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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.
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Which of the following teaching scenarios best illustrates the nurse providing informal teaching on a low-sodium diet?
- A. The nurse discusses dietary guidelines while the client watches a cooking show on television.
- B. The nurse, client, and spouse review dietary orders on the discharge instructions.
- C. The nurse and client discuss the sodium contained in prepared canned soup.
- D. The nurse and client meet with a dietitian to discuss ways of limiting sodium.
Correct Answer: A
Rationale: Informal teaching is unplanned and occurs spontaneously such as when the client is watching television and a teaching moment occurs. The remaining options involve formal teaching to meet the goal of dietary teaching on a low-sodium diet.
The nurse is instructing a client in a crowded semiprivate room. The nurse approaches and moves equipment to allow for a comfortable conversation. At which distance should the nurse stand?
- A. Within 1 feet
- B. 2 to 3 feet
- C. At least 5 feet
- D. Over 6 feet
Correct Answer: B
Rationale: Proxemics refers to the use of space when communicating. Most Americans feel comfortable when individuals are 2 to 3 feet away.
The nurse is caring for a client who is hard of hearing. The nurse is in the room during a discussion between the client and health care provider. At the end of the discussion, the client asks the nurse to further explain certain terms used by the health care provider. In explaining the terms, which role has the nurse assumed?
- A. Educator
- B. Caregiver
- C. Collaborator
- D. Delegator
Correct Answer: A
Rationale: In this scenario, the nurse will assume the role of educator by explaining information provided during the client/health care provider discussion. The nurse as educator provides client teaching regarding the plan of care, medications, or prescribed tests and procedures. The nurse as a caregiver performs health-related activities that the client is unable to perform independently due to illness. The nurse as a collaborator works with others to achieve a common goal, such as sharing or exchanging information with other health care professionals (dietitians, physical therapists, or respiratory therapists). The nurse as a delegator assigns tasks to someone else such as another nurse, a nursing assistant, or other unlicensed assistive personnel (UAP).
Which of the following nursing statements, made to the client, provides an example of a broad opening?
- A. Wow, the weather is looking nice outside.
- B. Would you like your pills whole or cut in half?
- C. So you live in a ranch-style home with a bathroom off your bedroom.
- D. Oh, your daughter lives within walking distance of your home.
Correct Answer: A
Rationale: A broad opening is intended to open communication on a common topic and relieve tension. Focusing on the weather provides that common topic to initiate communication. Further communication and specific topics flow from this point. Inquiring about medication administration is on a specific topic and in need of a specific response. The other options deal with specific topic points presented during a discussion.
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.