Nokea
The charge nurse in a long-term facility is addressing a breach in care with a client's family. Which body language would the family interpret as being sincere in the statement?
- A. Open hands
- B. Downcast eyes
- C. Shifting from foot to foot
- D. Steepled fingers
Correct Answer: A
Rationale: Open hands is a form of body language representing sincerity. This body language shows that the staff and facility care for the quality of care of the client and are open about the details of care. Downcast eyes convey remorse. Shifting from foot to foot denotes a desire to get away or avoid the discussion. Steepled fingers is interpreted as an authoritative approach.
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The nurse is evaluating the comprehension of a client's knowledge of the subcutaneous administration of an anticoagulant medication. Which method provides the best feedback?
- A. Having the client explain the medication and injection site
- B. Having the client demonstrate the injection technique on an orange
- C. Having the client watch the nurse prepare the medication and administer it
- D. Having the client prepare the syringe and independently administer the injection
Correct Answer: D
Rationale: Having the client prepare the syringe and independently administer the injection is the 'show back' portion of learning comprehension because it includes demonstrating the skill. By independently demonstrating, the nurse is able to evaluate the knowledge base and skill. Having the client watch the nurse administer the medication involves teaching, but not performing the skill. Having the client explain the medication and injection site or administer the injection into an orange demonstrates parts of the skill but does not allow the nurse to evaluate the entire skill.
The nurse is caring for a client who is newly diagnosed with atrial fibrillation. The client expresses having many questions. At what point in the client contact experience should the nurse begin client education?
- A. During a morning assessment
- B. When presenting the client with a brochure
- C. Once the health care provider confirms the diagnosis
- D. As soon as possible after admission to the hospital
Correct Answer: D
Rationale: Client teaching should begin as soon as possible after admission to the hospital. Even when the client is in the emergency department, health care providers and staff are explaining testing and procedures. The nurse will continue client education whenever there is an opportunity for teaching, such as during a morning assessment, when presenting the client with new information, or when the health care provider confirms a diagnosis.
Which of the following nurse statements is completed in the working phase of the nurse-client relationship?
- A. Tell me about your religious beliefs during this season of the year.
- B. I will put a chair in the bathroom so you can begin personal care. I will return to assist you as needed.
- C. I understand that you are feeling anxious about going home. Let me assess you before we talk.
- D. Let's talk about a way to assist you to a standing position so you can walk in the hall.
Correct Answer: B
Rationale: During the working phase of the nurse-client relationship, the nurse and the client puts the mutually developed plan into action. Each person shares in performing the task that leads to the desired outcome, which supports the client's independence. In the introductory phase, the nurse should be gathering information regarding religious beliefs. In the terminating phase, the client may feel apprehensive about assuming independent activity or self-care. Developing the plan with activities such as assisting to a standing position to walk in the hall is completed in the introductory phase.
The nurse is caring for a client who received a poor prognosis when the physician made rounds. The client is quiet, tearful at times, and prefers to be in a darkened room. The nurse observes a nursing assistant entering the room, turning on the lights, and stating 'Are we ready to get out of bed yet, the day is half over?' When addressing the statement of the nursing assistant, which communication technique would the nurse be most correct to discuss?
- A. Giving disapproval
- B. Belittling
- C. Using clich?©s
- D. Patronizing
Correct Answer: D
Rationale: Patronizing treats the client condescendingly as if incapable of making a decision. Giving disapproval holds the client to a rigid standard and is sarcastic in response. Belittling disregards how the client is responding as an individual and groups them with others in the similar position. Using clich?©s provides worthless advice and curtails exploring alternatives.
The student nurse is providing skilled care for a palliative care client. The client is bedbound, requiring skin care during bathing, oral care, and every 2 hours positioning. In which NCLEX-PN test category would the student anticipate finding questions related to this clinical care situation?
- A. Health promotion and maintenance
- B. Psychosocial integrity
- C. Physiologic integrity
- D. Safe and effective care environment
Correct Answer: C
Rationale: The role of the NCLEX-PN is to ensure that the student has sufficient knowledge to progress to a competent entry-level practitioner. Linking clinical experiences to classroom knowledge base is essential. This content falls under the physiologic integrity subcategory of basic care and comfort. This category tests the skill of the nurse in a clinical situation completing basic care and comfort needs. The health promotion and maintenance category has content areas including caring for individuals through life transitions. Psychosocial integrity includes caring for mental health needs and using therapeutic communication. Safe and effective care environment ensures appropriate nursing care and infection control.