Your Results for: "NCLEX® Review" |
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|  | A nineteen year old student has had a breast biopsy and is nervous about the results. The resident physician peeks into her room and says, "The biopsy is negative." The nurse finds the student in her room sobbing. What is the nurse's best response to this situation?
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| Objective: Discuss nurse-patient communication as a dynamic process. Rationale: The physician, in delivering important news to the client, should have taken time to sit with her to discuss the results of the test. In telling the client that the test was "negative" the physician did not clarify what "negative" actually meant. Using typical medical jargon without an explanation can lead to misinterpretation of the message. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Comprehension Strategy: Decide what is the best action for client and situation. | ||||
| | The nurse is preparing to communicate educational information to an 83-year-old, English-speaking client of Hispanic descent. The nurse determines that the best way to verbally communicate with this client is to:
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| Objective: Describe factors influencing the communication process. Rationale: Slower pace, brevity, and simplicity are necessary to ensure accurate verbal communication with this client. Direct and simple messages are more effective for all ages of clients, but especially for elders and those from other cultures. Speaking slowly, enunciating carefully, and facing the client will assist with any age-related cognitive or sensory deficits. Since the client speaks English, an interpreter is not necessary. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | The nurse observes the following client behaviors: fidgeting, hand-wringing, body tenseness, and wrinkled brow. How should the nurse best analyze and interpret these nonverbal cues?
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| Objective: Discuss nurse-patient communication as a dynamic process. Rationale: Nonverbal communication varies widely among people and cultures. Interpretation of nonverbal behavior requires sharing of the observations and validation with the client. Probing questions requiring explanation of behavior may be threatening and may block further communication. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | The nurse learns from a report that a client has suffered severe, disfiguring injuries in an accident. What is the best way for the nurse to prepare for the first encounter with this client?
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| Objective: Discuss how nurses use communication skills in each phase of the nursing process. Rationale: Clients who have disfiguring injuries will watch the nurse's facial expressions for signs of acceptance or disgust. Facial expressions will be easier to control if the nurse is adequately prepared for the encounter beforehand. Being prepared for care and knowing about the client's support systems are important, but control of facial expression so that the nurse conveys acceptance of the client is the top priority in establishing trust. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | The nurse comes into a client's room to obtain an admission history, moves the chair next to the top bed rail by the client's head, and sits down to better hear the client. The client draws back and moves to the opposite side of the bed. The best nursing response would be to:
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| Objective: Describe factors that influence the communication process. Rationale: When an individual's space is invaded, he will withdraw. The nurse had moved into the client's intimate space by moving the chair so close (under 1½ feet). The nurse can convey involvement and respect the client's need for space by using the personal space distance of 1½-4 feet, which is less overwhelming to the client. Spaces beyond 4 feet convey less involvement. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | A client is crying. The nurse is very busy, but recognizes the client's need for interaction. The best way for the nurse to convey a willingness to be with the client for support is to:
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| Objective: The client is in need of support by the nurse now. Despite the nurse's schedule, a willingness to spend time with the client must be communicated both verbally and nonverbally through body language (congruence) for the client to trust the nurse's words. Rationale: Attentive listening requires full attention of the nurse, which cannot happen when the nurse is attending to other tasks. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | The nurse is assessing a new client for possible impairment of verbal communication. What components need to be in the assessment?
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| Objective: Discuss how nurses use communication skills in each phase of the nursing process. Rationale: Impairments to communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis. Ability to read and write would not affect ability to communicate verbally. Level of education, personal experience, and socioeconomic status may affect the nurse's choice of words to use when communicating, but are not part of the assessment data for impaired communication. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | A client asks about a procedure with which the nurse is unfamiliar. What is the best nursing response?
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| Objective: State why communication is imperative among health professionals. Rationale: An important component of a helping relationship is honesty. If the nurse does not know something, that should be acknowledged. The client however, does have the right to information, and the nurse should strive to provide it. "Passing the buck" to others is not appropriate to fostering a helping relationship between the nurse and client. Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | A client presents with the following: history of cancer of the esophagus, treatment with surgery and radiation, speech garbled and thick, able to read and write English. The most appropriate nursing diagnosis for the nurse to determine, based upon this information, is:
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| Objective: Discuss how nurses use communication skills in each phase of the nursing process. Rationale: Impaired verbal communication indicates specifically that the client has a decreased ability, or an inability, to speak. However, the client can understand speech of others. Impaired communication is when the client cannot speak at all, or cannot speak the dominant language. Self-esteem disturbance and social isolation may also be nursing diagnoses made as a result of the impaired verbal communication or the surgery, but more assessment data is required for either of these diagnoses. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
| | A client is able to understand only minimal English, and no interpreter is available. What alternative measures can the nurse to use to enhance communication?
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| Objective: Describe factors influencing the communication process. Rationale: Since the client understands almost no English, any verbal attempts of speaking more slowly or writing words will not enhance communication. The client is not hard of hearing, therefore speaking loudly will not be helpful. Using pictures and gestures (pointing to objects, facial expressions) that are more easily understood across cultures may enhance communication efforts. There are language phones for different languages available in most hospitals now if interpreters are not available. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection | ||||
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