Nokea
The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority?
- A. Directing the discussions so that teaching needs are met
- B. Focusing directly on the client's message regarding needs
- C. Reflecting only facts related to the client's expressed concerns
- D. Reacting to the client's responses in a matter-of-fact, professional manner
Correct Answer: B
Rationale: For effective communication, the nurse uses active listening and assesses for verbal and nonverbal communication to receive the client's intended message, thus creating an environment in which the client feels comfortable expressing feelings. An authoritarian approach is directive and not permissive, and it is unlikely to create an environment for the free exchange of thoughts and ideas. Reflecting facts only is a barrier to effective communication because subjective information can also provide a stimulus for effective communication. Reacting in a matter-of-fact manner can be an ineffective strategy for facilitating communication.
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The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?
- A. Do you have concerns about managing your condition?'
- B. Do you think you might need to go to the nursing home?'
- C. If you take the correct medications, I doubt this will happen again.'
- D. Don't worry. I'm sure your family will provide all the help you need.'
Correct Answer: A
Rationale: The nurse should provide time and listen to the client's concerns while attempting to clarify the client's feelings as in the correct option. Option 2 is not an appropriate nursing response because it is making suggestions regarding care options without appropriately identifying the client's true concerns. Options 3 and 4 provide inappropriate false hope and disregard the client's concerns.
A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What question best demonstrates the nurse's ability to use therapeutic communication techniques to effectively assess the teenager's feelings about using a cane?
- A. How do you feel about needing a cane to walk?'
- B. Do you have questions about ambulating with a cane?'
- C. Are you worried about what your friends will think about your cane?'
- D. What types of problems do you think you'll have ambulating with a cane?'
Correct Answer: A
Rationale: The nurse effectively uses therapeutic communication techniques when posing an open-ended question to elicit assessment data about how the teenager feels about using a cane. The remaining options are closed-ended questions. Option 3 makes assumptions about how the teenager feels, and options 2 and 4 focus on the physical aspects of using the cane.
The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, 'I don't think that this ECT will be helpful, especially since it makes people's memory worse.' What form of communication should the nurse implement to address the family member's concern?
- A. Ask other family members and the client if they think that ECT makes people worse.
- B. Immediately reassure the client and family that ECT will help and that the memory loss is only temporary.
- C. Involve the family member in a dialog to ascertain how the family member arrived at this conclusion.
- D. Reinforce with the client and the family member that depression causes more memory impairment than ECT.
Correct Answer: C
Rationale: Involving the family member in a dialog allows the nurse to understand their concerns and provide accurate information about ECT, addressing misconceptions about memory loss. Option 1 shifts focus away from the family member's concern, option 2 provides premature reassurance without exploring the concern, and option 4 makes an assumption about the cause of memory impairment without addressing the family member's specific worry.
When responding to the call bell, the nurse finds the client lying on the floor beside the bed. After a thorough assessment and appropriate care, the nurse completes an incident report. How should the incident be described in the report?
- A. The client fell out of bed and was found on the floor.
- B. The client fell while climbing over the bed's side rails.
- C. The client was found lying on the floor beside the bed.
- D. The client was restless and fell while getting out of bed.
Correct Answer: C
Rationale: The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only option that describes the facts as observed by the nurse. All the remaining options are interpretations of the situation and are not factual data as observed by the nurse.
The nurse assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document?
- A. Phlebitis
- B. Infection
- C. Infiltration
- D. Thrombosis
Correct Answer: C
Rationale: The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and insert a new IV. All the remaining options are likely to be accompanied by warmth at the site.