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The charge nurse overhears an AP yelling loudly to a patient who is hard of hearing, while transferring them from the bed to a chair. Upon entering the room, which response by the charge nurse is most appropriate?
- A. Please speak more quietly so you don't disturb the other patients.
- B. Let me help you with your transfer technique.
- C. When you are finished, be sure to apologize for shouting.
- D. When your patient is safe and comfortable, meet me at the desk.
Correct Answer: D
Rationale: The charge nurse should direct the AP to see to the patient's safety, then address any concerns privately. The nurse then can discuss appropriate use of therapeutic communication.
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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 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 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 nursing student is nervous and concerned about working at a clinical facility. Which action would best decrease anxiety and help ensure successful delivery of patient care?
- A. Determining the established goals of the institution
- B. Ensuring that verbal and nonverbal communication is congruent
- C. Engaging in self-talk to plan the day and decrease fear
- D. Speaking with fellow colleagues about how they feel
Correct Answer: C
Rationale: By engaging in positive self-talk, or intrapersonal communication, the nursing student can plan the day, decrease fear and anxiety, and enhance clinical performance.
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.