A nurse is caring for a client who states, “I have to check with my wife and see if she thinks I am ready to be discharged.” The nurse replies, “How do you feel about going home today?” Which clarifying technique is the nurse displaying to enhance communication between the nurse and the client?
Pacing
Reflecting
Paraphrasing
Restating
A nurse is caring for a client who is concerned about being discharged home with a new colostomy because he is an avid swimmer. Which of the following statements made by the nurse indicates use of an effective communication technique? (Select all that apply.)
“You will do great! You just have to get used it.”
“Why are you worried about going home?”
“Your daily routines will be different when you get home.”
“Tell me about your support system when you leave the hospital.”
“Let me tell you about a friend of mine with a colostomy who also enjoys swimming.”
A nurse recognizes that a helping relationship is established with a client if the communication
is equally reciprocal between the nurse and the client.
encourages the client to express his thoughts and feelings.
has no time limits.
occurs spontaneously throughout the nurse-client relationship.
A nurse is caring for a school-age child who is seated. In order to facilitate effective communication, the nurse should
touch the child.
sit at eye level with the child.
stand facing the child.
stand with a relaxed posture.
Which of the following are behaviors of active listening? (Select all that apply.)
Maintaining an open posture
Writing down what the client says so that details are not forgotten
Establishing and maintaining eye contact
Nodding in agreement with the client throughout the conversation
Responding positively when giving feedback
A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, “How could you possibly understand what I am going through?” Which of the following is an appropriate response by the nurse?
“It takes time to get over the loss of a loved one.”
“You are right; I cannot really understand. Perhaps you’d like to tell me more about what you’re feeling.”
“Why don’t you try something to take your mind off your troubles, like watching a funny movie.”
“I might not share your exact situation, but I do know what people go through when they deal with a loss.”
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client’s vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?
Exhaustion stage
Resistance stage
Alarm reaction
Recovery reaction
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan would be appropriate at this time? (Select all that apply.)
Suggest coping skills for the client to utilize in this situation.
Allow the client to provide input in the treatment plan.
Assist the client with time management, and address the client’s priorities.
Provide extensive instructions on the client’s treatment regimen.
Encourage the client in the expression of feelings and concerns.
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client’s role problem?
Role conflict
Role overload
Role ambiguity
Role strain
Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?
Prescribing tasks unilaterally
Delegating care to one member
Speaking to the primary client privately
Convening a family meeting
A nurse is using an interpreter to communicate with a client. Which of the following are appropriate when communicating with a client and his family? (Select all that apply.)
Talk to the interpreter about the family while the family is in the room.
Ask the family one question at a time.
Look at the interpreter when asking the family questions.
Use lay terms if possible.
Do not interrupt the interpreter and the family as they talk.
A nurse is caring for a client who shares the same religious background. The nurse should recognize that
members of the same religion share similar feelings about their religion.
a shared religious background generates mutual regard for one another.
the same religious beliefs may influence individuals differently.
they should discuss the differences and commonalities in their beliefs.
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions is appropriate for the nurse to take?
Contact the hospital’s spiritual services.
Ask him what is making him cry.
Provide quiet times for these moments.
Turn on the television for a distraction.
A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the Muslim client?
“I will make sure the menu includes kosher options.”
“I will discuss the daily schedule with the client to make sure the client will have time for prayer.”
“I will make sure to use direct eye contact when speaking with this client.”
“I will make sure daily communion is available for this client.”
A nurse is caring for a client who is a Jehovah’s Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses by the nurse is appropriate?
“I believe in this case you should really make an exception and accept the blood transfusion.”
“I know your family would approve of your decision to have a blood transfusion.”
“Why does your religion mandate that you cannot receive any blood transfusions?”
“Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?
Allowing the client to function independently will strengthen her muscles and promote healing.
The client needs to be given privacy at times for self-reflecting and organizing her life.
The client’s sense of loss can be lessened through retaining control of certain areas of her life.
Performing ADLs is required prior to discharge from an acute care facility.
A nurse is caring for a client who has stage 4 lung cancer and is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter’s wedding.” Based on Kübler-Ross’ Five Stages of Grief, which stage is the client experiencing?
Anger
Denial
Bargaining
Acceptance
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, “I hate him for leaving me.” Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.)
“Would you like me to contact the chaplain to come speak with you?”
“You will feel better soon. You have been expecting this for a while now.”
“Let’s talk about your children and how they are going to react.”
“You know, it is quite normal to feel anger toward your husband at this time.”
“Tell me more about how you are feeling.”
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client’s family is at the bedside and asks the nurse what are anticipated clinical findings at this time. Which of the following is an appropriate response by the nurse?
Regular breathing patterns
Warm extremities
Increased urine output
Decreased muscle tone
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (Select all that apply.)
“I will remove the dentures from the body.”
“I will make sure the body is lying completely flat.”
“I will apply fresh linens and place a clean gown on the body.”
“I will remove all equipment from the bedside.”
“I will dim the lights in the room.”
Which of the following is NOT a symptom of severe anxiety?
Severe muscle tension
Hyperventilation
Headache and nausea
Confused; withdrawn
Bradycardia and agorophobia
Which of the following mnemonics is used as a patient-centered bedside report process that is becoming more and more popular?
SBARR
I-SHAPED
SAMPLE
RACER
When caring for patients, the nurse must understand the difference between religion and spirituality. Religious care helps individuals
Maintain their belief systems and worship practices.
Develop a relationship with a higher being.
Establish a cultural connectedness with the purpose of life.
Achieve the balance needed to maintain health and well-being.
