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A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and grunting sounds. Based on these nonverbal cues, what action will the nurse take next?
- A. Assess for pain and the need for analgesia.
- B. Ask the patient if they feel anxious.
- C. Offer to sit with the patient and listen to their feelings.
- D. Suggest the patient increase their fluid intake to prevent constipation.
Correct Answer: A
Rationale: A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and grunting sounds is most likely communicating pain. The nurse should clarify this nonverbal behavior.
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A primary nurse is preparing a discharge plan for a patient who has been hospitalized following a double mastectomy. Which statement is most appropriate for the nurse to use in the termination phase of the therapeutic relationship?
- A. Let's review the progress you've made in meeting your goals.
- B. I'd like to review your medication schedule with you.
- C. I need to document today's teaching session in the electronic health record.
- D. Should we include your family in today's session?
Correct Answer: A
Rationale: The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning correlates with the termination phase of a therapeutic relationship and the progress toward the patient's goals are reviewed.
A toddler with vomiting, diarrhea, and dehydration is being seen at an acute care center. During the admission interview, what question will the nurse ask the parents to elicit the most useful information?
- A. Watching your child vomiting and in discomfort must have been scary.
- B. This started yesterday, correct?
- C. Has this child had anything to drink?
- D. Could you tell me the color and approximate amount of the vomiting?
Correct Answer: D
Rationale: Using a clarifying question or comment allows the nurse to gain an understanding of the parents' observations, avoiding misunderstandings that could lead to an inappropriate nursing diagnosis. A reflective question technique involves repeating what the person has said or describes the person's feelings. Assertive questions are direct, demonstrating the ability to stand up for self or others, using open and honest communication. Open-ended questions encourage free verbalization and expression of what the parents believe to be true.
A nurse enters the room of a patient with cancer. The patient is crying and states, 'I feel so alone.' How will the nurse best communicate a therapeutic response?
- A. The nurse stands at the patient's bedside and states, 'I understand how you feel. My mother said the same thing when she was ill.'
- B. The nurse places a hand on the patient's arm and states, 'You feel so alone.'
- C. The nurse stands in the patient's room and asks, 'Why do you feel so alone? Your wife has been here every day.'
- D. The nurse holds the patient's hand and asks, 'Tell me what feeling so alone is like for you?'
Correct Answer: D
Rationale: The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.
A nurse enters a patient's room and examines the patient's intravenous (IV) fluids and cardiac monitor. When asked, 'who are you?', which response by the nurse is most appropriate?
- 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. I am John Smith, your nurse, and I'll be caring for you until 11 PM.
Correct Answer: D
Rationale: The nurse should identify themselves, ensure the patient knows what will be happening, and the duration of their relationship.
A nurse says to their nurse manager, 'I need the day off, and you didn't give it to me!' The manager replies, 'I wasn't aware you needed the day off, and it isn't possible since staffing is inadequate.' How could the nurse best modify the communication for a more positive interaction?
- A. I placed a request to have 8th of August off for a doctor's appointment, but I'm scheduled to work.
- B. Could I make an appointment to discuss my schedule with you? I requested the 8th of August off for a doctor's appointment.
- C. I will need to call in on the 8th of August because I have a doctor's appointment.
- D. Since you didn't give me the 8th of August off, will I need to find someone to work for me?
Correct Answer: B
Rationale: Effective communication involves sending clear, nonthreatening, and respectful information to the receiver. The nurse identifies the subject of the meeting and determines a mutually agreed upon time.