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Practice Quiz Answers

Unit 3
Question 1
A parent tells the pediatric nurse practitioner, Ive never told anyone this information about my
son. This is an example of:
A) Identifying problems and goals
B) Building trust
C) Clarifying roles
D) Revealing
Correct Answer: B
Explanation: This response is an example of trust. Trusting another person involves risk and
vulnerability, but it also fosters open, therapeutic communication and enhances the expression of
feelings, thoughts, and needs.
A. This statement is not an example of identifying problems and goals.
C. This statement is not clarifying roles of the nurse and client.
D. This statement is not an example of revealing. Although the parent may have provided
information that was never before revealed, in this statement the parent is indicating that there is
trust between himself or herself and the nurse practitioner.
Question 2
Which of the following is the best example of complete documentation?
A) 8:30 AM - Client received aspirin and oxycodone (Percodan; 1 tablet) PO
B) 12:15 PM - I gave the client morphine 10 mg IM at 11:10 AM, but did not document it then
C) 2:45 PM - Acetylsalicylic acid (ASA) gr X given for temperature of 38.1 C
D) 8:30 PM - Abdominal dressing change at 7:30 PM. No s/s of infection, and wound edges
approximating well
Correct Answer: C
Explanation: This is the best example of a late entry. The time is indicated along with the action
and an objective observation
A. This notation is not complete. It does not indicate why the aspirin and oxycodone (Percodan)
was given (i.e., what was the clients level of pain? Where was the pain located?)
B. The nurse does not need to document about herself, only about the client. In this option, the
nurse does not indicate why the morphine was given (such as the clients level of pain or location
of pain).
D. This entry is not complete. It does not state the size of the wound, type of dressing used, or the
clients tolerance of the procedure.
Question 3
Client is wheezing and experiencing some dyspnea on exertion. This is an example of:
A) The S in SOAP documentation
B) FOCUS documentation
C) The P of PIE
D) The R in DAR documentation
Correct Answer: C
Explanation: This datum is an example of the P of PIE because it describes the problem.
A. The S in SOAP documentation represents subjective data (verbalizations of the client).
B. FOCUS charting does not concentrate on only problems. It is structured according to a clients
concerns.
D. The R in DAR documentation is the response of the client. This situation describes the
clients problem, not the clients response.
Question 4
The client draws back when the nurse reaches over the side rails to take his blood pressure. To
promote efective communication, the nurse should frst:
A) Tell the client that the blood pressure can be taken at a later time
B) Rotate the nurses who are assigned to take the clients blood pressure
C) Continue to perform the procedure quickly and quietly
D) Apologize for startling the client and explain the need for contact
Correct Answer: D
Explanation: Nurses often have to enter a clients personal space to provide care. The nurse
should convey confdence, gentleness, and respect for privacy. This response demonstrates
respect and provides information so the client may understand the need for personal contact.
A. Telling the client that the blood pressure can be taken at a later time does not promote efective
communication.
B. Rotating the nurses who are assigned to take the clients blood pressure impedes the nurses
ability to form a therapeutic, helping relationship.
C. Continuing to perform the procedure quickly and quietly may send a negative nonverbal
message. It also does not promote efective communication.
Question 5
Recording a nurses description of the teaching provided to the client on performance of self-
medication administration is found in a(n):
A) Kardex
B) Incident report
C) Nursing history form
D) Discharge summary form
Correct Answer: D
Explanation: A nurses description of the teaching provided to the client on performance of self-
administration of medication is recorded in the discharge summary form.
A. A Kardex is a written form that contains basic client information. A Kardex contains an activity
and treatment section and a nursing care plan section that organizes information for quick
reference as nurses give change-of-shift report. It does not include a description of teaching that
was provided to the client.
B. An incident report concerns any event that is not consistent with the routine operation of a
health care unit or routine care of a client (e.g., a client falls).
C. A nursing history form guides the nurse through a complete assessment to identify relevant
nursing diagnoses or problems. It provides baseline data about the client.
Question 6
The charge nurse is evaluating the documentation of the new staf nurse. On review of the
charting, the charge nurse notes that appropriate documentation is evident when the new staf
nurse:
A) Uses a pencil to make the entries
B) Uses correction fuid to correct written errors
C) Identifes an error made by the attending physician
D) Dates and signs all of the entries made in the record
Correct Answer: D
Explanation: Each entry should begin with the time and end with the signature and title of the
person recording the entry.
A. All entries should be recorded legibly and in black ink because pencil can be erased.
B. The nurse should never erase entries or use correction fuid and never use a pencil. The use of
correction fuid could make the charting become illegible, and it may appear as if the nurse were
attempting to hide something or to deface the record.
C. If the physician made an error, the nurse should not document it in the clients chart. It should
be documented in an incident report.
Question 7
The nurse is establishing a helping relationship with the client. In addressing the client, the nurse
should:
A) Use the clients frst name.
B) Touch the client right away to establish contact.
C) Sit far enough away from the client.
D) Knock before entering the clients room.
Correct Answer: D
Explanation: Common courtesy is part of professional communication. To practice courtesy, the
nurse says hello and goodbye, knocks on doors before entering, and uses self-introduction.
Knocking on doors is important in addressing the client.
A. Because using last names is respectful in most cultures, nurses usually use the clients last
name in the initial interaction, and then use the frst name if the client requests it.
B. Touching the client right away would not be an appropriate action in establishing a helping
relationship. It would more likely be interpreted as invading the clients personal space.
C. Sitting far enough away from the client is important, in that the nurse should not enter the
clients personal space when establishing a helping relationship. However, leaning toward the
client conveys that the nurse is involved and interested in the client. Knocking on the door before
entering the clients room would be the frst step in addressing the client properly.
Question 8
In using communication skills with clients, the nurse evaluates which response as being the most
therapeutic?
A) Why dont you stick to the special diet?
B) I noticed that you didnt eat lunch. Is something wrong?
C) I think you need to fnd another physician thats better than this one.
D) We cant continue talking about your fnancial problems right now. Its time for your bath.
Correct Answer: B
Explanation: The nurse who is sharing an observation is using the most therapeutic response.
Sharing observations often helps the client communicate without the need for extensive
questioning, focusing, or clarifcation.
A. This is an example of a nontherapeutic response. It is asking for an explanation. Why
questions can cause resentment, insecurity, and mistrust.
C. This is not a therapeutic response. It is giving a personal opinion.
D. Changing the subject is not therapeutic.
Question 9
In working with a client who is newly diagnosed with diabetes mellitus, the nurse provides
feedback to the client on her progress in learning the treatment regimen. Of the following, the
nurse demonstrates the use of therapeutic communication by stating:
A) I believe that you have come a long way in learning how to manage your care.
B) It didnt look as if you were ever going to be able to get the injection technique.
C) You really need to be checking your blood sugar more often unless you want to come back
here to the hospital.
D) You dont appear to have any interest in your dietary intake.
Correct Answer: A
Explanation: The nurse is demonstrating the use of therapeutic communication by sharing hope.
The nurse is pointing out that personal growth can come from illness experiences.
B. This is a negative statement. The nurse should not state observations that might embarrass or
anger the client.
C. This response does not demonstrate the use of therapeutic communication. It implies
disapproval and is an aggressive, threatening type of response.
D. This is not a therapeutic statement. It is negative and aggressive in nature. If it is a true
observation, it is one the nurse should not state, as it could anger the client.
Question 10
Guidelines should be followed when documenting client care. The nurse recognizes that the
following is the most appropriate notation:
A) 1230 Clients vital signs taken
B) 0700 Client drank adequate amount of fuids
C) 0900 Meperidine (Demerol) given for lower abdominal pain
D) 0830 Increased intravenous (IV) fuid rate to 100 ml per hour according to protocol
Correct Answer: D
Explanation: Information within a recorded entry must be complete, containing appropriate and
essential information. This notation provides the time and action taken by the nurse, including the
reason for doing so.
A. This entry does not indicate what the vital signs were.
B. This entry does not provide a specifc amount the client drank. Stating adequate is subjective,
not objective.
C. This notation does not have the client describe his or her pain or rate it according to a pain
scale for comparison later. It also does not indicate whether the clients pain was in the lower left
or lower right quadrant, or both. It does not provide route or dose of medication given.
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