Therapeutic Communication
A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?
A. "The home health dietitian will visit and help you learn to cook all over again."
B. "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control."
C. "The dietitian will help you choose foods you are used to that also meet your health needs."
D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian."
Correct Answer: C. This response shows respect for the client's food preferences and cultural needs by offering choices from among the client's usual foods.
A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?
A. Complete an incident report
B. Check the client for injuries
C. Make sure the client has skid-free footwear
D. Remind the client to ask for help when getting out of bed
Correct Answer: B Using the nursing process, the nurse should first evaluate the client for any injuries or physiological changes. The nurse should also notify the provider to determine the need for any further examination or intervention.
A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen?
A. Auscultation
B. Light palpation
C. Percussion
D. Deep palpation
Correct Answer: A. According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results.
After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have
which of the following qualities?
A. Bounding
B. Full
C. Variable
D. Weak
Correct Answer: A. Bounding
A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+).
A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions?
A. Judgment
B. Short-term memory
C. Attention span
D. Abstract reasoning
Correct Answer: D. Abstract reasoning
This exercise evaluates higher-level thinking and the ability to understand and interpret abstract thoughts.
An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him.
Which of the following statements should the nurse make?
A. "Don't worry; teenagers often have friends who give bad advice."
B. "I think you should stop seeing those friends since they discourage you from following your treatment plan."
C. "Tell me more about how your friends discourage you."
D. "Where did you meet these friends?"
Correct Answer: C.
The nurse should ask an open-ended question that encourages the client to elaborate on these problems.
A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take?
A. Discourage the use of unregulated medications and supplements
B. Verify the herbal supplements do not interact with medications the provider has prescribed
C. Tell the client to limit the number of herbal supplements to no more than 2
D. Describe the dangers of taking plant-derived medications and supplements
Correct Answer: B. Many herbal products interact with other prescription and nonprescription medications. Valerian, for example, interacts with antihistamines as well as barbiturates and other sleep-promoting medications. The nurse should report any potential interactions to the provider.
A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?
A. Document the client's food allergies in the medical record
B. Ask the client to identify the specific food allergies
C. Monitor the client for indications of anaphylaxis
D. Have epinephrine available for administration
Correct Answer: B. The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision.Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals.
While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following
documents?
A. Informed consent form
B. Living will document
C. Do-not-resuscitate (DNR) directive
D. Durable power of attorney document
Correct Answer: D.
A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.
A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows theinstructions for which of the following tests?
A. Romberg
B. Kinesthetic sensation
C. 2-point discrimination
D. Weber
Correct Answer: A. Romberg
A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during this test.
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the
nurse understands family-centered care?
A. "Social services can contact various community resources that will be helpful."
B. "I will review the care plan to make the necessary changes."
C. "Let's set up a meeting time with the doctor to discuss your options for home care."
D. "I will make a list of things we need to do before discharge."
Correct Answer: C. In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family- centered nursing environment.
A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?
A. Shaking soiled linen before putting it in a hamper
B. Removing a face mask when standing 0.5 m (1.6 ft) from the client
C. Assigning another client with the same infection to share the room with the client
D. Allowing the client to visit a family member in the lobby of the facility
Correct Answer: The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available.
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?
A. Evaluate pedal pulses
B. Obtain a medical history
C. Measure vital signs
D. Assess for leg pain
Correct Answer: A. Evaluate pedal pulses
For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?
A. Incontinence
B. Mental state
C. Nutrition
D. General physical condition
Correct Answer: Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers.
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an exampleof primary prevention?
A. Teaching clients to perform self-examinations of breasts and testicles
B. Educating clients about the recommended immunization schedule for adults
C. Teaching clients who have type 1 diabetes mellitus about care of the feet
D. Recommending that clients over the age of 50 have a fecal occult blood test annually
Correct Answer: B. Primary prevention includes health education about disease prevention.
A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?
A. Assume an open position
B. Sit upright and lean back into the chair
C. Avoid direct eye contact until the client initiates it
D. Sit next to the client
Correct Answer: A. The nurse should sit with arms and legs uncrossed. Crossing them suggests a defensive posture.
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?
A. "It provides a distraction from the pain."
B. "It modulates the transmission of the pain impulse."
C. "It promotes increased circulation to the painful area."
D. "It elicits a relaxation response."
Correct Answer: The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief.
A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation?
A. Sims'
B. Supine
C. Sitting
D. Standing
Correct Answer: C. Sitting
The costovertebral angle is the area where the spine and the twelfth rib intersect. A sitting position promotes relaxation and allows access to the back for percussion of that region.
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
A. Tenderness when touched
B. Pink, shiny tissue with a granular appearance
C. Serosanguineous drainage
D. Halo of erythema on the surrounding skin
Correct Answer: D. The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection (e.g. purulent drainage, swelling, warmth, or a strong odor) should be reported to the provider.
A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?
A. Gloves
B. Gown
C. Eyewear
D. Mask
Correct Answer: A
According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally, the nurse should remove the respirator or mask because it is the least contaminated piece of PPE.
A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?
A. "A lot of clients who are cared for at home have the same problem."
B. "Don't worry about it. He will get a bath, and that will take care of the odor."
C. "It must be difficult to care for someone who is confined to bed."
D. "When was the last time that he had a bath?"
Correct Answer: C. This response addresses the feelings of the partner by reflecting her feelings, which facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
A. Vastus lateralis
B. Dorsogluteal
C. Deltoid
D. Ventrogluteal
Correct Answer: D
According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?
A. Auscultate the blood pressure at the dorsalis pedis artery
B. Measure the blood pressure with the client sitting on the side of the bed
C. Place the cuff 7.6 cm (3 in) above the popliteal artery
D. Place the bladder of the cuff over the posterior aspect of the thigh
Correct Answer: D. This is the correct position for the bladder of the cuff when the nurse is measuring a lower-extremity blood pressure.
A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?
A. Increased blood pressure
B. Decreased blood glucose level
C. Decreased oxygen use
D. Increased gastrointestinal motility
Correct Answer: A.
The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood pressure and heart rate as a result ofsympathetic stimulation.
A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?
A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration
B. Apply pressure to the nasolacrimal duct following administration
C. Place a cotton ball into the inner ear canal for 30 minutes following administration
D. Straighten the ear canal by pulling the auricle down and back prior to administration
Correct Answer: A. The nurse should administer the otic medication by holding the dropper 1 cm (0.5 in) above the ear canal.