A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both the patient and his wife become very concerned, and the patient's call light is activated. What referent initiated communication between the patient and the nurse?
a. Interaction between the patient and...
A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both
the patient and his wife become very concerned, and the patient's call light is activated. What
referent initiated communication between the patient and the nurse?
a. Interaction between the patient and his wife
b. Concern on the part of the patient's spouse
c. Pain experienced by the patient
d. Activation of the call light - ANS c. Pain experienced by the patient
Which defense mechanism is being exhibited when a 27-year-old patient insists on having a
parent present during routine care?
a. Denial
b. Regression
c. Repression
d. Displacement - ANS b. Regression
Which factors influence whether a message is effectively communicated? (Select all that apply.)
a. Timing of the conversation
b. Educational level of participants
c. Mode of communication used
d. Physical environment of discussion - ANS a. Timing of the conversation
b. Educational level of participants
c. Mode of communication used
d. Physical environment of discussion
If a patient is grimacing, what assessment statement or question would be most beneficial in
identifying the underlying cause of the nonverbal communication?
a. "Did you lose something?"
b. "You appear to be having pain."
c. "I will turn off the lights and let you rest."
d. "May I get you something to relieve your tension?" - ANS b. "You appear to be having
pain."
Which statement is most accurate regarding symbolic expression?
a. Skills confidence can be shared most effectively by nurses through wearing distinctive
clothing.
b. Clothing choices by a hospitalized patient rarely reflects his or her economic resources.
,c. Make-up use by a patient is unnecessary for any reason during hospitalization.
d. Nondramatic make-up use and minimal accessorizing by nurses demonstrates
professionalism. - ANS d. Nondramatic make-up use and minimal accessorizing by nurses
demonstrates professionalism.
What action by the nurse would most ensure accurate interpretation of patient communication?
a. Providing feedback regarding the conveyed message
b. Writing down the patient's conversational highlights
c. Assuming significant cultural differences exist
d. Verifying the patient's emotional state - ANS a. Providing feedback regarding the
conveyed message
If a patient's verbal and nonverbal communications are inconsistent, which form of
communication is most likely to convey the true feelings of the patient?
a. Written notes
b. Facial expressions
c. Implied inferences
d. Spoken words - ANS b. Facial expressions
What would be the best therapeutic response to a patient who expresses indecision about
recommended chemotherapy treatments?
a. "Can you tell me why you are undecided?"
b. "It's always a good idea to have chemotherapy."
c. "What are you thinking about the treatments at this point?"
d. "You should follow whatever your health care provider recommends." - ANS c. "What are
you thinking about the treatments at this point?"
What action should the nurse take if an alert and oriented patient asks the nurse for personal
contact information?
a. Ask the patient why the personal information is needed.
b. Report the interaction to the nursing supervisor immediately.
c. State that it would not be appropriate to share that information.
d. Change the subject, and hope that the patient does not ask again. - ANS c. State that it
would not be appropriate to share that information.
What strategy would be most effective in communicating with a highly anxious adult immediately
before surgery?
a. Providing specific, concise instructions
b. Detailing likely causes of their anxiety
c. Focusing on postoperative details
d. Using instructional multimedia DVDs - ANS a. Providing specific, concise instructions
A hospital has just implemented the use of electronic health records (EHRs). While learning to
use this new system, the nurse realizes that EHRs may do which of the following?
,a. Limit access to the patient record to one person at a time
b. Improve access to patient information at the point of care
c. Negate the use of nursing documentation
d. Increase the potential for medication errors - ANS b. Improve access to patient
information at the point of care
2. Which statement best contributes to the nurse's documentation of assessment of patient
status in the patient's medical chart?
a. "Patient had a good day with minimal complaints. Patient was pleasant and cooperative
during morning care."
b. "Patient complained that the nurse didn't come quickly enough when she pressed the call
button."
c. "Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m. reporting pain 3/10
at 8:30 a.m."
d. "Patient was grumpy today, even after administration of pain medication, a back massage,
and a nap." - ANS c. "Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8
a.m. reporting pain 3/10 at 8:30 a.m."
A patient requests a copy of his medical record. What is the correct response by the nurse?
a. Inform him that his record is the property of the facility and cannot be accessed by anyone
but staff.
b. Tell him that the Code for Nurses does not allow you to give him access to his records.
c. Acknowledge that he has the right to have a copy of his records, and make arrangements per
facility policy.
d. Refer his request to the hospital administrator because all such requests need to go through
proper channels. - ANS c. Acknowledge that he has the right to have a copy of his records,
and make arrangements per facility policy.
A patient's sister comes to visit and asks to read the patient's medical records. What is the best
response by the nurse?
a. Settle her in a chair at the nurses' station and give her access.
b. Respond that the contents of a patient's medical records are private and confidential.
c. Tell her she can read the medical records only if the patient sits with her.
d. Distract the sister by changing the subject and then walking away. - ANS b. Respond
that the contents of a patient's medical records are private and confidential.
Which are reasons that accurate documentation in the medical record is important? (Select all
that apply.)
a. Reimbursement for care
b. Evidence of care provided
c. Communication between health care providers
d. Nonlegal documentation of a nurse's actions
e. Promotion of continuity of care - ANS a. Reimbursement for care
b. Evidence of care provided
, c. Communication between health care providers
e. Promotion of continuity of care
Which note is an example of the S in SBAR?
a. Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic.
b. Patient was admitted on evening shift with a fractured right femur after a fall at home.
c. Patient's pain was rated 8/10 before administration of narcotic pain medication.
d. Assess pain every 2 hours, continue pain medication as prescribed, and provide backrub. -
ANS a. Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic.
Which attributes are important in nursing documentation? (Select all that apply.)
a. Inconsequentiality
b. Timeliness
c. Relevancy
d. Accuracy
e. Factual basis - ANS b. Timeliness
c. Relevancy
d. Accuracy
e. Factual basis
When should administered medications be documented?
a. At the end of a shift when all medications have been given
b. As given to avoid the possibility of double dosing
c. After every meal to document at least three times daily
d. When the nurse has time before going on break - ANS b. As given to avoid the
possibility of double dosing
What is an advantage of the use of paper medical records?
a. Charts with paper records are always available to all health care team members.
b. Paper records do not need much storage space in the health care facility.
c. Writing implements are always available on nursing units and patient rooms.
d. Recording on paper does not require any special computer knowledge. - ANS d.
Recording on paper does not require any special computer knowledge.
What is a purpose of a hand-off report?
a. Ensures continuity of care and patient safety
b. Keeps the doctor informed
c. Completed when a patient is discharged to home
d. Determines patient assignments - ANS a. Ensures continuity of care and patient safety
What is the purpose of the nursing process?
a. Providing patient-centered care
b. Identifying members of the health care team
c. Organizing the way nurses think about patient care
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