CH 8 Communication
A nurse enters a patient’s room and examines the patient’s IV fluids and cardiac monitor. The patient states, “Well, I haven’t seen you before. Who are you?” What is the nurse’s BEST response?
A) "I’m just the IV therapist checking your IV."
B) "I've been transferred to this division and will be caring for you."
C) "I'm sorry, my name is John Smith, and I am your nurse."
D) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."
D) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."
An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis?
A) Personal perception of health and aging
B) Floor plan of the client’s dwelling
C) Orthopedic surgical history
D) Formal religious beliefs
A) Personal perception of health and aging
The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?
A) Only patients with diagnosed infections
B) Only patients with visible blood, body fluids, or sweat
C) Only patients with nonintact skin
D) All patients receiving care in hospitals
D) All patients receiving care in hospitals
The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?
A) Supervise your child on the changing table.
B) Keep medications out of reach.
C) Buy protective sporting equipment.
D) Peer pressure causes children of this age to take risks.
A) Supervise your child on the changing table.
A client is admitted to the oncology unit with a diagnosis of leukemia. Her sister comes to visit. The healthy sibling tells the nurse that her sister is sick because “I got mad at her and wished she would go away.” Based on this information, the nurse would estimate the sister's age to be:
A) 15 years
B) 3 years
C) 7 years
D) 21 years
C) 7 years
When interacting with a patient, the nurse answers, “I am sure everything will be fine. You have nothing to worry about.” This is an example of what type of inappropriate communication technique?
A) Cliche
B) Giving Advice
C) Being Judgmental
D) Changing the Subject
A) Cliche
A nurse may attempt to help a client solve a situational crisis during what type of counseling session?
A) Professional counseling
B) Motivational counseling
C) Long-term counseling
D) Short-term counseling
D) Short-term counseling
A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply.
A) Providing a bed bath for a patient
B) Visibly soiled hands after changing the bedding of a patient
C) Removing gloves when patient care is completed
D) Inserting a urinary catheter for a female patient
E) Assisting with a surgical placement of a cardiac stent
F) Removing old magazines from a patient’s table
A) Providing a bed bath for a patient
C) Removing gloves when patient care is completed
D) Inserting a urinary catheter for a female patient
F) Removing old magazines from a patient’s table
An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?
A) Accompany the client to the bathroom every 4 hours around the clock.
B) Limit the client's fluid intake during the evening.
C) Obtain an order for insertion of an indwelling urinary catheter.
D) Provide a bedside commode and ensure adequate lighting.
D) Provide a bedside commode and ensure adequate lighting.
Prior to the client's scheduled bone marrow biopsy, the nurse has devoted time to educating him about the rationale and the specific details of the procedure. The nurse's actions constitute what stress management technique?
A) Guided imagery
B) Relaxation
C) Normalization
D) Anticipatory guidance
D) Anticipatory guidance
When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse–client relationship?
A) Orientation Phase
B) Working Phase
C) Termination Phase
D) Maintenance Phase
A) Orientation Phase
A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client?
A) You have to take your warfarin and go to the clinic every week for a blood draw. It’s not the most convenient way to live, but you have to do it.”
B) “The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?”
C) “Your doctor wants you to take your warfarin every day, go to the clinic every week to have blood drawn, and then wait for any dosage change. Do you understand?”
D) “Atrial fibrillation is when your upper heart beats ineffectively and blood clots can go to your brain. Would you like some printed information about this?”
B) “The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?”
In addition to standard precautions, the nurse would initiate-droplet precautions for which patients? Select all that apply
A) Patient diagnosed with rubella
B) Patient diagnosed with MRSA
C) Patient diagnosed with TB
D) Infant diagnosed with adenovirus infection
E) Patient diagnosed with varicella
F) Patient diagnosed with diphtheria
A) Patient diagnosed with rubella
D) Infant diagnosed with adenovirus infection
F) Patient diagnosed with diphtheria
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?
A) Request a sedative from health care provider
B) Conceal IV tubing with gauze wrap
C) Assure bed alarms are activated
D) Ask visiting family member to stay
B) Conceal IV tubing with gauze wrap
A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client’s heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client’s needs?
A) Attempt to calm the client and administer oxygen
B) Place the client in the semi-Fowler position and have the client explain what happened to cause this reaction
C) Administer an antianxiety medication and report to the health care provider
D) Offer a distraction by asking about the client’s family or interests and continue to monitor vitals
A) Attempt to calm the client and administer oxygen
A nurse is completing a health history with a client being admitted for a mastectomy. During the interview the client states, “I do not know what to do. I am not sure if I really need this surgery.” Which response by the nurse demonstrates active listening?
A) “You seem unsure, please let me know if you decide to postpone the surgery until you are no longer unsure.”
B) “You seem unsure. Tell me your concerns about your surgery.”
C) “I understand you are not sure about having the surgery. Why do you think you really do not need the surgery?”
D) “I understand your confused, what do you think you should do?”
B) “You seem unsure. Tell me your concerns about your surgery.”
A client is reluctant to learn to do finger sticks for home international normalized ratio (INR) monitoring. What is the best statement by the nurse?
A) Most people are afraid of sticking themselves.
B) Tell me what you know about these tests.
C) Are you worried about the pain?
D) Why don’t you want to do this?
B) Tell me what you know about these tests.
A school nurse is performing an assessment of a student who states "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indication which stage of infection?
A) Incubation Period
B) Prodromal Stage
C) Full Stage of Illness
D) Convalescent Period
B) Prodromal Stage
Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?
A. Call an ambulance immediately
B. Administer ipecac syrup
C. Punish the child for being bad
D. Call the poison control center
D. Call the poison control center
A young woman, who has recently suffered acute stress, asks the nurse why she seems to be more sensitive to stress than her husband. The nurse explains that a contributor to this phenomenon is:
A) cortisol.
B) estrogen levels.
C) adrenal function.
D) thyroid production.
E) glucose.
B) estrogen levels.
A nurse and an older adult client with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?
A) Explaining in detail all of the pain management options available
B) Being sensitive to the client's emotional barriers
C) Sharing the nurse's own family and personal history of back pain
D) Reassuring the client that back surgery will likely alleviate the pain completely
A) Being sensitive to the client's emotional barriers
A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner?
A) Their readiness to learn is often related to a developmental task or social role.
B) Peer group acceptance is a critical issue for this age group.
C) The material presented should focus on future application.
D) Previous experiences have little impact on learning.
A) Their readiness to learn is often related to a developmental task or social role.
A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear?
A. Gloves
B. Gown and gloves
C. Gown, gloves, and mask
D. Gown, gloves, mask, and eye goggles or eye shield
D. Gown, gloves, mask, and eye goggles or eye shield
A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan?
A) Booster seats should be used for children until they are 4'9" tall and weigh between 80-100 lb
B) Most US states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle
C) Infants and toddlers up to 2 years of age (or up to maximum height and weight for the seat) should be in a front-facing safety seat
D) Children older than 6 years may be restrained using a car seat belt in the back seat
A) Booster seats should be used for children until they are 4'9" tall and weigh between 80-100 lb
The client asks the nurse to explain stress and its effect on the body. Which information will the nurse include? Select all that apply.
A) Stress begins in children at about age 2
B) All stress has a negative effect on the human body in some form
C) Stress begins in utero
D) Stress is ever-present
E) Some forms of stress are positive events
C) Stress begins in utero
D) Stress is ever-present
E) Some forms of stress are positive events