Therapeutic Communication
1. A nurse is caring for a client who states, “I have to check with my partner and see if they think I am ready to go home.” The nurse replies, “How do you feel about going home today?” Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating
CORRECT: B
Reflecting directs the focus of the conversation back to the client so that they can further explore their own feelings.
A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client’s oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently
. A. CORRECT: The provider can prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain culture specimens before initiating antimicrobial therapy to prevent interference with the detection of the infection.
C. CORRECT: Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production.
E. CORRECT: Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips.
A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.)
A. Address the client with the appropriate title and their last name. B. Use a mix of open‑ and closed‑ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.
B. CORRECT: Open‑ended questions help the client tell a story in their own words. Closed‑ended questions are useful for clarifying and verifying information gathered from the client’s story.
C. CORRECT: A quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview.
E. CORRECT: The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process (the examination)
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing the pain.
A. CORRECT: Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care.
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction
C. CORRECT: The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hr.
Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.) A. Use an open posture. B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Sit facing the client.
A. CORRECT: Having an open posture, facing the client, and leaning forward are ways that can demonstrate an empathic presence.
C. CORRECT: Establishing and maintaining eye contact are ways that can demonstrate an empathic presence.
E. CORRECT: Sitting while facing the client directly can demonstrate an empathic presence. It also helps clients who have a hearing loss understand verbal communication.
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. “Do not measure the client’s temperature rectally.” B. “Count the client’s radial pulse for 30 seconds and multiply it by 2.” C. “Do not let the client know you are counting their respirations.” D. “Let the client rest for 5 minutes before you measure their blood pressure.”
CORRECT: The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client
A nurse in a provider’s office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.)
A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status
A. CORRECT: Posture is part of the body structure or general appearance portion of the general survey.
B. CORRECT: Skin lesions are part of the body structure or general appearance portion of the general survey.
C. CORRECT: Speech is part of the behavior portion of the general survey.
2. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?
A. Assessment B. Planning C. Intervention D. Evaluation
A. CORRECT: The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain.
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.)
A. Instruct the client not to perform the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client’s knees and lower extremities. E. Assist the client to change positions often.
B. CORRECT: Elastic stockings promote venous return and prevent thrombus formation. E. CORRECT: Frequent position changes prevents venous stasis.
A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. “You will do great! You just have to get used it.” B. “Why are you worried about going home?” C. “Your daily routines will be different when you get home.” D. “Tell me about the support system you’ll have after you leave the hospital.” E. “It sounds like you are not sure how having a colostomy will affect swimming.”
C. CORRECT: Presenting reality is an effective communication technique that can help the client focus on what will really happen after the changes the surgery has made. D. CORRECT: Asking open‑ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the client to express feelings through dialogue and offer additional information. E. CORRECT: Focusing is an effective communication technique that clearly directs the interaction to the relevant point.
A nurse is instructing a group of assistive personnel in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi‑Fowler’s position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 sec if it is irregular. E. Count and report any sighs the client demonstrates.
A. CORRECT: Having the client sit upright facilitates full ventilation and gives the assistive personnel a clear view of chest and abdominal movements. B. CORRECT: With the client’s arm across the abdomen or lower chest, it is easier for the AP to see respiratory movements. C. CORRECT: Observing for one full respiratory cycle before starting to count assists the AP in obtaining an accurate count.
A nurse is collecting data for a client’s comprehensive physical examination. After inspecting the client’s abdomen, which of the following skills of the physical examination process should the nurse perform next?
A. Olfaction B. Auscultation C. Palpation D. Percussion
B. CORRECT: Because palpation and percussion can alter the frequency and intensity of bowel sounds, auscultate the abdomen next and before using those two techniques.
. A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.)
A. Respiratory rate is 22/min with even, unlabored respirations. B. The client’s partner states, “They said they hurt after walking about 10 minutes.” C. The client’s pain rating is 3 on a scale of 0 to 10. D. The client’s skin is pink, warm, and dry. E. The assistive personnel reports that the client walked with a limp.
C. CORRECT: Showing a client how to use progressive muscle relaxation is an appropriate nurse‑initiated intervention for stress relief. Unless there is a contraindication for a specific client, use this technique with clients without a provider’s prescription.
D. CORRECT: Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider’s prescription.
E. CORRECT: Repositioning a client every 2 hr is an appropriate nurse‑initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider’s prescription.
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?
A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client’s fluid intake. D. Reposition the client every 4 hr
A. CORRECT: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation.
. Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally distributed between the nurse’s and client’s desires. B. Encourage the client to communicate their thoughts and feelings. C. Give the nurse‑client communication no time limits. D. Allow communication to occur spontaneously throughout the nurse‑client relationship
B. CORRECT: Therapeutic communication facilitates a helping relationship that maximizes the client’s ability to express their thoughts and feelings openly.
. A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the client’s blood pressure.
CORRECT: The first action that should be taken using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefore, the priority is to perform a pain assessment. If the client’s blood pressure is still elevated after pain interventions, report this finding to the provider.
A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client’s age? (Select all that apply.)
A. Expect the session to be shorter than for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom before beginning the examination.
B. CORRECT: Because many older adults have mobility challenges, plan to allow extra time for position changes.
C. CORRECT: Make sure clients who use sensory aids have them available for use. The client has to be able to hear the nurse and see well enough to avoid injury.
D. CORRECT: Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication.
E. CORRECT: This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who have a smaller bladder capacity
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (Select all that apply.)
for pain B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure injury risk
C. CORRECT: Showing a client how to use progressive muscle relaxation is an appropriate nurse‑initiated intervention for stress relief. Unless there is a contraindication for a specific client, use this technique with clients without a provider’s prescription. D. CORRECT: Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider’s prescription. E. CORRECT: Repositioning a client every 2 hr is an appropriate nurse‑initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider’s prescription.
A nurse is evaluating a client’s understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding?
A. “This device will keep me from getting sores on my skin.” B. “This device will keep the blood pumping through my leg.” C. “With this device on, my leg muscles won’t get weak.” D. “This device is going to keep my joints in good shape.”
CORRECT: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation
A nurse is caring for a school‑age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child’s arm. B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture
B. CORRECT: Be at the same eye level as the child to facilitate communication.
A nurse is performing an admission assessment on a client. The nurse determines the client’s radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client’s pulse deficit?
16/min The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit
A nurse in a provider’s office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature?
A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers
C. CORRECT: The dorsal surface of the hand is the most sensitive to temperature.
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?
A. “I will determine the most important client problems that we should address.” B. “I will review the past medical history on the client’s record to get more information.” C. “I will carry out the new prescriptions from the provider.” D. “I will ask the client if their nausea has resolved.”
A. CORRECT: Prioritize the client’s problems during the planning step of the nursing process.
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.)
A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.
A. CORRECT: The client should hold the cane on the uninjured side to provide support for the injured left leg. B. CORRECT: The client should keep two points of support on the ground at all times for stability. D. CORRECT: The client should advance the weaker leg first, followed by the stronger leg.