice than normal.

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication?

Give the charge nurse information about what care should be given while the nurse is at lunch. Hand-off of care communication is an interactive communication allowing the opportunity for questioning between the giver and receiver of client information, including up-to-date information regarding the client's care, treatment, and services, as well as the client's current condition and any recent or anticipated changes. "Hand-off" communication does occur when a nurse is leaving the nursing unit, but the purpose is not to let the charge nurse know that the nurse is going to lunch or to have someone else assigned to care for the client. "Hand-off" communication focuses on current information, not the client's history.

In developing a plan of care for a client who has had previous episodes of angry verbal outbursts, the nurse plans to take an educational approach to the problem. Arrange the following steps the nurse should take from first to last. All options must be used.

Help the client identify triggers for anger. Assist the client to recognize the early cues of anger. Identify alternate ways to express anger. Practice with the client appropriate ways to express anger. Angry clients may not realize what makes them angry and the cues that their behavior is becoming out of control. The nurse should first help the client identify what triggered the anger. Once the cause of the anger and cues to the loss of control are discovered, the nurse should assist the client in identifying safe and appropriate alternative expressions of anger and then practice those techniques prior to facing a real anger-producing situation.

The nurse is preparing to administer oral medication to an 8-year-old child who is resistant to taking the medication. Which is the most effective statement made by the nurse that would encourage the child to take the medication?

I have your medication. Swallow these please." By informing the child what the expectation is, he or she will not be able to delay or avoid taking the medication as easily. If the child is asked if he or she would like to take the medication, the child can say no, leaving the nurse with little to no options. A threat is not likely to create any trust with the child and the nurse is unable to follow through with the threat. Medication should always be given in the presence of the nurse and never left with the child.

A nurse implements a healthcare facility's disaster plan. Which action should be performed first?

Identify a command center at which activities are coordinated. During a disaster, having a command center to provide direction and coordinate activities is crucial. Cellular phones and pagers may be essential communication tools during a disaster. Essential off-duty personnel should respond to a disaster as quickly as possible. Admitted clients should be triaged and treated in accordance with the facility's triage policy.

A client who has been chronically unemployed with a history of explosive anger and depression is now experiencing significant hopelessness. What would be most appropriate for the nurse to include in the client's treatment plan? Select all that apply.

Identify personal goals. Gain insight into feelings. Assess for suicidal ideation. Identifying personal goals will assist the client to be active and forward looking. At the same time, gaining insight into the feeling will help to develop a plan for the client to move forward. Due to the expression of hopelessness, it is important to rule out any suicidal ideation. Teaching new skills and role-playing are not appropriate interventions at this time.

A female client enjoys wearing men's clothing. Her sibling tells the nurse that the client would like to have gender reassignment surgery. The client tells the nurse that she just wants to be left alone. Which nursing intervention should the nurse take first?

Inform the client's sibling of medical privacy laws. the client's sibling must understand that the client's health care is private and cannot be discussed with the sibling. The client needs to verbalize her feelings regarding wearing male attire, as well as her desire to be left alone. Telling the client that she is repressing her true feelings is judgmental. It's inappropriate for a nurse to have the client change her clothes for no safety or therapeutic reason, or to advise the client to avoid her sibling.

A client's spouse has arrived prior to surgery. When the client is transferred to the operating room, what would be appropriate for the nurse to tell the spouse?

Inform the spouse that the client will be going to the recovery room after the operation, and that someone will notify the unit when the client is ready to come back. Informing the spouse of what to expect will allay apprehension. The spouse can phone the unit and check for the client's return. Encouraging the spouse to go to work is not supportive. The client would be in recovery after the operating room, so the spouse might not be able to see the client immediately after surgery. A discussion about concerns should occur with the client as well.

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times. A correctional officer should be with the client at all times. To protect the safety of the nurse and the client, the nurse should refuse to administer care without an officer present. The other options put the nurse and the client at risk.

An IV infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?

It may be necessary to remove a small amount of hair from the infant's scalp. Parents are typically quick to notice changes in their infant's physical appearance. The removal of the infant's hair may be upsetting to them if they have not been told why it is being done. Hair may be removed on the scalp at the site of needle insertion for IV therapy to provide better visualization and a smooth surface on which to attach tape to secure the needle. Sedatives are not ordinarily prescribed before IV fluid administration. In most instances, it is acceptable for parents to visit their infant while the IV solution is infusing. Holding the infant is encouraged to provide comfort.

During a prenatal visit, the client has told the nurse that she intends to give birth at a spiritual retreat center that is distant from population centers or healthcare facilities. What is the nurse's best response?

It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?" Asking about what the woman hopes to gain or experience is an empathic and therapeutic way of initiating dialogue about this client's decision. Offering a warning will likely sever any follow-up discussion. Ultimately, clients do not need permission to enact a care plan. Acknowledging that nonhospital births are increasingly common is appropriate, but it is helpful to follow a statement with a question.

A client is hospitalized in a medical unit for stabilization of his hypertension, dementia, and diabetes after it was confirmed that he suffered a third mini-stroke within 5 months. The hospital chaplain saw the client and family and then says to the nurse, "The family is so ambivalent about arranging for a nursing home now, even though they know it is inevitable." Which response to the chaplain would be appropriate? Select all that apply.

It's premature to recommend a nursing home at this time." "Stabilizing his hypertension and diabetes could reduce the risk of strokes." "It is possible that medication could reduce the risk of more blood clots." Uncontrolled hypertension, diabetes, and blood clots can increase the progression of vascular dementia. Treating the underlying causes may prevent or slow the progress of this form of dementia. It is premature to recommend long-term care before the medical conditions are stabilized.

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). What should be the nurse's first response?

Notify the anesthesiologist. The nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L (5.8 mmol/L) places the client at risk for arrhythmias when under general anesthesia. It is not the role of the nurse to cancel surgery. The nurse should not automatically send a client with abnormal laboratory findings to surgery because the procedure may be canceled. Once the client is inside the operating room and sterile supplies have been opened up for the procedure, the client is usually charged. The nurse should call ahead of time to communicate the abnormal laboratory result instead of noting the finding on the client's record. The information on the record should not be reviewed until after the client has been transported to the operating room and the supplies have been opened.

When assessing for pain in a toddler, which method would be the most appropriate?

Observe the child for restlessness. Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. While the FACES pain scale can be used in young children numeric rating pain scales are more appropriate for children who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed first.

The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse?

Seek input from all groups and strive for consensus on what would benefit most or all of these people. The responsibility is to conduct the community assessment and to identify the key needs. All members need to have representation in this process. It is best to strive for consensus on what the key issues are and to implement programs that would benefit most of the people, rather than responding to one interest group. Listening to the majority viewpoint or helping everyone to change their views and have homogeneity would not be effective. Decisions based on the community alone are also not an appropriate answer.

A community nurse is making a home visit to an elderly, depressed client. During the assessment, the client experiences periods of silence. What would be the appropriate nursing response during these periods of silence?

Sit quietly and allow the client to think. Silence should be respected as an integral quality of therapeutic communication. Clients often need brief periods of time to process their thoughts and develop answers to questions. The nurse should allow brief periods of silence to occur. The other options are not correct because they do not promote a therapeutic nurse-client relationship.

A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication?

Swallow this medication whole. Do not chew it." Digestion begins in the mouth. Pancrelipase needs to be swallowed whole in order to reach the stomach before digestion begins and cannot be crushed, chewed, or held in the mouth. In order for the medication to be effective, it must be taken before meals or snacks. The medication needs to be stored in a dry place but does not require refrigeration.

A nurse on a surgical unit is caring for a client who needs to provide informed consent for surgery. When the surgeon arrives on the unit to obtain consent, which client condition must the nurse immediately bring to the surgeon's attention?

The client was given morphine 6 mg IM 20 minutes ago. The nurse is aware that a client is unable to provide informed consent if the client has been given sedation or a narcotic. These medications may cause mental status changes, such as disorientation, which could interfere with the ability to provide consent. The other options, on their own, do not lead to disorientation and, therefore, would not prevent the client from providing informed consent.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine if the client is positive for the disorder. Which statement by the nurse is most accurate?

The diagnosis won't be based on the findings of a single test but by combining all data found." There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the physician, stating that SLE is a serious systemic disorder, and asking the client to express their feelings about the potential diagnosis don't answer the client's question.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved?

The entry should include clearer descriptions of the client's mood and behavior. Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

A client with schizophrenia was brought to the hospital after being hit by a car. Assessment reveals no serious injuries. The client states, "All these machines are reading my thoughts! Turn them off!" Which response by the nurse is best?

The machines can't harm you, so you're safe. I use them to check your blood pressure." The client is experiencing delusions, which are false sensory perceptions. The best therapeutic response by the nurse addresses the client's safety and provides factual information. Nurses should not tell the client not to worry or explore the delusion. Asking whether the client took the medications is a yes/no question and is focused on the past, not on the here and now. Additionally, this response does not address the safety concern of the client.

A nurse is caring for a client who fell and fractured the neck of femur. When documenting the site for the family members, indicate on the image the area where the fracture occurred.

The neck of the femur is a flattened pyramidal process of bone connecting the femoral head with the femoral shaft just below the ball and socket. When a femoral neck fracture occurs, the ball is disconnected from the rest of the thigh bone.

A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse?

The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization. The nurse can document the interaction but does not need to escort the caregiver and child out of the office. The nurse should not state an opinion and inject the child without permission. The nurse is responsible for communication refusal, but asking the provider to return is not necessary as the caregiver has the right to refuse immunizations for the child.

A client with hepatitis B is visiting with a sibling when the client's I.V. catheter dislodges and bleeds onto the surface of the bedside table. Which action, if observed, would cause the nurse to intervene?

The nursing assistant uses tissue to blot up the blood. The nursing assistant should have waited for housekeeping to clean up the blood. Cleaning with a bleach solution will kill the virus and prevent transmission. The use of tissues only adds to the risk of accidental transmission. The blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. The client can hold pressure over the area. Asking the client's sibling to move from the area will protect the sibling from accidental exposure.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which is a use of the medical record?

To investigate the quality of care in the agency. Medical records may occasionally be used to investigate the quality of care in the agency. A medical record is not used to transmit health records between insurance companies, to inform family and others concerned about the client's care, or to release the entire health record for research, as these actions would jeopardize the individual's right to privacy.

A nursing student is meeting a client during the pre-interaction phase of the nurse-client relationship. What questions are appropriate for the nusring student to pose during this phase? Select all that apply.

What is your name? Can you tell me what brought you to the hospital? What type of house do you live in? The nursing student is gathering introductory information, so asking for the client's name, what brought the client to the hospital, and what type of house the client lives in will be introductory information. Asking the client if the client knows the nursing instructor is irrelevant to the client information for nursing care, and it is too early to ask the client about their biopsy results.

The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do?

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller. To assure client safety, the nurse first writes the results on the chart, then reads them back to the caller and waits for the caller to confirm that the nurse has understood the results. The nurse may receive results by telephone; and although electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nurses station.

Several nurses from the medical unit access the electronic medical record of a well-known public official who was admitted to the emergency department. How should the the nurse manager respond to the nurses regarding this situation?

"Accessing the official's medical record is a breach of confidentiality." The only people entitled to access the medical record are those who require access for care delivery. The other answers condone the medical unit nurses' breach of confidentiality and do not do anything to stop it from occurring. Clients identities are sometimes protected using pseudonyms or denial, but this is not routine or done simply because the cilent is well-known.

A client comes to the emergency department reporting a headache. The client is diagnosed with hypertension and is given a prescription for an antihypertensive. In reviewing the discharge instructions, the client declines the prescription and tells the nurse "it is in God's hands now." What is the nurse's best response to the client?

"Can you tell me more about what that means?" By asking for clarification about the client's feelings, the nurse can gain understanding about the client's intentions. This also develops a more trusting and nurturing relationship between the client and nurse. The client is not attempting suicide. The medication will assist with the blood pressure, but the client is expressing a statement that the nurse needs to understand.

A hospital uses the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?

"Client reporting abdominal pain rated at 8/10." The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a report of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

The nurse is caring for a client who is in the transitional stage of labor. The client's partner is concerned and asks, "What else can I do for my partner? She is so irritable." Which of the following interventions would the nurse suggest? Select all that apply.

"Encourage your partner to rest in between contractions." "Continue to praise your partner and give her encouragement." "Stay by your partner's side. It is important that she knows you are there to support her." Transition is the time during labor where the client is 8-10 cm dilated. This is too early for the client to push and it is not uncommon for the client to be very irritable. Encouragement to sleep during contractions with praise and encouragement are appropriate interventions. During this period, the client is very anxious and may have a fear of being left alone. Keeping a presence at the client's bedside is an important intervention.

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay?

"How is this illness impacting you and your family?" This question helps address how illness affects the client as well as the family. This question seeks to assess the impact of the stressor and coping abilities. It also examines how the support system, the family, is responding. It is too late to address prevention issues. Taking away worries is not realistic because the client needs to work through concerns. Asking about worst challenges changes the topic of what the client is experiencing right now.

A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply.

"I am not able to provide that information." "Client privacy is part of the hospital code of conduct." The two statements: I am not able to provide that information and client privacy is part of the hospital code of conduct are honest statements that do not breach privacy. The two statements: you should know better than to ask that question and you will need to ask your manager are reprimanding the asking employee. Telling the asking employee that the client is in a specific room breaks privacy and confirms what the employee is asking.

The nurse is caring for a client on the psychiatric unit. The client states, "The voices are bothering me. They are yelling and telling me stuff. They are really bad." Which responses by the nurse would be most appropriate?

"I do not hear any voices. What are you hearing?" A hallucination is a false sensory perception. It involves all five senses and bodily sensations. Initially, the nurse needs to assess what kind of voices are being heard. That is, are they friendly, commanding, or controlling voices? Acknowledging that the client is experiencing the voices but telling the client that the nurse does not may help the client realize that the voices are not real. Then the nurse can focus on the client's feelings or redirect the client to reality by initiating a simple task with the client such as coloring. When the voices are less severe, the nurse can do a more thorough assessment of the client's hallucinations and begin to assist the client in learning to deal with the voices.

The nurse is performing an admission interview when the client attempts to shift the session focus to the nurse by asking personal questions. Which statement by the nurse is most appropriate

"I have a family. Tell me about you and your family." The nurse's self-disclosure should be brief, vague, and to the point so that the interaction can be refocused on the client's experience. Because the client is the focus of the nurse-client relationship, discussion should not dwell on the nurse's experience. Telling the client that the nurse should control the conversation or not give personal personal information could be considered argumentative.

The nurse is caring for a client with a terminal illness who is awaiting transfer to hospice. The client states, "It is all out of my hands now." How should the nurse respond?

"I hear you saying things are out of your hands. Can you tell me more about what has you feeling this way?" The client has a complex situation involving both a transfer to a new area of care and facing a terminal illness. While the nurse may have the focus of preparing the client for transfer to a new care area, this may not be the client's primary concern. Assuming the client's comment is related to the transfer could impede exploration of the client's actual reason for the comment. The priority is to clarify the comment's meaning before offering to explore coping strategies or how the nurse can help.

During an insight group on a mental health unit, a client is demanding attention, interrupting others, and talking most of the time. What would be the best response by the nurse?

"I invite you to summarize your point briefly so that we can then hear from others." Inviting the client to summarize assists in refocusing and making a point, and acknowledges that others require time for the group as well. Ignoring the behavior does not facilitate group communication and process. The other options are judgmental and focus more on the client's opinions than on the group process.

An anxious client asks the nurse for the results of recent blood work and wants to know what the results mean. Which response by the nurse is the most appropriate?

"I understand your concern. I'll call the physician to review the results with you." It is not within the nurse's scope of practice to provide clients with diagnoses based on laboratory results. The nurse should advocate for the client to receive the results from the physician and facilitate that discussion. The other options are incorrect because the nurse is providing information that the nurse is not permitted to release. Stating that the client should "not worry" will not address the client's anxiety about receiving the results (and interpretation) of the lab work.

A pregnant client is seeking information from the nurse about a home birth with registered midwives. Which of the following statements lets the nurse know that the client has considered the risks and benefits of using a midwife? Select all that apply.

"I will develop a list of questions to use in interviewing potential midwives." "I understand the complications that could occur in a home birth setting." "I realize that I may need to be transferred to a hospital if complications develop." Developing a list of questions, understanding the complications that could occur with a home birth, and realizing that a transfer to a hospital might be necessary all demonstrate that the client has researched a home birth and is aware of the positive and negative factors that could occur. These choices show that the client is approaching the situation in a realistic and educated manner. Looking for an obstetrician and stating that a home birth is safer with a physician are not appropriate answers.

A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process?

"I will have the transplant coordinator speak with you to answer your questions." The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation processes, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.

The nurse is caring for a client being treated for pedophilia. The client discloses that the dose of medroxyprogesterone is not helping to reduce sexual impulses. What is the nurse's mostappropriate response?

"I will review your lab results and medication dosage." The nurse should reinforce that testosterone suppression can take from 3 to 10 months to realize symptom relief. It is important to understand serum levels as well as dosage before contacting the prescriber about a change in dosage. It is also helpful to learn how the client is tolerating the hormone, but this is not of primary importance. Hormone replacement therapy, as a treatment for this disorder, is not done universally. It is inappropriate to overreact about the disorder, or the provider's chosen treatment for this client.

The parents of a pregnant adolescent are outraged that they are being refused medical information about their daughter's condition. What is the best response by the nurse to address their anger?

"If we obtain permission from her, we can include you in our discussions." The reality of this situation is that the parents may be included in the exchange of medical information but only with the daughter's consent. Sharing that fact with the parents clearly identifies that the decision is the daughter's to make and that she is entitled to make it. The nurse must support the client's right to privacy and confidentiality. The client is responsible for her own health, and her information is confidential, but stating these facts does not adequately address the parents' concern. The client may not be ready to share any information, but this does not help the parents understand what is occurring. It is best to simply explain that the client's permission is necessary in order to include the parents in the sharing of medical information.

The nurse teaches the family of child with leukemia about preventing infections. How should the nurse explain to the parents why their child is at risk for infections?

"Immature white blood cells are incapable of handling an infectious process." In leukemia although there is an increased number of immature white blood cells, they are unable to combat infection. Lack of mature white cells puts a child with leukemia at risk for infection. The major morbidity and mortality factor associated with leukemia is infection resulting from the presence of granulocytopenia. Decreased red blood cells are not directly caused by infection. While platelets play a role in the body's response to infection, bleeding does not directly cause infections.

A 24-year-old client with diabetes mellitus sustains a large laceration that requires suturing. Which statement indicates that the client understands wound healing?

"It's so hard to predict when this scar will disappear." In a client with diabetes, wound healing is delayed and unable to be predicted. A specific time frame for healing is unrealistic as is the statement that suturing does not produce a scar.

During a well-baby visit, a toddler's parent states that the parent keeps all medications out of the toddler's reach in the kitchen cabinet. Which is an appropriate response by the nurse?

"Medications should be kept in a locked location." Most toddler deaths are accidental. Medications should be kept in a locked location to prevent accidental ingestion by the toddler. Toddlers are curious and are beginning to climb and explore. Keeping medications out of sight and/or out of reach is not enough to prevent the toddler from finding/reaching and accidentally ingesting medication.

The parents of an infant with a colostomy are concerned that their child's colostomy bag is filling up frequently with gas. What is the most appropriate response by the nurse?

"Open the bag slightly whenever this happens." Gently expelling the gas will relieve the risk of the bag disconnecting from the appliance. Placing pin pricks in the bag compromises the integrity of the appliance. It is not necessary to restrict the intake of bottled formula. While expelling gas is normal, doing nothing would not be the best option for relieving the situation.

The nurse is admitting a client to the psychiatric unit. Suddenly, the client states, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response?

"Please explain that to me." Clients with fixed false beliefs truly believe the content of the delusion. Arguing or explaining will not help as in the other options. Initially the nurse needs to know the content and depth of the delusion while the client is being admitted. Then the nurse needs to focus on how the client feels about the delusion or distract the client from the delusion during the conversation.

The son of a client with Alzheimer's disease excitedly tells the nurse, "Mom was singing one of her favorite old songs. I think she is getting her memory back!" What response by the nurse is mostappropriate?

"She still has long-term memory, but her short-term memory will not return." The ability to remember an old song is related to long-term memory, which persists after short-term memory is lost. Therefore, the nurse should respond by providing the son with this information. Stating that the nurse is happy to hear about the change and that the client is getting better is inappropriate and inaccurate. This statement ignores the issue of long-term versus short-term memory. Telling the client not to get his hopes up because the improvement is only temporary is inappropriate. The information provided does not indicate that the client has expressive aphasia, which would be suggested by the statement that the client cannot talk to the son

The nurse providing health promotion education to the parents of a 6-year-old child should include which statements about 6-year-old children in the education?

"They are very sensitive to criticism." A nurse should explain that a 6-year-old child has a precarious sense of self that can cause overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and actually love the routine of a schedule. Tattling is more common at age 4 or 5; by age 6, the child wants to make friends and be a friend.

Which questions should the nurse ask when completing a cultural assessment for a new client? Select all that apply.

"What are some of your health-related beliefs and practices?" "What are some of your personal values?" "What are your spiritual beliefs?" Important components of a cultural assessment include values orientation, cultural sanctions and restrictions, communication, health-related beliefs and practices, nutrition, socioeconomic considerations, organizations providing cultural support, educational background, religious affiliation, and spiritual considerations. Components of cultural assessments do not include asking the client about their age and address.

A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. Which question would be appropriate for the nurse to ask to assist the client?

"What have you done so far to try to solve this problem?" To help the client resolve this situation, the nurse assists the client in determining what has worked or not worked in the past. This general understanding helps the client see the bigger picture and begin the problem-solving process. Immediately seeking alternatives is not advised. It is important to focus on helping the client identify strengths to manage the work situation, rather than providing quick solutions at this early stage of assessment.

A client was experiencing marital discord with a spouse of 4 years. When the spouse walked out, the client became angry and began to throw things and break dishes. A friend talked the client into seeking help at the local mental health center. Which of these questions should the nurse ask initially to begin to assess this client's immediate problem?

"What led you to come in for help today?" Beginning with an open-ended question that brings out the client's view of his situation and reasons for seeking treatment is the most neutral beginning and helps to gain the client's perception of events. Blaming the client for problems is accusatory and nonproductive. A time for reviewing what could have been done differently will come later.

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply

"When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What have you been using to treat the rash?" "Have you recently traveled outside the country?" The nurse would first find out when the rash began; this can assist with the correct diagnosis. The nurse would also ask about allergies; rashes can occur when a person changes medications, eats new foods, or contacts pollen. It is also important to find out how the client has been treating the rash; some topical ointments or oral medications may worsen it. The nurse would ask about recent travel; exposure to foreign foods and environments that can cause a rash. The client's ethnic background and smoking and drinking habits would not provide further insight into the rash or its cause.

A client is placed on a temporary pacemaker due to having symptomatic bradycardia. When educating the client regarding the pacemaker, which statement by the nurse is accurate?

"You will need to stay on bedrest while the pacing pads are connected to you." A temporary pacemaker is used with symptomatic bradycardia to ensure the client has an adequate cardiac output. The client would not necessarily need a permanent pacemaker depending on the reason for the bradycardia. The client would have pacing pads connected externally and would need to stay on bedrest to maintain the contact of the pads with the client. The client would be unable to get out of bed with this and so it would not be appropriate to go home. The temporary pacemaker can be painful with the muscle contraction and the client may need sedation and analgesia

The nurse is preparing to provide details on a client to the healthcare team coming on duty for the next shift. Which form of communication should the nurse use to best enhance a safe transfer of care?

bedside report A change-of-shift report is a discussion among healthcare team members leaving their shift and healthcare team members coming on duty for the next shift. It includes a summary of each client's condition and current status of care. Current evidence supports the use of bedside report in most cases as this allows for the client to be informed and helps identify gaps in information. Other forms of report, such as written and audio recording, can be used; however, since these do not allow for the oncoming nurse to get clarification, they are less safe. Team report, where each nurse reports to the oncoming group of nurses, may be appropriate in some areas, especially if clients are not able to participate, but the best choice for safety is the bedside report.

A client asks the nurse why the prostate-specific antigen (PSA) level is determined before the digital rectal examination. What should the nurse tell the client?

A prostate examination can possibly increase the PSA." Manipulation of the prostate during the digital rectal examination may falsely increase the PSA levels. The PSA determination and the digital rectal examination are no longer recommended as screening tools for prostate cancer. Prostate cancer is the most common cancer in men and the second leading killer from cancer among men in the United States and Canada. Incidence increases sharply with age, and the disease is predominant in the 60- to 70-year-old age group.

A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which documentation method should the nurse suggest?

charting by exception The nurse should suggest the use of charting by exception, which is an abbreviated form of documentation. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a focus can be a problem area, but does not need to be. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The medication administration record documents only medication administration.

A client needs to be transferred to the oncology unit for further care. Which information is necessary to include in the transfer report

current client assessment The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report.

A nurse is providing care to a client with cancer. The client tells that nurse that the care provider is not giving enough information about the client's condition. Which behavior by the nurse demonstrates advocacy?

helping the client create a list of questions to ask the care provider Advocacy refers to taking the client's side and supports the client's right to information necessary to make decisions. However, sometimes client advocacy conflicts with the care provider's viewpoint, and the nurse must make sure to maintain a collaborative working relationship with the car provider and not intrude on the care provider-client relationship. In this situation, the nurse demonstrates advocacy by helping the client be assertive by developing a list of questions to ask the care provider. Confronting the care provider would be inappropriate and detrimental to the collaborative relationship. Telling the client the information also violates the care provider-client boundaries and could be detrimental to the collaborative relationship. Advising the client to get a second opinion is inappropriate because it does not address the client's need for information.

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action and they are not commonly used to communicate within the interdisciplinary team.

A nurse is completing a health assessment with an adult client in a healthcare provider's office. What assessment findings will the nurse report to the healthcare provider as inidcations of fluid volume deficit? Select all that apply.

increased heart rate dry mucous membranes muscle hyperreflexia The nurse will identify increased heart rate, dry mucous membranes, and hyperactive muscle responses as indications of fluid volume deficit. Hyperglycemia and hyperactive bowel sounds are not common findings of fluid volume deficit.

During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?

introducing new issues to the client The nurse shouldn't introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?

making a copy of the incident report for the client A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

narrative notes One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

A nurse is caring for a newly admitted client on the psychiatric unit. The nurse would most hindertherapeutic communication by performing what action?

offering advice and opinions The goal of therapeutic communication is to help clients develop insight and skills to solve their own problems. Offering advice and the nurse's own opinions can hinder communication. The nurse should avoid advice, judgment, false reassurance, and approval. Using open-ended questions and providing factual information is an effective therapeutic communication strategy

The nurse is admitting a client with a suspected diagnosis of abruptio placentae. When assessing client symptoms, which symptoms require healthcare provider notification of this medical emergency? Select all that

overt vaginal bleeding rigid abdomen Increased blood pressure rapid uterine contractions Abruptio placenta occurs when there is a partial or complete detachment of the placenta from the uterus. One third of infants die from this complication of pregnancy. Symptoms include dark red vaginal bleeding, a rigid, boardlike abdomen, rapid uterine contractions with little relief between, and severe pain. An elevated heart rate and blood pressure are commonly noted early from the pain and anxiety. Gastrointestinal upset is not a common symptom.

The client is Asian and does not speak English. The nurse arranges for the interpreter who can speak the client's dialect and begins the health assessment. The client is describing symptoms as numbness, feeling "hot under the skin," and thinking too much. The nurse should next ask specific questions about which symptom?

pain The client may be describing symptoms of pain. Culture specific symptoms for "feeling bad" include numbness, thinking too much, feeling hot under the skin. Asian clients may describe pain in terms of Yin and Yang (hot and cold). Nurse's knowledge of pain associated with health problems is necessary to assist this client manage pain. Clients from some cultures may associate mental health symptoms with evil spirits and will not report them as being unusual. Clients from Asian cultures may not describe symptoms locally but in a diffuse fashion.

When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, the nurse realizes the client doesn't fully understand the surgery. The nurse approaches the physician, who curtly says, "I've told this client all about it. Just get the consent." The nurse should

tell the physician the client isn't comfortable consenting to surgery at this point. The nurse has evaluated the client's knowledge concerning the surgery and determined that the client doesn't have enough information to give informed consent. Even though the physician might want to move ahead, the nurse should advocate for the client by telling the physician the client isn't ready for the surgery. Telling the physician that the client hasn't been given enough information would be rude. The nurse shouldn't ask the charge nurse to talk with the physician unless the physician refuses to accept the nurse's professional opinion. Explaining surgery for the purpose of obtaining consent is beyond the nurse's scope of practice.

After the client has a temporary pacemaker inserted, the nurse should verify documentation on the medical record about which information?

the client's cardiovascular status The cardiovascular status of the client is the first information documented and will validate the effectiveness of the temporary pacemaker. The client's emotional state and the type of sedation are important but not a high priority. The nurse will need to document the pacemaker information (settings of the pacemaker); this will be considered part of the cardiovascular information.

The nurse is reviewing preoperative teaching with a client scheduled for a hip replacement. What information will the nurse review with the client before the health care provider obtains the client's informed consent?

the consequences and implications of the scheduled procedure Informed consent involves providing the client with factual information regarding the treatment, tests, or surgery they are about to undergo. It often includes information about the risks versus benefits of a procedure. It does not include statistical data, and the client is given only the name of the main provider, not the names of those assisting with the procedure. The client is often already aware of the date and time of the procedure. When the professional nurse is involved in the informed consent process, the nurse is only witnessing the process, and doesn't actually obtain the consent. Obtaining consent is the responsibility of the healthcare provider.

The nurse should monitor evidence-based research and incorporate it into clinical practice and client teaching. When teaching a Hispanic client about an infectious skin condition, the nurse should focus on which factors? Select all that apply.

the level of health care literacy demonstrated by the client the specific health questions that the client asks the nurse illness and treatment information specific to the client The nurse's teaching should be based on professional and evidence-based research. This necessarily includes illness and treatment information that is specific to the client, as well as specific health questions that the client may have. Additionally, the nurse must insure that teaching meets the health care literacy level demonstrated by the client if the teaching is to be fully effective. The client's language is not a direct factor in planning health teaching, and there can be no requirement or expectation that clients are able to access or use online tools such as health care translation services. The use of a facility for primary or supplemental care does not influence client treatment or education.

The nurse is preparing discharge instructions for a client with bipolar disorder who has been prescribed lithium. Which information is most important for the nurse to provide to this client? Select all that apply.

the signs and symptoms of drug toxicity the need to consistently monitor blood levels the expected time frame for improvements in mood Client education should cover the signs and symptoms of drug toxicity, as well as the need to report them to the healthcare provider. The importance of monitoring lithium levels on a regular basis to avoid toxicity should be included. The nurse should explain that seven to 21 days may pass before a change in mood is noticed. Lithium does not have addictive properties. Tardive dyskinesia is not associated with lithium. Tyramines in the diet are a potential concern for clients taking monoamine oxidase inhibitors.

A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply.

type of surgery current vital signs amount of blood loss fluids infusing including rate and type of fluid Transfer reports must include information about the client's surgery, all current treatments and medications, vital signs, including pain level, fluid status including blood loss, and current IV infusions. It is not necessary to identify the surgeons who were present during the surgery or report the name of the insurance provider.

A 47-year-old client has been taking prescribed medication for an intestinal ulcer. During a routine office visit for blood pressure monitoring, the client reports he is no longer able to have sexual intercourse with his spouse. The nurse determines that this is most likely the result of:

ulcer medication. Impotence in men is a lesser known side effect of ulcer medications prescribed for them. Impotence can occur at any time and is not age related. Elevated blood pressure itself doesn't cause impotence, but antihypertensive medication can produce this unwelcome side effect. It could contribute to the present difficulty in addition to possible side effects of the prescribed ulcer medication. Stress may cause erectile dysfunction, but there is no evidence that the client is under stress. Men are usually able to have an erection throughout their lives.

Nurses who provide care in a large, long-term care facility use charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawbacks?

vulnerability to legal liability because the nurse's safe, routine care is not recorded A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality and safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make?

"You are not authorized to view all of the details on the client." To protect confidentiality, it is important to control the type of information that personnel in various departments can retrieve. Unlicensed nursing assistants can retrieve information from the medical records, but they cannot view information from the social worker. The reason the assistant wants to view that information is irrelevant. The information technology department does not need to be notified, because there is not a problem with the nursing assistant's log-in information. The nurse should not pull up the data for the assistant, because it is information that the assistant is not authorized to have.

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which choice?

A referral. Referring is the process of sending or guiding a client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about his or her treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response?

Approach the client and ask if there are questions about the condition. This is the best therapeutic response that is client focused. The other answers do not demonstrate therapeutic response: nurses should not offer false assurances, and calling the family is not addressing the problem between nurse and client.

The nurse is caring for an 8-year-old with a life-threatening illness. The parents do not speak the native language and want the child discharged so they can pursue alternative therapies that they believe will be less expensive. What is the most important action taken by the nurse to help the family and the child?

Arrange to have a translator present when talking with the parents. A translator is an immediate priority. No effective health teaching or social intervention will be effective until there is an established means of communication with the family.

The nurse uses which part of the SBAR acronym when stating, "I think the client is dry."

Assessment. SBAR stands for Situation, Background, Assessment, and Recommendation. It is a proven standardized method of communication between members of the health care team and a client's condition. SBAR is used as a standardized method of hand-off communication. A hand-off is a transfer of responsibility from one caregiver to another caregiver. The information communicated during a hand-off must be accurate, with minimal interruptions, in order to meet client safety needs

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. The client's 0600 glucose level is 300 mg/dL (16.7 mmol/L). What should the nurse do?

Call the health care provider (HCP) for specific prescriptions based on the glucose level. The nurse should notify the HCP directly for specific prescriptions based on the client's glucose level. The nurse cannot ignore the elevated glucose level. The surgical experience is stressful, and the client needs specific insulin coverage during the perioperative period. The nurse should not administer the insulin without checking with the surgeon because there are specific prescriptions to withhold all medications. It is not necessary to notify the surgery department unless the HCP cancels the surgery.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take?

Contact the previous nurse requesting that the nurse correct the error. The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.

A nurse overhears a second nurse making plans to meet a hospitalized client for a drink after the client has been discharged. Which is the best action for the first nurse to take?

Discuss the conversation directly with the other nurse. Planning to meet a client for a social event while the client is still hospitalized could blur the boundaries of the therapeutic relationship. This could result in an unhealthy outcome for the client. The nurse should take the second nurse aside and point out that the behavior is inappropriate and not in the client's best interest. The other options do not demonstrate behavior that is consistent with the therapeutic nurse-client relationship.

The client diagnosed with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. What should the nurse do first?

Discuss the meaning of the client's statement with her. Any suicidal statement must be assessed by the nurse. The nurse should discuss the client's statement with her to determine its meaning in terms of suicide, overwhelming feelings of anxiety, abandonment, or other need that the client cannot express appropriately. It is not uncommon for a client with borderline personality disorder to make threatening comments before discharge. Extending the hospital stay is inappropriate because it would encourage dependency and manipulation. Ignoring the client's statement on the assumption that it is a sign of manipulation is an error in judgment. Asking a family member to stay with the client temporarily at home is not appropriate and places the responsibility for the client on the family instead of the client.

The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client

Enlist the help of a hospital interpreter; ask the son to translate if none is readily available. Whenever possible, interpreters should be used to communicate with clients who do not speak English. If none is available, however, it may be necessary to have a family member translate. It would be unsafe to put off an emergency assessment pending the arrival of an interpreter.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are mostappropriate? Select all that apply.

Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies. Physical needs are met first, and then the determination of the existence of abuse will wait until the client's physical condition is stable. It is the duty of the nurse to tell the client the truth about what will happen and to support the client should not be turned away for telling a lie. A nurse should not tell the client that a secret will be held, as the client or another person may be put in danger if the abuser is not stopped.

What should be charted by the nurse when the client has an involuntary commitment or formal admission status?

The client's receipt of information about status and rights should be charted. Nurses are required to document that clients have been given information about their status and rights. Seclusion is not related to people becoming involuntary or certified clients. Including details contained within the certificates, such as a healthcare provider (HCP) signing the certificates, is not required.

A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation?

Your verbal threats to the client are legally considered assault." Assault is conduct that makes a person fearful and produces a reasonable apprehension of harm. The nurse's behavior in legal terms is assault.

The nurse is documenting assessment findings of the newborn. When assessing the neonate's head, the above is noted. Upon further examination, swelling is limited to below the scalp on the left side of the head. How does the nurse document this finding most accurately on the admission assessment to the nursery?

a cephalhematoma contained on the left side The nurse notes a swelling, which does not cross the suture lines and is limited to the left side of the neonatal head. This is documented as a cephalohematoma. Caput succedaneum, a specific condition from the pressure of the birth, crosses the suture line and presents with diffuse edema. Identifying the condition is the best documentation. It is true that there is edema present but the documentation is inaccurate when it identifies the dorsal aspect. The documentation is also inaccurate in stating that there is bleeding on the brain.

A physician orders ampicillin, 500 mg by mouth every 6 hours. This medication order is an example of

a standing order. A standing order applies until the prescriber writes another order to alter or discontinue the first one. Many health care facilities have established policies dictating how long orders for certain classes of drugs, such as opioids or antibiotics, are to remain valid. A single order allows a one-time dose only. An as-needed order allows a nurse to administer the drug whenever the client needs it. A stat order includes such words as now, immediately, or stat.

When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply.

allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy When assessing the past health history of a child, it is important to determine if the child has any medication and/or non-medication allergies, the reaction the child has to the allergen, as well as the severity of the allergy. Favorite foods and sibling history of allergies are not important to assess here.

A young Middle Eastern woman's father and brother arrive at the hospital to learn that the physician arrived early and discussed the results of the client's skin biopsy directly with her. They become agitated and begin yelling. The best action for the nurse to take is to:

ask the the father and brother if they would like the physician to meet with the family. The best action for the nurse is to recognize that in some cultures the male members of the family are very protective of female members and to respect their cultural expectations. In this case they are apt to perceive the physician as having acted disrespectfully by not communicating directly with them. In this case the nurse should alert the physician to establish his availability and communicate this to the client's father and brother. It may not be helpful to offer to review the information with them. It is inappropriate to call security or to initiate a psychiatric emergency at this time.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

by supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

A client who recently immigrated from Korea to the US or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?

checking vital signs and assessing for nonverbal indications of pain The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may result in inadequate intervention. Calling the family or giving pain medication isn't warranted at this time because the client denies pain and the nurse needs to obtain more information.

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is mostimportant for the nurse to address with the mother to promote a trusting relationship?

communication barriers between the mother and staff The communication barrier is the most significant and would require immediate attention. Strategies need to be implemented that include taking the time to share information via the written word with all new members of the healthcare team and the mother. Fear, loss of control, and lack of knowledge about the illness of the child may contribute to the overall stress of the situation.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.