A 70-year-old client had a cholecystectomy 4 days ago. The
client's daughter tells the nurse, "My mother seems confused
today." Which question would be best for the nurse to ask to
assess the client's orientation? Correct Answer What is you
name
A client is diagnosed with diabetes. The client's adult child
offers to serve as an interpreter, because the client does not
speak the dominant language. Which is the best action for the
nurse to take? Correct Answer Contact a professional
interpreter.
A client is scheduled for thoracentesis. The nurse assesses that
the client appears anxious about the procedure and needs honest
support and reassurance. What is the most appropriate response
by the nurse to this client? Correct Answer "The needle causes
discomfort or pain when it goes in, but I will be by your side
throughout and will help you hold your position."
A client with a cardiac arrythmia was recently prescribed
metoprolol and is at a follow-up appointment at the
cardiologist's office. The client tells the nurse, "I feel depressed,
tired, and I have no desire to exercise." To determine a cause-
and-effect relationship, the nurse should ask: Correct Answer
"Were you tired and depressed before starting the new
medication?
,A family has lost a member who was treated for leukemia at a
nursing unit. The nurse provides emotional support to the family
and counsels them to cope with their loss. Which quality should
the nurse use in this situation? Correct Answer Empathy
A home care nurse discusses with a client when visits will occur
and how long they will last. In what phase of the nurse-client
relationship is this type of agreement established? Correct
Answer Orientation phase
A nurse and an older adult client with chronic back pain are
beginning to communicate. What activity should the nurse focus
on at this point? Correct Answer Being sensitive to the client's
emotional barriers
A nurse during orientation notices that the preceptor gives all
subcutaneous injections on a 45-degree angle. When the new
nurse asks the preceptor the rationale for the practice the
preceptors states, "This is how I do it, and this is how you will
do it." The new nurse recognizes this behavior to be: Correct
Answer aggressive.
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."I am John Smith, your nurse, and
I'll be caring for you until 11 PM."
The nurse should identify themselves, ensure the patient knows
what will be happening, and the duration of their relationship.
A nurse enters the room of a patient with cancer. The patient is
crying and states, "I feel so alone." How will the nurse best
communicate a therapeutic response?
a. The nurse stands at the patient's bedside and states, "I
understand how you feel. My mother said the same thing when
she was ill."
b.The nurse places a hand on the patient's arm and states, "You
feel so alone."
c.The nurse stands in the patient's room and asks, "Why do you
feel so alone? Your wife has been here every day."
d.The nurse holds the patient's hand and asks, "Tell me what
feeling so alone is like for you?" Correct Answer d. The nurse
holds the patient's hand and asks, "Tell me what feeling so alone
is like for you?"
The use of touch conveys acceptance, and the implementation of
an open-ended question allows the patient time to verbalize
freely.
A nurse has performed an admission assessment on a patient.
What step does the nurse perform after clustering the data?
a. Developing interventions
b. Nursing judgments
c. Diagnosing and analyzing
d. Concept mapping Correct Answer c. Diagnosing and
analyzing
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