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During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after hearing the plan of care. How does the nurse best respond? Select all that apply.
- A. Fill the silence with lighter conversation directed at the patient.
- B. Use the time to perform the care that is needed uninterrupted.
- C. Discuss the silence with the patient to ascertain its meaning.
- D. Allow the patient time to think and explore inner thoughts.
- E. Determine if the patient's culture requires pauses between conversation.
- F. Arrange for a counselor to help the patient cope with emotional issues.
Correct Answer: C,D,E
Rationale: Appropriate use of silence allows the patient to initiate or to continue speaking; the nurse can reflect on what has been shared while observing the patient without having to concentrate simultaneously on conversation. In due time, the nurse might discuss the meaning of silence with the patient. The nurse considers whether the patient's culture may require longer pauses between verbal communication.
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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.
The nurse preceptor and a new graduate nurse on the surgical unit are performing preoperative assessments on a group of patients. What statement by the graduate nurse requires the preceptor to intervene?
- A. I am sure everything will be fine; you have nothing to worry about.
- B. When you return from surgery, you'll need to cough and deep breathe.
- C. Many people on this unit have had that procedure with good success.
- D. You seem fearful, can I answer any questions about the procedure?
Correct Answer: A
Rationale: Telling a patient that everything will be fine is a clich?©. This statement gives false assurance and may give the patient the impression that the nurse is dismissive of a patient's concerns or condition.
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.
A nurse enters a patient's room and finds them vomiting bright red blood. After taking vital signs, the nurse communicates the event to the health care provider using the SBAR format. Which information will the nurse include in the 'A' portion of the SBAR communication?
- A. Admitted with peptic ulcer and bleeding disorder
- B. Found vomiting in bathroom
- C. Anti-ulcer medication recommendation
- D. Vital signs, oxygen saturation, bright red emesis
Correct Answer: D
Rationale: The SBAR method is used to improve hand-off communication. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a clear, structured, and easy to use framework. Vital signs, oxygen saturation, and the presence of emesis and its color are assessments.
A patient states, 'I have been experiencing complications of diabetes.' What question will the nurse use to elicit additional information?
- A. Do you take two injections of insulin to prevent complications?
- B. Are you using diet and exercise to help regulate your blood sugar?
- C. Have you been experiencing the complications of neuropathy?
- D. Can you tell me about the complications you've experienced?
Correct Answer: D
Rationale: Requesting information regarding the patient's specific complications of diabetes will guide the nurse to further questioning and related assessments.