Term
| A nurse is trying to encourage a client with paraplegia who is depressed and not adhering to the treatment program to join a support group. Which statement by the nurse is most appropriate? |
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Definition
| “What do you know about support groups?” |
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Term
| An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis? |
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Definition
| Personal perception of health and aging |
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Term
| The nurse is planning to teach an exercise class to a group of older adults. What guideline should the nurse adopt when planning this education? |
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Definition
| Allow ample time for psychomotor skills. |
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Term
| Which topics would the nurse be most likely to explore with a client with the aim of restoring health? Select all that apply. |
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Definition
Education of a client about living with a suprapubic catheter
Postoperative teaching for the client after prostate surgery
Orientation to treatment center and staff
The medical and nursing regimens and how the client can participate in care |
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Term
| Which strategy should the nurse use when providing education to the older adult client? |
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Definition
| Remain calm and conduct the teaching session in a quiet environment. |
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Term
| A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult: |
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Definition
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Term
| The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate? |
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Definition
| Review the hospital's process for allowing clients to view their health care records. |
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Term
| A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the health care provider. What would the nurse most likely use to evaluate the client? |
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Definition
Return demonstration
The nurse is evaluating psychomotor skills; thus, a return demonstration, which is a method of testing skill performance, would be the most appropriate method for evaluating the client's learning. Written tests are time-consuming, intimidating, and not always specific to the client. Oral tests can be useful in testing cognitive learning. Simulation evaluates whether the client can apply learning in different situations, but not the ability to perform the exercises. |
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Term
| Which are appropriate actions for protecting clients’ identities? Select all that apply. |
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Definition
Document all personnel who have accessed a client’s record.
Place light boxes for examining X-rays with the client’s name in private areas.
Have conversations about clients in private places where they cannot be overheard. |
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Term
| A nurse is caring for a client who sustained a spinal cord injury and has paraplegia. The client is frustrated, crying, and tells the nurse, "I just want to die.” What is the nurse’s best response to the client? |
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Definition
The nurse says, "I can only imagine how hard this is on you. How can I help you?"
Empathy is identifying with the way another person feels. An empathetic nurse is sensitive to the client’s feelings and problems but remains objective enough to help the client work to attain positive outcomes. By retaining this quality, the nurse can establish successful helping relationships without appearing cold or stern. Sympathy differs from empathy because it shifts the emphasis from the client to the nurse as the nurse shares feelings and personal concerns and projects them onto the client, limiting ability to focus objectively on the client’s needs. Instead of leaving the room, the nurse should stay to communicate with the frustrated client. Placing a warm blanket over the client's legs covers the paralyzed legs and may upset the client more. Stating "I am sorry this happened to you" is an expression of sympathy, not empathy. |
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Term
| Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached? |
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Definition
Empathy
Empathy refers to intuitive awareness of what the client is experiencing. It helps the nurse perform activities and remain emotionally neutral. Sympathy means feeling as emotionally distraught as the client. If the nurse sympathizes with the client, the nurse may feel equally disturbed, and performance may be affected. Kindness and commiseration also have an emotional component attached to them. |
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Term
| When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: |
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Definition
| limiting abbreviations to those approved for use by the institution. |
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Term
| A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should: |
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Definition
| allow the client to set the pace. |
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Term
| A nurse may attempt to help a client solve a situational crisis during what type of counseling session? |
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Definition
Short-term counseling
Short-term counseling would help a client solve a situational crisis. A client experiencing a developmental crisis, for example, might need long-term counseling. Motivational counseling is an evidence-based counseling approach that involves discussing feelings and incentives with the client. Professional counseling is a general term. |
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Term
| Which finding from a nursing audit reflects high standards for client safety and institutional health care? |
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Definition
| The nurse documents clients’ responses to nursing interventions. |
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Term
| A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? |
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Definition
| identifying risks and ensuring future safety for clients |
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Term
| A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. |
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Definition
The nurse maintains eye contact with the client.
The nurse shows patience with the client and gives the client time to respond.
The nurse keeps communication simple and concrete. |
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Term
| A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? |
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Definition
| Their readiness to learn is often related to a developmental task or social role. |
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Term
| Which response from the client enables the nurse to determine the effectiveness of a recent medication teaching session for an older adult client who is diagnosed with tuberculosis (TB)? |
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Definition
| “I will be taking the TB medication for at least 6 months, because it takes a long time to kill the TB germs.” |
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Term
| A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning? |
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Definition
Cognitive
As the client is able to understand the need for a balanced diet after the session and follows the nutritional chart accurately, the client is demonstrating successful learning in the cognitive domain. Learning in the cognitive domain involves processing information by listening to or reading facts and descriptions. Learning in the affective domain involves appealing to a person's feelings, beliefs, or values. Learning in the psychomotor domain involves learning by doing. Interpersonal is not a domain of learning but a type of communication in which ideas are exchanged between two or more people. |
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Term
| The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client’s daughter asks, “How do you know that my mother understands what to do?” What is the appropriate nursing response? |
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Definition
| “When 15 minutes have passed, I will ask your mother to show me how to instill the drops.” |
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Term
| The nurse is discussing the use of the client-controlled analgesia pump with the postoperative client. Which statement by the client indicates a need for additional education? |
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Definition
"I should not press the button more often than every 3 to 4 hours."
Specific dosages and time intervals can be programmed into the machine to prevent overdose; medication is delivered when the client pushes a control button. The medicine will help the client control pain. The client need not worry about pressing the button too often, as the machine has been programmed to not allow delivery of too much medication. |
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Term
| A pregnant client presents to the emergency department with vaginal bleeding. A transvaginal ultrasound is performed, and the health care provider informs the client that there are normal fetal heart tones noted. The client begins to tear-up and has a worried appearance. To facilitate therapeutic communication, what statement would the nurse make after observing the client’s nonverbal communication? |
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Definition
| “Take your time and tell me how you are feeling. I have plenty of time to answer your questions and discuss any thoughts or feelings with you.” |
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Term
| A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not often performed wound care on a complex wound. Using effective intrapersonal communication, this nurse should: |
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Definition
tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.
Intrapersonal communication, or self-talk, is communication within a person. This communication is crucial because it affects the nurse’s behavior and can enhance or detract from positive interactions with the client and family. Understanding the importance of intrapersonal communication can also help the nurse work with clients and families whose negative self-talk affects their health and self-care abilities. Speaking directly to the client, a UAP, or charge nurse is interpersonal communication, not intrapersonal. This duty cannot be delegated to an UAP. The nurse should not ask the charge nurse to change the assignment but could ask for help in dealing with the complex wound. |
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Term
| A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse declines. The nurse's unwillingness to divulge the requested information is based on the understanding that which people would be entitled to access to the client's records? |
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Definition
| those directly involved in the client's care |
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Term
| The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill? |
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Definition
The client organizes materials needed and gives return demonstration.
Confirmation that a client has learned a skill requires more than the client verbalizing understanding, passing a written test, nodding, or assisting with cleanup. Being able to gather all equipment needed for a skill and then perform it demonstrates proficiency. |
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Term
| The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate? |
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Definition
| Ask the client if information can be given to the parent. |
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Term
| The nurse will be caring a client who will soon be admitted to the medical unit. The nurse should establish a working relationship and discuss how communication will take place during what phase of the nurse–client relationship? |
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Definition
orientation phase
The orientation phase of the relationship represents the first phase of therapeutic work and involves establishing roles and expectations for communication. The working phase consists of the nurse and client then working together to achieve the client goals established in the orientation phase. There is no intimate phase in the nurse–client relationship. Therapeutic interactions take place at all times and do not exist in a specific "therapeutic phase." |
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Term
| A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? |
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Definition
| “Clipboards with client data should not leave the unit.” |
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Term
| The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I do not want to live anymore. I am a burden on everyone. I do not feel like doing anything at all. I do not even want to get up today." Which should the nurse record in the client's chart? Select all that apply. |
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Definition
The client is crying.
The client states, "I do not want to live anymore." |
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Term
| The nurse needs to understand the teaching-learning process when administering |
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Definition
Educational interventions.
Educational interventions require the application of the teaching-learning process. The other interventions listed would not, as their primary goal is not to educate the client. |
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Term
| A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? |
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Definition
| identifying risks and ensuring future safety for clients |
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Term
| A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the “S” information? |
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Definition
Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
In the SOAP format, "S" refers to subjective data, which are usually recorded as the client's statement or anything verbalized by the client. The statement about pain secondary to postoperative status and increased activity reflect the "A," or assessment, portion of the SOAP format. The statements about the abdomen being soft, bowel sounds, and so on reflect the "O," or objective data, portion of the SOAP format. The statement about physical manifestations of pain is not subjective data. |
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Term
| The nurse is providing education to a client about performance of breast self-examination. What learning outcome would be appropriate regarding this education? |
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Definition
The client will demonstrate effective breast self-examination technique.
This client education is focused on teaching the client a psychomotor skill for the purpose of early detection of breast cancer. Therefore, an appropriate learning outcome would be that the client is able to perform the skill properly. Understanding cannot be gauged without a demonstration by the client. Stating correct information does not prove the client can perform this psychomotor action. |
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Term
| 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? |
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Definition
“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.”
The nurse should provide correct knowledge as well as reassurance. Thoracentesis is a painful procedure and it is important for the client to sit still to avoid injuring the pleura. The nurse should reassure the client that the nurse will be present during the procedure and help the client throughout. Likewise, the nurse should avoid giving false reassurance by saying that the procedure will be painless. Additionally, the nurse should abstain from stating reasons that could scare the client. |
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Term
| While applying dressings to a client's wound, the nurse teaches the client about wound care. To promote the most effective teaching-learning relationship with this client, what would be most important for the nurse to keep in mind? |
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Definition
| The nurse and client relationship is based on mutual sharing and negotiation. |
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Term
| A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication? |
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Definition
Assess how the client would like to communicate
Clients with hearing impairment pose unique challenges for communication. Assessing how the client communicates best is important. For example, if a deaf client can read and write, writing can facilitate communication. If the client knows sign language, the nurse could use a person trained in sign language. Using hand gestures and exaggerated facial movements does not allow for adequate acquisition of knowledge. |
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Term
| The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information? |
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Definition
| "Could you tell me more about how you are feeling right now?" |
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Term
| The nurse-client relationship depends on communication. Effective communication between the nurse and the client encompasses which aspects? Select all that apply. |
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Definition
Touch
Spoken words
Observation
Sight |
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Term
| A nurse is working as part of a team that has been asked to address the issue of confidentiality and documentation of client health information electronically. Which activity(ies) would the team suggest to help ensure confidentiality? Select all that apply. |
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Definition
having each person responsible for documenting in the electronic health record not share his or her password
placing computer screens in locations that face away from any public areas such as hallways
ensuring that individuals log off a computer terminal when documentation is completed |
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Term
| A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client? Select all that apply. |
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Definition
Available resources
Learning style preferences
Literacy level |
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Term
| A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce the client's risk for cancer, improve respiratory status, and enhance the quality of life. The nurse also shares a personal story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client? |
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Definition
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Term
| During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: |
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Definition
| "What did your health care provider tell you about your need to be admitted?" |
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Term
| A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, “I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor.” What is the best response from the nurse? |
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Definition
“You're worried about how you will tolerate the pain associated with labor.”
Reflecting or paraphrasing confirms that the nurse is following the conversation and demonstrates listening, thus allowing the client to elaborate further. False reassurance may initially relieve the client’s anxiety, but it actually closes off communication by trivializing the client's unique feelings and discourages further discussion. Using clichés provides worthless advice and curtails exploring alternatives. |
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Term
| When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? |
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Definition
SOAP charting
The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. FOCUS charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation. |
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Term
| A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: |
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Definition
a referral.
Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others. |
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Term
| The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? |
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Definition
“Only authorized persons are allowed to access client records.”
The client must give a formal permission for anyone outside of the interdisciplinary healthcare team who is directly involved in client care to review the records. The other answers are therefore inappropriate responses. |
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Term
| The nurse is reassessing a client after pain medication has been administered to manage the pain from a bilateral knee replacement procedure. Which statement most accurately depicts proper documentation of pain assessment? |
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Definition
The client reports that on a scale of 0 to 10, the current pain is a 3.
The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient," "appears comfortable," "resting adequately," and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management. |
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Term
| A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? |
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Definition
"You can fill in information from your own records and store it on your computer or the Internet."
With a stand-alone personal health record, clients fill in information from their own records, and the information is stored on clients' computers or the Internet. A tethered, or connected, PHR is linked to a specific health care organization's electronic health record (EHR) system or to a health plan's information system. An electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers, and clients to appropriately access and securely share a client's vital medical information electronically—improving the speed, quality, safety, and cost of client care. The health care provider cannot share information with any outside sources unless the client has given permission through a HIPAA release. |
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Term
| A client is diagnosed with diabetes. The client’s adult child offers to serve as an interpreter, because the client does not speak the same language as the nurse. Which is the best action for the nurse to take? |
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Definition
| Contact a professional interpreter. |
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Term
| A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should: |
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Definition
involve the child's stuffed animal in the educational session.
Communication happens best when the environment facilitates an easy exchange of needed information. The environment most conducive to communication is one that is calm and nonthreatening. The goal is to minimize distractions and ensure privacy. The use of music, art, and interior decorations might help put the client at ease. A client with newly diagnosed human immunodeficiency virus (HIV) infection will find it difficult to discuss sexual history or genital warts in an area that lacks privacy. A toddler might find it easier to communicate if a parent, favorite stuffed animal, or blanket is nearby. The parent should not be asked to leave the room and this may cause panic or anxiety in the child. A 3-year-old child will not be able to read written materials. Showing the child the catheter may frighten the child. |
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Term
| When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: |
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Definition
interpretation of data.
A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today. |
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Term
| A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain? |
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Definition
Demonstrating the technique for insulin self-injection
The psychomotor domain involves skill performance. In this case, demonstrating the insulin self-injection technique would apply. Describing signs and symptoms, explaining what to do if hypoglycemia occurs, and reviewing appropriate food choices are appropriate for the cognitive domain. |
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Term
| A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario? |
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Definition
The working phase
There are three phases of a helping relationship: the orientation phase, the working phase, and the termination phase. The introduction phase is not a valid phase, yet the nurse introduces oneself during the orientation phase. The scenario defines characteristics of the working phase, during which the nurse and client work together to meet the client's physical and psychosocial needs. During the orientation phase, the nurse and client establish the tone and guidelines for the relationship . The termination phase occurs when the nurse and client acknowledge that they have met the goals of the initial agreement or that the client would be better served by another nurse or health care provider. |
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Term
| Besides being an instrument of continuous client care, the client's health care record also serves as a(an): |
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Definition
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Term
| A client describes feelings of despair and helplessness to the nurse. The nurse can maintain the circle of confidentiality while reporting this information to which individual(s)? Select all that apply. |
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Definition
client's health care provider
nurse from the oncoming shift
unit's mental health technicians |
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Term
| An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's: |
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Definition
critical thinking.
Cognitive learning refers to rational thought or critical thinking. Affective learning is influenced by emotions or feelings. Psychomotor learning refers to the muscular movements learned to perform new skills and procedures; for example, when a mother successfully and independently breastfeeds an infant, the mother has physically demonstrated psychomotor learning. |
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Term
| The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? |
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Definition
Inform the health care provider that a written order is needed.
Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order. |
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Term
| The nurses at a health care facility were informed of the change to organize the clients’ records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? |
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Definition
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers is an advantage of problem-oriented recording and is therefore correct. Giving clients the right to withhold the release of their information to anyone is a beneficial disclosure and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving clients’ problems among caregivers and having numerous locations for information where members of the multidisciplinary team can make entries about their own specific activities in relation to the client’s care are examples of source-oriented recording. |
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Term
| The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, “I’m not sure how many days I’m supposed to take this antibiotic.” What is the nurse's appropriate response? |
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Definition
Reteach the length of time to take the prescription.
Client teaching requires a circular approach, specifically if the client has not understood the teaching. The nurse needs to reteach the information that has not been understood. Asking the client to restate the teaching, telling the client to take the antibiotic, and proceeding with teaching about the decongestant are not effective teaching methods. |
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Term
| The nurse communicates with a newly admitted client. Which nonverbal behavior will the nurse note? |
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Definition
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Term
| A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client? |
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Definition
The client describes signs and symptoms of hypoglycemia.
The client's ability to describe the signs and symptoms of hypoglycemia demonstrates cognitive learning (the storing and recalling of new knowledge in the brain). Demonstrating a skill, such as insulin injection, is an example of psychomotor learning. Affective learning includes changes in attitudes, values, and feelings (e.g., desire to lose weight). |
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Term
| What nursing care behavior by the nurse engenders a client's trust in the nurse? |
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Definition
| A nurse answers the client’s questions about an upcoming test in a calm gentle voice while making eye contact with the client. |
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Term
| An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis? |
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Definition
Personal perception of health and aging
Knowing about the client’s orthopedic history, religious beliefs, and barriers to mobility in the home are all helpful for an overall plan of care, but do not address individualism. Gaining insight into the client’s own perceptions of health and aging, however, will allow the nurse to tailor the plan of care to the client’s personal needs. |
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Term
| A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? |
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Definition
charting by exception (CBE)
Charting by exception (CBE) is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time. FOCUS charting does not use a problem list of nursing or medical diagnoses, but incorporates many aspects of the client and client care into a FOCUS column. The focus may be a client strength, problem, or need. Problem, intervention, evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome, or when a planned intervention is not implemented in the case management model. |
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Term
| 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? |
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Definition
Empathy
The nurse should empathize with the family for their loss. Empathy helps the nurse to provide effective care and support without being emotionally distraught by the family's condition. If the nurse becomes indifferent to the family's condition, the nurse may not be able to assess their needs. The nurse should not pity, or provide sympathy to, the family for their loss, as it would involve the nurse emotionally. |
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Term
| The nurse completed education with a client. Which documentation entry represents the most complete teaching plan? |
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Definition
| Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled. |
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Term
| A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? |
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Definition
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Term
| A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the “S” information? |
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Definition
Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."
In the SOAP format, "S" refers to subjective data, which are usually recorded as the client's statement or anything verbalized by the client. The statement about pain secondary to postoperative status and increased activity reflect the "A," or assessment, portion of the SOAP format. The statements about the abdomen being soft, bowel sounds, and so on reflect the "O," or objective data, portion of the SOAP format. The statement about physical manifestations of pain is not subjective data. |
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Term
| A client has cancer, but the significant other does not want the client to know the diagnosis. The nurse demonstrates sensitivity to the significant other and works with the couple to achieve desired outcomes. What kind of behavior is the nurse exhibiting? |
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Definition
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Term
| The nurse is providing education to a client about performance of breast self-examination. What learning outcome would be appropriate regarding this education? |
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Definition
The client will demonstrate effective breast self-examination technique.
This client education is focused on teaching the client a psychomotor skill for the purpose of early detection of breast cancer. Therefore, an appropriate learning outcome would be that the client is able to perform the skill properly. Understanding cannot be gauged without a demonstration by the client. Stating correct information does not prove the client can perform this psychomotor action. |
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Term
| A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. |
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Definition
The nurse keeps communication simple and concrete.
The nurse maintains eye contact with the client.
The nurse shows patience with the client and gives the client time to respond. |
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Term
| A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: |
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Definition
swaddling the child and gently stroking its head.
Touch is the most highly developed sense at birth. Tactile experiences of infants and young children appear essential for the normal development of self and awareness of others. It has also been found that many older people long for touch, especially when isolated from loved ones because of hospitalization or long-term care facility care. Vision, taste, and hearing are not as fully developed as touch in the neonate. |
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Term
| The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply. |
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Definition
The client exhibits agitation and shouts at the nurse.
The client's blood pressure is 135/82 mm Hg.
The client's skin turgor is normal.
The client has redness around the ankles bilaterally.
The client participates in range-of-motion exercises. |
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Term
| The nurse documents a progress note in the wrong client’s electronic health record (EHR). Which action would the nurse take once realizing the error? |
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Definition
Create an notation with a correction.
If the nurse is using an electronic health record (EHR) and the documentation cannot be changed, an notation will need to be written. According to facility policy, that may require coordination with nursing management and then IT staff if needed. Each facility has legal policies to provide for these contingencies. The health care provider does not need to be contacted to make a correction, but does need to be informed if this caused any direct harm or effects to the client. |
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Term
| A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: |
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Definition
have group members confront the dominant member to promote the needed team work.
Effective groups have members who are mutually respectful. If a group member dominates or thwarts the group process, then the leader or other group members must confront the member to promote the needed collegial relationship. Planning a secret meeting does not solve the underlying issue. Picking a team leader who is not the dominant member will not address the dominance issue. A written warning would be inappropriate; a verbal communication is what is required among the team. |
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Term
| When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way? |
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Definition
Talk with animation and vocal inflection to stimulate the client aurally.
Talking with animation and vocal inflection to stimulate the client is effective for keeping the client’s attention when the client loses focus. It is not appropriate to request family members to serve as translators, provide less teaching due to communication barriers, or elongate the teaching session. |
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Term
| A client states, “I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin.” Which domains of learning does the nurse identify for this client as having been successfully addressed by education? |
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Definition
| Cognitive, affective, and psychomotor |
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Term
| When communicating with a client, the nurse uses reflection for which purpose? |
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Definition
| To have the client elaborate on thoughts and feelings |
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Term
| A nurse may attempt to help a client solve a situational crisis during what type of counseling session? |
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Definition
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Term
| The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan? |
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Definition
| Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique. |
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Term
| The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? |
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Definition
| The nurse meets with nurses or other health care professionals to discuss some aspect of client care. |
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Term
| A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? |
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Definition
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Term
| The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse? |
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Definition
| “You have made an amazing recovery.” |
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Term
| The following statement is documented in a client's health record: "Client c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? |
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Definition
The client reports waking up this morning with a severe headache.
The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn. |
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Term
| The nurse is teaching a client with diabetes how to inject daily insulin. Which method is most effective in evaluating the teaching? |
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Definition
| Ask the client to demonstrate how to self-inject the morning insulin. |
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Term
| The nurse will be caring a client who will soon be admitted to the medical unit. The nurse should establish a working relationship and discuss how communication will take place during what phase of the nurse–client relationship? |
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Definition
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