1. A female nurse is caring for a 21-year-old male client with a questionable
gastrointestinal blockage. The healthcare provider prescribes an enema. Which
reaction by the client would the nurse anticipate when planning care?
2.
3. A) "May I have a visitor in the room with me for support during the procedure?"
4. B) "I would rather have my doctor perform this procedure."
5. C) "I don't know what an enema is."
6. D) "I am afraid of having an enema." - ANS-Answer: B
7.
8. Explanation: A) The nurse would anticipate that most young adult clients will be
embarrassed by this procedure when the nurse and client are of different genders.
When the client states that he would rather have his doctor perform the enema, he is
probably motivated by embarrassment and acting on the assumption that the doctor
is male. The nurse should approach the client beforehand to address the issue. Most
clients would only experience annoyance, not fear, in relation to this procedure. Most
clients in this age group would also be familiar with what an enema is, even if they
have not had an enema themselves. The nurse would definitely not expect the client
to request the presence of another individual in the room for this procedure.
9. A home health nurse is precepting a new nurse during a routine wound care visit.
The new nurse is assessing the client's wound and notes that it is showing signs and
symptoms of infection. The client's spouse asks the new nurse how the wound looks.
The new nurse responds by stating, "It looks fine," but the new nurse's face indicates
a different story. When evaluating the new nurse, the preceptor should note a need to
work on which aspect of communication?
10.
11. A) Credibility
12. B) Congruence
13. C) Timing
14. D) Clarity and brevity - ANS-Answer: B
15.
16. Explanation: A) Congruence is adjusting one's tone of speech and facial expression
to match one's spoken message. If a nurse's facial expression and words are not
congruent, the client and family will often suspect that something is wrong. Credibility
is the quality of being truthful, trustworthy, and reliable. Although the nurse's words in
this situation may not be completely true, they do not necessarily reflect a larger
problem with credibility. Timing means that a message is delivered when the client
and family are capable of processing it fully and correctly. Clarity and brevity are
characteristics involving preciseness and use of few words.
17. A nurse educator in a medical-surgical unit is demonstrating the use of new
equipment to the rest of the nurses on the unit. After initial efforts at having the class
gather closely around the models were met with discomfort and inattention, the nurse
, educator sets up the models in the front of the classroom. Which level of proxemics
would be ideal for this situation?
18.
19. A) 4 to 12 feet
20. B) 1 1/2 to 4 feet
21. C) 12 to 15 feet
22. D) Less than 1 1/2 feet - ANS-Answer: A
23.
24. Explanation: A) Because the nurse is communicating with a group and all members
of the group must be able to see the models clearly, a social distance of 4 to 12 feet
would be appropriate. Social distance is characterized by a clear, visual perception of
the whole individual, and it is expedient for communicating with several people at the
same time. In contrast, an intimate distance of 1 1/2 feet or less would likely make
the group members extremely uncomfortable and prevent them from seeing all
aspects of the demonstration. A personal distance of 1 1/2 to 4 feet might still cause
discomfort among participants and make it difficult for them to observe the models in
full. Finally, a public distance of 12 to 15 feet would make it hard for participants to
observe the models' smaller features and would also make the communication
process less personal for all parties involved.
25. A nurse is providing care for a client who has vocal cord damage and wants to
implement strategies that will promote communication with this client. Which
interventions would be appropriate? Select all that apply.
26.
27. A) Facing the client when speaking
28. B) Having pen and paper on hand for the client
29. C) Making sure that the language spoken is the client's dominant language
30. D) Using a picture board to facilitate communication
31. E) Employing an interpreter - ANS-Answer: B, D
32.
33. Explanation: A) The client who is nonverbal would respond best to use of a picture
board or pen and paper. Because the client cannot communicate verbally, facing the
client when talking, using an interpreter, or using the client's dominant language
would not address the client's inability to communicate.
34. A nurse is providing care to a client who is scheduled for a colonoscopy. The client
requires a bowel prep prior to the diagnostic test. Which approach should the nurse
use to facilitate the client's understanding of the procedure?
35.
36. A) Use layman's terms to explain the procedure, then ask the client to describe the
procedure in her own words
37. B) Use medical terminology when explaining the procedure to the client to ensure
maximum accuracy and clarity
38. C) Focus on intonation when describing the procedure to the client
39. D) Speak slowly and loudly when providing client teaching about the procedure -
ANS-Answer: A
40.
41. Explanation: A) Good verbal communication incorporates simplicity, brevity, and
completeness. Simplicity involves the use of commonly understood words rather than
medical terminology. For example, the term "bowel prep" may be completely
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