Integrated Process - Communication and Documentation

INTEGRATED PROCESS: Communication and Documentation
Level of Cognitive Ability: Applying; Client Needs: Safe and Effective Care Environment; Content Area: Fundamental Skills: Safety; Priority
Concepts: Communication, Safety
1. A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which
written statements exemplify correct documentation on the report? Select all that apply.
 1. The client fell out of bed.
 2. No bruises or injuries are noted on the client.
 3. The client apparently climbed over the side rails when the nurse was out of the room.
 4. The physician was notified that the client was found lying on the floor next to the bed.
 5. The client is alert and oriented and stated that he needed to “go to the bathroom and didn’t want to bother the nurse.”
 6. Vital signs are temperature: 98.6°F; pulse 78 beats per minute and regular; respirations 16 breaths per minute and regular;
blood pressure 188/78 mm Hg.
Rationale:
An incident report is a tool used by health care facilities to document situations that have caused harm or have the potential to cause harm to
clients, employees, or visitors. The nurse who identifies the situation initiates the report. The report identifies the people involved in the
incident, including witnesses; describes the event; and records the date, time, location, factual findings, actions taken, and any other relevant
information. The health care provider is notified of the incident and completes the report after examining the client. Documentation on the
report should always be as factual as possible and needs to avoid accusations. Because the client was found lying on the floor, it is unknown
whether the client actually fell out of bed. Additionally, the nurse does not know that the client climbed over the side rails when the nurse
was out of the room. Huber (2014), pp. 318-319; Potter et al (2013), pp. 305, 358
Priority Nursing Tip:
An incident (unusual occurrence) report is considered a legal document and should not be placed in the client's chart after completion. It
should be maintained and filed in a designated area as determined by agency procedure.
Level of Cognitive Ability: Applying; Client Needs: Safe and Effective Care Environment; Content Area: Fundamental Skills: Medication/IV
Calculations; Priority Concepts: Clinical Judgment, Safety
2. When administering a medication intramuscularly, the nurse documents the intervention by including which information? Select all that
apply.
 1. The site of the injection
 2. The amount of medication injected
 3. The name of the medication that was injected
 4. The time the medication was prepared for injection
 5. Confirmation that the medication was injected intramuscularly
Rationale:
Safe administration of medication requires appropriate documentation that includes the name; route; and amount of the medication
administered; and in the case of an injection, the site is also included. The time the medication is given (not prepared) is included in the
documentation. Potter et al (2013), pp. 605-606, 629
Proper documentation is a necessary part of safe medication administration.
Level of Cognitive Ability: Applying; Client Needs: Safe and Effective Care Environment; Content Area: Adult Health: Ear; Priority
Concepts: Communication, Sensory Perception
3. What instruction should the nurse give to the unlicensed assistive personnel (UAP) in preparation for communicating with a hearing
impaired client? Select all that apply.
 1. Speak using a normal tone of voice.
 2. Speak clearly when communicating with the client.
 3. Speak slowly and directly into the client's impaired ear.
 4. Face the client directly when carrying on a conversation.
 5. Be aware of signs that the client does not understand the conversation.
Rationale:
When communicating with a hearing-impaired client, the caregiver should speak in a normal tone to the client and should not shout. One
should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is being said, the
caregiver should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but
one must avoid talking directly into the impaired ear. Ignatavicius, Workman (2013), p. 1103
Hearing impairment occurs with aging; usually high-frequency tones are less perceptible.
Level of Cognitive Ability: Applying; Client Needs: Safe and Effective Care Environment; Content Area: Leadership/Management:
Ethical/Legal; Priority Concepts: Collaboration, Communication
4. The administration of a community hospital is asked by the board of directors to restructure the way the hospital conducts business to
ensure the hospital's long-term survival as a competitor in the local area. The administration asks the nurse manager to set up a meeting with
several other nurse managers to develop a formal plan for how nursing will be involved in this change. The nurse managers meet to develop
a formal plan by initiating which action first?
 1. Setting goals for each nursing unit
 2. Planning strategies for each nursing unit
 3. Collecting information about the organization
 4. Discussing the problem identified by administration
Rationale:
The initial action in the change process is problem identification. The problem identified by administration is a need to restructure the way
the hospital conducts business to remain competitive. The nurse managers need to discuss the problem first in order to understand what they
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are charged to accomplish. It is also important that the problem at hand is clear to everyone that is involved with the change. After
identifying the problem, the steps in the change process include assessment (option 3), goal setting (option 1), planning (option 2),
implementation, and evaluation. Potter et al (2013), pp. 278-279
Planned change is a deliberate effort to improve a situation. Unplanned change is change that is unpredictable but is beneficial and may go
unnoticed.
Ethical/Legal; Priority Concepts: Communication, Health Care Law
5. The nurse documents a written entry regarding client care in the client's medical record. When checking the entry, the nurse notices that she
documented some incorrect information. Which approach should the nurse implement?
 1. Obliterate the incorrect information with a black marker.
 2. Use correction fluid to cover up the incorrect information.
 3. Erase the error completely and write in the correct information.
 4. Draw a line through the incorrect information and initial the change.
Rationale:
To correct a written error documented in a medical record, the nurse draws one line through the incorrect information and then initials the
error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are
never used on a legal document such as the medical record. Potter et al (2013), p. 351
Documentation in a client's medical record is legally required by accrediting agencies, state licensing laws, and state nurse and medical
practice acts.
6. The nurse made an error when documenting vital signs on a client's paper-based medical record. Which procedure should the nurse use
when correcting a written narrative error?
 1. Document the correction as a late entry.
 2. Draw a line through the error to identify it.
 3. Cover the error completely using a permanent marker.
 4. Conceal the error with correction fluid approved by the facility.
Rationale:
If the nurse makes a narrative documentation error in the client's record, the agency's policy should be followed to correct the error. Agency
policy usually includes drawing one line through the error, initialing and dating the line, and then providing the correct information. The
nurse uses a late entry to document additional information that was not documented at the time that it occurred. The nurse avoids concealing
the error with a marker or correction fluid because these actions raise the suspicion of wrongdoing. Potter et al (2013), p. 351
Principles of documentation must be followed and data recorded accurately, concisely, completely, legibly, and objectively without bias or
opinions. Always follow agency protocol for documentation.
5. When responding to the call bell, the nurse finds the client lying on the floor. After a thorough assessment and appropriate care, the nurse
completes an incident report. What information should be included?
 1. The client fell out of bed.
 2. The client climbed over the side rails.
 3. The client was found lying on the floor.
 4. The client was restless and got out of bed.
Rationale:
The incident report should contain the client's name, age, and diagnosis. It should contain a factual description of the incident, any injuries
experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the
nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual data as observed by the nurse. Huber (2014), pp. 318-319;
Potter et al (2013), pp. 305, 358
The incident report is used as a means of identifying risk situations and improving client care. The report form should not be copied or
placed in the client's record.
6. A client receives meperidine (Demerol) by the intramuscular (IM) route. Thirty minutes after receiving the medication, the client develops
signs of an allergy to the medication. The client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest
and back. The nurse further assesses the client, contacts the health care provider, and begins to document on an incident report. Which
information should the nurse accurately document?
 1. "The client had an allergic reaction to the meperidine."
 2. "The health care provider was notified because the client developed a rash after receiving meperidine."
 3. "The client apparently is allergic to meperidine as noted by a temperature of 101° F, warm and flushed skin, and a rash on the
chest and back."
 4. "Thirty minutes after receiving meperidine, the temperature was 101° F., the client's skin was warm and flushed, and a rash
was noted on the chest and back; the health care provider was notified."
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Rationale:
The nurse should document relevant information in an accurate, complete, and objective form. Option 1 does not exemplify objective data.
Although option 2 expresses accurate data, it is incomplete. Option 3 makes an interpretation about the occurrence. Potter et al (2013), pp.
351-352, 587
The incident report is not a substitute for a complete entry in the client's record regarding an untoward event. If a client injury or error in
care occurs, the nurse should assess the client often.
Ethical/Legal; Priority Concepts: Communication, Leadership
7. The nurse manager notes that the nursing staff has not been documenting client teaching in the nursing progress notes. The nurse manager
calls a staff meeting and leads a discussion to seek information on the possible causes of this occurrence and planning strategies. In this
situation, the nurse manager is implementing which leadership style?
 1. Autocratic
 2. Situational
 3. Democratic
 4. Laissez-faire
Rationale:
Democratic leadership, also called participative leadership, is characterized by a sense of equality among the leader and other participants.
In this situation, the nurse manager uses the democratic style of leadership. The nurse manager decides that staff members need to be
included in the problem-solving approach and that the staff will be more motivated to document their teaching if they have a say in how the
changes will be implemented. The autocratic leadership style, also called directive leadership, involves the leader assuming complete
control over the decisions and activities of the group. Situational leadership is a comprehensive approach that incorporates the leader's style,
the maturity of the work group, and the situation at hand. Laissez-faire is a permissive style of leadership in which the leader gives up
control and delegates all decision making to the work group. Huber (2014), p. 10
Resistance to change occurs when an individual rejects proposed new ideas for delivering client care without critically thinking about the
proposal.
Ethical/Legal; Priority Concepts: Communication, Leadership
8. The nurse manager of a maternity unit has read a research article that supports a change in the current instructions being given to new
mothers who are breast-feeding. The nurse manager posts the article with a summary of the findings in all of the nurses' stations in the
maternity unit. In this situation, the nurse manager is implementing which leadership style?
 1. Autocratic
 2. Situational
 3. Democratic
 4. Laissez-faire
Rationale:
Laissez-faire leadership, also called nondirective leadership, is a permissive style of leadership in which the leader gives up control and
delegates all decision making to the work group. This approach encourages independent activity by group members. In this situation, the
nurse manager uses this leadership style and is confident that individual staff members are professionals who are concerned with keeping up
with current research findings that they will use to improve their nursing care. The autocratic leadership style, also called directive
leadership, involves the leader assuming complete control over the decisions and activities of the group. Situational leadership is a
comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic
leadership, also called participative leadership, is characterized by a sense of equality among the leader and other participants. Huber
(2014), pp. 10-11
Quality improvement processes improve the quality of care delivery to clients and ensure safety in health care agencies.
Ethical/Legal; Priority Concepts: Communication, Professionalism
9. The nurse manager asks the nurse to work on her day off because of a short-staffing problem. The nurse has already made plans and does
not want to work on the day scheduled to be off. Which is an assertive response by the nurse to the nurse manager?
 1. "I can't work that day."
 2. "You know how I hate to work extra shifts."
 3. "I will if you need me, but I might be a few minutes late."
 4. "I have planned to take the day off and will not be able to work on that day."
Rationale:
The most assertive response is the one that is direct and conveys a clear message in a positive manner. Option 1 is an aggressive response.
Option 2 is a passive response. Option 3 is a passive-aggressive response. Potter et al (2013), p. 304
Assertive responses by the nurse clearly convey the intended message without causing conflict among coworkers.
Ethical/Legal; Priority Concepts: Communication, Professionalism
10. The nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-
staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is
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angry with the assignment because she believes that the assignment is more difficult than the assignments delegated to other nurses on the
unit. Which action is most appropriate for the nurse to take?
 1. Refuse to do the assignment.
 2. Tell the nurse manager to call the nursing supervisor.
 3. Ask the nurse manager of the neurological unit to discuss the assignment.
 4. Return to the cardiac unit and discuss the assignment with the nurse manager on that unit.
Rationale:
If the nurse feels that an assignment is more difficult than the assignment delegated to other nurses on the unit, the nurse would most
appropriately discuss the assignment with the nurse manager of the neurological unit. The nurse may or may not have a more difficult
assignment than the other nursing staff. However, this action will assist in either identifying the rationale for the assignment or determining
if the assignment is actually more difficult. The nurse would not refuse an assignment. Option 2 is an aggressive action and does not address
the conflict directly. The nurse would not return to the cardiac unit; this would be considered client abandonment, and this action does not
address the conflict directly. Specific situations may occur in which the nurse should not take care of a specific client (e.g., if a pregnant
nurse is assigned to care for a client with rubella or a client with an internal radiation implant). In these situations, the nurse would also
discuss the assignment with the nurse manager. Potter et al (2013), p. 304
Nurses in a floating situation must not assume responsibility beyond their level of experience or qualification.
Ethical/Legal; Priority Concepts: Ethics, Health Care Law
11. The nurse is caring for a client with a diagnosis of end-stage kidney disease. The client tells the nurse that a lawyer has prepared a living
will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a
witness to sign the will and requests that the nurse act as a witness. Which should be the nurse's response to the client?
 1. "I would be pleased to do that for you."
 2. "You need to talk to the nursing supervisor."
 3. "I never sign anything, and I need to refuse to do this too."
 4. "The nurse caring for a client cannot serve as a witness to a living will."
Rationale:
A living will addresses the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the person
who will make care decisions if the client is unable to take action. It is witnessed and signed by 2 people who are unrelated to the client.
Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as witnesses. Hammond,
Zimmermann (2013), p. 7; Ignatavicius, Workman (2013), pp. 107-108
A living will lists the medical treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is
terminally ill.
12. The nurse overhears a client ask the health care provider if the results of a biopsy indicated cancer. The health care provider tells the client
that the results have not returned when, in fact, the health care provider is aware that the results of the biopsy indicated the presence of
malignancy. The nurse is upset that the health care provider has not shared the results with the client and tells another nurse that the health
care provider has lied to the client and that this health care provider probably lies to all of the clients. Which legal tort has the nurse violated
by this statement?
 1. Libel
 2. Slander
 3. Assault
 4. Negligence
Rationale:
Defamation takes place when something untrue is said (slander) or written (libel) about a person, resulting in injury to that person's good
name and reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves
the actions of professionals that fall below the standard of care for a specific professional group. Although the health care provider may be
aware of the biopsy results, the health care provider decides when it is best to share such a diagnosis with the client. Potter et al (2013), p.
302
The nurse should participate through individual and collective action in establishing, maintaining, and improving health care environments
in accordance with the values of the profession.
13. The nurse suspects that a coworker is substance impaired and is self-administering opioid medications rather than administering them to
clients as prescribed. Which action should the nurse take?
 1. Report the information to the police.
 2. Report the information to a supervisor.
 3. Confront the coworker about the suspicion.
 4. Call the impaired nurse organization and report the coworker.
Rationale:
An impaired nurse is one who is unable to function effectively because of some type of substance abuse. The Nurse Practice Act requires
reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for
treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the Board of Nursing.
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Options 1, 3, and 4 are incorrect. The supervisor will report the substance abuse situation as necessary. Confronting the nurse may cause a
conflict. Potter et al (2013), p. 300
If the nurse suspects that a coworker is abusing chemicals and potentially jeopardizing a client's safety, the nurse must report the individual
to the nursing administration in a confidential manner. Client safety is always the first priority.
14. The pediatric nurse arrives at work and is told to report (float) to the emergency department for the day because the emergency department
is expecting numerous victims to arrive following a train accident. The nurse has never worked in the emergency department and is anxious
about floating to this area. What should the nurse do?
 1. Refuse to float to the emergency department.
 2. Ask another pediatric nurse to float to the emergency department.
 3. Tell the nursing supervisor that she is feeling sick and needs to go home.
 4. Discuss her anxieties and concerns about floating with the nursing supervisor.
Rationale:
Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, the nurse cannot refuse to float
unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the
performance of assigned tasks. When encountered with this situation, the nurse should discuss any anxieties and concerns about floating
with the nursing supervisor. Options 1 and 3 may be interpreted as client abandonment. Although option 2 may be an alternative option at
some point, it is not the appropriate action. Potter et al (2013), pp. 304-305
Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can
prove lack of knowledge for the performance of assigned tasks.
15. Based on a request made by the client's spouse and children, a health care provider asks the nurse to discontinue the feeding tube in a client
who is in a chronic debilitated and comatose state. The nurse understands the legal basis for carrying out the prescription and first checks
the client's record for which documentation?
 1. A court approval to discontinue the treatment
 2. Approval by the institutional ethics committee
 3. Authorization by the family to discontinue the treatment
 4. A written prescription by the health care provider to remove the tube
Rationale:
The family or a legal guardian can make treatment decisions for the client who is unable to do so. As soon as the decision is made, the
health care provider writes the prescription. Generally, the family makes decisions in collaboration with health care providers, other health
care workers, and other trusted advisors. Although a written prescription by the health care provider is necessary, the nurse first checks for
documentation of the family's request. Unless special circumstances exist, a court order is not necessary. Although some health care
agencies may require reviewing such requests through the ethics committee, this is not the nurse's first action. Huber (2014), pp. 102-103;
Potter et al (2013), pp. 290-291
An important nursing responsibility is to act as a client advocate and protect the client's rights.
16. What is the nurse's role in the informed consent process for a surgical procedure? Select all that apply.
 1. The nurse is responsible for providing detailed information about the surgical procedure.
 2. The nurse clarifies facts about the procedure that have been presented by the health care provider.
 3. The nurse verifies that the consent form has been signed prior to the client leaving the nursing unit.
 4. The nurse contacts the surgeon if he or she believes the client is not adequately informed about the procedure.
 5. The nurse who signs the consent form as a witness verifies that the client has been informed in detail about the procedure.
Rationale:
Nursing responsibilities with regard to informed consent include: clarifying any facts that have been presented by the health care provider
and dispelling any myths about the surgical procedure, assuring that the consent has been signed prior to the client leaving the nursing unit
and before any sedation is administered, and contacting the surgeon if the client is unclear about explanations provided by the health care
provider. The nurse is not responsible for providing detailed information about the procedure; this is the role of the health care provider.
The nurse should not act as a witness of the client being informed during the informed consent proceedings because it represents a conflict
of interest; the nurse can only act as a witness to the client's signature. Ignatavicius, Workman (2013), pp. 250, 252; Potter et al (2013), pp.
302-303
In order for consent to be obtained, the client must be informed, in understandable terms, of the risks and benefits of the surgery or
treatment, what the consequences are for not having the surgery or procedure performed, treatment options, and the name of the health care
provider performing the surgery or procedure.
Ethical/Legal; Priority Concepts: Health Care Law, Health Policy
17. The nurse administers furosemide (Lasix) 80 mg by mouth, but the prescription is written for furosemide 40 mg by mouth. Which should
the nurse document on an incident report?
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 1. "I gave the wrong dose of the medication."

 2. "Furosemide (Lasix) 80 mg by mouth administered."
 3. "A double dose of furosemide was given to the client."
 4. "Furosemide 80 mg given to the client instead of 40 mg."
Rationale:
When completing an incident report, the nurse should state the facts clearly. The nurse avoids documenting subjective data, including
assumptions and opinions about what occurred, and avoids assigning blame. Furthermore, the nurse avoids documenting to any
wrongdoing. Therefore, option 2 is the only correct option. Huber (2014), pp. 318-319
A completed incident report form should not be copied or placed in the client's record. Once completed and signed by the health care
provider, the form is maintained in the risk management office or other office as designated by hospital procedures.
Ethical/Legal; Priority Concepts: Health Policy, Professionalism
18. The nurse manager notes that an employee is demonstrating an unacceptable level of absenteeism. Which initial action should the nurse
manager take to handle this problem?
 1. Remind the employee verbally of the employment standards of the agency.
 2. Tell the employee that termination will occur if employment standards are not adhered to.
 3. Provide a written reminder to the employee about the employment standards of the agency.
 4. Send the employee home and ask the employee to think about a plan to change the behavior.
Rationale:
When an employee demonstrates an unacceptable level of absenteeism, the nurse would first remind the employee of the employment
standards of the agency. Sometimes an employee does not know, or has forgotten, the existing standards, and a reminder with no threats or
discipline is all that is needed. If the verbal reminder does not result in a change in behavior, the reminder should be placed in writing. If the
written reminder fails, the employee should be granted a day of decision to determine whether or not to accept the standards for work
attendance. Pay is given for this day so that it is not interpreted as punishment, and the employee needs to return to work with a written
decision. If the employee decides not to adhere to standards, then the employee is terminated. Potter et al (2013), pp. 278-279
If an employee is demonstrating unacceptable behavior, the nurse manager should remind the employee of the agency's standards,
determine the cause of the behavior, and work with the employee to devise a plan to change the behavior.
Ethical/Legal; Priority Concepts: Leadership, Professionalism
19. The nurse who has been employed in an ambulatory care unit for 8 weeks is consistently 10 to 20 minutes late for work. The nurse's
lateness has caused unrest with other staff members. She is due to receive a 3-month probation evaluation in 1 month. How should the nurse
manager appropriately deal with this situation?
 1. Tell the other staff members to cover for the nurse until she arrives.
 2. Tell the nurse that she will be fired if the behavior does not change.
 3. Address the lateness with the nurse at the 3-month probation evaluation.
 4. Confront the nurse to discuss the lateness and initiate problem-solving measures.
Rationale:
Arriving late to work is an unacceptable behavior. Although the nurse's behavior has caused unrest with other staff members, the primary
concern is that this behavior affects client care. The nurse manager needs to confront the nurse, discuss the lateness, and initiate problem-
solving measures that ensure that the behavior does not continue. It is not appropriate to wait a month to address the behavior. It is also
inappropriate to expect other staff members to cover until the nurse arrives. Additionally, this action will increase the unrest with the staff
members. Telling the nurse that she will be fired if the behavior does not change does not provide confrontation or address problem-solving.
However, firing may be an outcome if adequate warning has been issued and a change in behavior does not occur. Potter et al (2013), pp.
278-279
Face-to-face meetings to confront a conflict will allow verbalization of feelings, identification of problems and issues, and the development
of strategies to solve the problem.
Ethical/Legal; Priority Concepts: Leadership, Professionalism
20. The nurse leader of a maternity unit is concerned because staff members openly verbalize racial comments about clients on the unit. How
should the nurse leader appropriately manage this concern?
 1. Ignore the racial comments.
 2. Discourage the racial comments.
 3. Report the racial comments to the grievance committee.
 4. Leave articles about racial prejudice in the nurses' lounge.
Rationale:
Prejudice reduction is a method of managing or discouraging racial comments made by others. The best approach that the nurse manager
would take is to directly discuss the concern with the staff members. This action is not identified in the options. Therefore from the options
presented, option 2 would most appropriately manage this concern. When racial comments are discouraged, fewer comments will be made.
Ignoring the racial comments is inappropriate because the concern will not be addressed. Reporting the racial comments to the grievance
committee does not directly address the issue. Leaving articles about racial prejudice in the nurse's lounge indirectly addresses the subject;
moreover, the nurse manager cannot ensure that the staff will read the articles. Huber (2014), p. 304; Potter et al (2013), pp. 103, 302
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Acting as a client advocate and leading and managing the nursing team are roles of the nurse. Ensuring culturally competent care is an
integral aspect of upholding these responsibilities.
Level of Cognitive Ability: Analyzing; Client Needs: Safe and Effective Care Environment; Content Area: Fundamental Skills: Safety;
Priority Concepts: Communication, Safety
21. Which actions should the trauma nurse in the emergency department take to ensure effective communication during the hand-off
communication process at shift change? Select all that apply.
 1. Report diagnostic findings.
 2. Report assessment findings.
 3. Report the client's situation.
 4. Report a brief medical history.
 5. Report assumptions about the client.
Rationale:
The trauma nurse in the emergency department needs to communicate with other nurses and other members of the health care team to
ensure continuity of care. During the hand-off communication process at shift change, the nurse should communicate: diagnostic findings,
the client's situation or reason for being in the emergency department, a brief medical history, and all assessment findings. The nurse should
not report assumptions made about the client because this is not pertinent to the care of the client. Ignatavicius, Workman (2013), p. 124
The use of effective communication techniques is essential for safe nursing care.
Level of Cognitive Ability: Analyzing; Client Needs: Safe and Effective Care Environment; Content Area: Fundamental Skills: Elimination;
Priority Concepts: Clinical Judgment, Elimination
22. The client has a closed catheter irrigation system. Which information should be included in the documentation? Select all that apply.
 1. Character of drainage
 2. Presence of blood clots
 3. Client complaint of pain/spasms
 4. Type and amount of irrigation used
 5. Amount of solution returned as drainage
 6. How often the drainage system was changed each shift
Rationale:
The character of drainage should describe details such as color and sediment and is a means of evaluating the effectiveness of the irrigation.
Presence and size description of blood clots, complaints of spasms, type and quantity of solution infused, and amount of solution returned as
drainage all provide information as to the effectiveness of the procedure and client status. The drainage system is not changed every shift.
Lewis et al (2014), pp. 1313-1314; Potter et al (2013), p. 1083
Documentation is a means of communicating a description of events and information to others. Legal guidelines related to documentation
need to be followed.
Level of Cognitive Ability: Analyzing; Client Needs: Safe and Effective Care Environment; Content Area: Developmental Stages: End-of-Life
Care; Priority Concepts: Health Care Law, Professionalism
23. The nurse is caring for a client who has just died. What end-of-life information needs to be documented in the client's medical
record? Select all that apply.
 1. Time and date of death
 2. Time of body transfer and destination
 3. Family members present at the time of death
 4. Name of health care provider certifying death
 5. Medical tubes, devices, or lines left in the body
Rationale:
Proper documentation of postmortem care, or care of the body after death, is required. Agency policies and procedures are always followed
to provide an accurate and reliable medical record of all activities and assessments surrounding a death. Time and date of death and all
actions taken to respond to the impending death; time of body transfer and destination; the name of the certifying health care provider;
persons notified of the death; and any medical tubes, devices, or lines left in the body are some of the essential aspects that should be
documented. Documentation of present family members is not required. Potter et al (2013), p. 724
A human body should be respected in life and death and end-of-life care should follow the client's religious beliefs and requests. It is
important to note and document the client's requests and beliefs before death to ensure they are properly implemented after death.
Level of Cognitive Ability: Evaluating; Client Needs: Safe and Effective Care Environment; Content Area: Leadership/Management:
Delegating; Priority Concepts: Communication, Sensory Perception
24. The nurse is observing the unlicensed assistive personnel (UAP) talking to a client who is hearing impaired. The nurse should intervene if
the UAP performed which action during communication with the client?
 1. The UAP is speaking in a normal tone.
 2. The UAP is speaking clearly to the client.
 3. The UAP is facing the client when speaking.
 4. The UAP is speaking directly into the impaired ear.
Rationale:
When communicating with a hearing-impaired client, the UAP should speak in a normal tone to the client and should not shout. Moving
closer to the client and toward the better ear may facilitate communication, but the UAP needs to avoid talking directly into the impaired
7
ear. The UAP should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is
said, the UAP should express the statement differently. Ignatavicius, Workman (2013), p. 1103
If the client has difficulty with communication and does not seem to understand what is being said, the nurse should express the statement
differently. Using a whiteboard or notepad to communicate may also be helpful.
Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Developmental Stages: Infancy to
Adolescence; Priority Concepts: Development, Health Promotion
25. A toddler with suspected conjunctivitis is crying and refuses to sit still during the eye examination. Which is the most
appropriate statement for the nurse to make to the child?
 1. "Would you like to see my flashlight?"
 2. "Don't be scared, the light won't hurt you."
 3. "If you will sit still, the exam will be over soon."
 4. "I know you are upset. We can do this exam later."
Rationale:
Fears in this age group can be decreased by getting the child actively involved in the examination. Option 2 tells the toddler how to feel.
Option 3 ignores the toddler's feelings. Although option 4 acknowledges the toddler's feelings, it falsely puts off the inevitable.
Hockenberry, Wilson (2013), p. 107; McKinney et al (2013), pp. 879, 978
When approaching the toddler, the examiner should learn the words the toddler uses for common items and use them in conversations. The
examiner should also use short, concrete terms, and use play for demonstrations.
Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Antepartum; Priority
Concepts: Communication, Reproduction
26. The nurse is performing an assessment on a 34-year-old primigravida client who has been a marathon runner for several years. The client
verbalizes concern because she is no longer able to run in marathons and is concerned about the brown discoloration on her face and her
increasing size. Which statements by the nurse are therapeutic? Select all that apply.
 1. "I can see you're disappointed at not being able to run."
 2. "Tell me how you are feeling about the changes in your body."
 3. "Don't worry. Your body will go back to normal after delivery."
 4. "You need to ask your obstetrician about whether or not you can run."
 5. "Wait and see. You will be back to marathon running after delivery before you know it."
 6. "Some of the changes in pregnancy are permanent and that is the price that you have to pay for that bundle of joy."
Rationale:
The client is concerned about the body changes and life changes being experienced as a result of pregnancy. Therapeutic communication
techniques include focusing on the client's feelings and concerns and acknowledging these concerns by the techniques of clarifying (option
1) and encouraging discussion of feelings (option 2). Telling a client "not to worry" (option 3), placing the client's feelings on hold (option
4), and avoiding discussion of the client's feelings (options 5 and 6) are nontherapeutic communication techniques. McKinney et al (2013),
pp. 30-31, 260
Chloasma (mask of pregnancy) is a blotchy brownish hyperpigmentation that occurs over the forehead, cheeks, and nose. It is a normal
occurrence during pregnancy.
Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Adult Health: Integumentary; Priority
Concepts: Clinical Judgment, Tissue Integrity
27. The nurse performs a skin assessment on an assigned client and notes the presence of lesions that are red-tan scaly plaques. What is
the most likely cause of this finding?
 1. Xerosis
 2. Pruritus
 3. Pruritus
 4. Actinic keratoses
Rationale:
Actinic keratoses refer to lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have
a silvery white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are
premalignant and may develop into squamous cell carcinoma. Dry skin is called, xerosis. In this condition, the epidermis lacks moisture or
sebum and is often characterized by a pattern of fine lines, scaling, and itching. Causes include bathing too frequently, low humidity, and
decreased production of sebum in aging skin. Pruritus refers to the symptom of itching, an uncomfortable sensation that leads to the urge to
scratch the skin. Seborrhea relates to any of several common skin conditions in which an overproduction of sebum results in excessive
oiliness or dry scales. Ignatavicius, Workman (2013), pp. 502-503
Sun exposure is a primary cause of skin cancer.
Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Adult Health: Cardiovascular;
Priority Concepts: Communication, Coping
28. While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit
the most useful client response for determining the client's degree of adjustment to the new diagnosis?
 1. "Is there anyone to help with housework and shopping?"
 2. "How do you feel about making changes to your lifestyle?"
 3. "Do you understand the schedule for your new medications?"
8
 4. "Did you make a follow-up appointment with your health care provider?"
Rationale:
Exploring feelings assists the nurse with determining the individualized plan of care for the client who is adjusting to a new diagnosis.
Option 2 is the best question to ask the client because it is likely to elicit the most revealing information about the client's feelings about
CAD and the requisite lifestyle changes that can help maintain health and wellness. The remaining choices are aspects of post–hospital care,
but they are unlikely to uncover as much information about the client's adjustment to CAD because they are closed-ended questions.
Ignatavicius, Workman (2013), p. 834; Potter et al (2013), pp. 320-322
Increased cholesterol levels, low-density lipoproteins (LDL) levels, and triglyceride levels place the client at risk for coronary artery
disease.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Safety; Priority
29. The nurse takes a client his morning medications. The client states, "I don't want them. They don't help worth a hoot anyway." Which
response should the nurse make to the client?
 1. "Well, you have a right to refuse them."
 2. "You don't seem to feel your pills are working?"
 3. "Just take the pills. I'm too busy for this nonsense."
 4. "I'll have the health care provider prescribe different pills."
Rationale:
Open-ended questions, such as reflection, are appropriate therapeutic communication techniques. Although option 1 is true, it is not
appropriate and does not address the client's concern. Options 3 and 4 are nontherapeutic and do not address the client's concern. Potter et al
(2013), pp. 320-322
Use therapeutic communication techniques to respond to a client because of their effectiveness in the communication process.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Diagnostic Tests; Priority
Concepts: Anxiety, Communication
30. A client says to the nurse, "I'm so scared to have this liver biopsy. I have been told that bleeding is a major complication, and I don't want to
bleed to death." Which therapeutic response should the nurse make to the client?
 1. "Bleeding is a rare complication, so don't be concerned."
 2. "You have the best doctor in the world! Don't worry about anything."
 3. "You're feeling scared about the procedure? Tell me more about what is scaring you."
 4. "You will receive medication that will make you sleep, so you won't be aware of anything that is happening."
Rationale:
Reflection is the therapeutic communication technique that redirects the client's feelings back to him or her to validate what the client is
saying. Option 3 uses the therapeutic technique of reflection. This option also encourages the client to communicate feelings. Options 1, 2,
and 4 ignore the client's concern and feelings and block the communication process. Pagana, Pagana (2013), pp. 602-604; Potter et al
(2013), pp. 320-322
The nurse should never tell a client "not to worry." This is a nontherapeutic statement to make to the client. The nurse should always
encourage the client to express feelings and concerns.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Diagnostic Tests; Priority
Concepts: Communication, Gas Exchange
31. A client who is to undergo thoracentesis is afraid of not being able to tolerate the procedure. The nurse interprets that the client needs honest
support and reassurance, which can best be accomplished by which statement?
 1. "I'll be right by your side, but the procedure will be totally painless as long as you don't move."
 2. "The procedure only takes 1 to 2 minutes, so you might try to get through it by mentally counting up to 120."
 3. "The needle hurts when it goes in, and you must remain still. I'll stay with you throughout the entire procedure and help you
hold your position."
 4. "The needle is a little uncomfortable going in, but this is controlled by rhythmically breathing in and out. I'll be with you to
coach your breathing."
Rationale:
The needle insertion for thoracentesis is painful for the client. The nurse tells the client how important it is to remain still during the
procedure so that the needle does not injure visceral pleura or lung tissue. The nurse reassures the client during the procedure and helps the
client hold the proper position. Options 1, 2, and 4 are inaccurate statements. Ignatavicius, Workman (2013), pp. 559-560; Pagana, Pagana
(2013), pp. 888-890; Potter et al (2013), pp. 320-322
The client undergoing thoracentesis should be positioned sitting upright with the arms and shoulders supported by a table or lying in bed
toward the affected side with the head of the bed elevated.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Perioperative Care; Priority
32. A client is awaiting surgery for the removal of a pancreatic mass, and she tells the nurse that she is scared that she will not wake up after
receiving the anesthesia. Which therapeutic response should the nurse make to the client?
 1. "This is a very common concern."
 2. "Tell me what makes you feel concerned about the anesthesia."
 3. "I had surgery a year ago and was afraid of the same thing. I did just fine."
9
 4. "You have the best anesthesiologist in this hospital. There is no need to be scared."
Rationale:
This client is concerned about surgery and is expressing fear about the anesthesia. The therapeutic response to the client is the one that
encourages the client to express her concerns. Option 1 is a stereotypical response. Option 3 avoids the client's concern and focuses on the
nurse's personal experience. Option 4 also avoids the client's concern. Ignatavicius, Workman (2013), p. 1333; Potter et al (2013), pp. 320-
322
The nurse must keep the client undergoing surgery who has received preoperative medications in bed. The call bell should be placed next to
the client, and the client should be instructed not to get out of bed and to call for assistance if needed.
33. Before inserting a peripheral intravenous (IV) catheter into a preoperative client, the nurse notes that the client's muscles are tense and she is
fidgeting with the bedsheet, stating she does not understand why she has to have the IV. Which statement should the nurse first verbalize to
the client?
 1. "This will be finished before you know it."
 2. "Inserting the IV does not hurt very much."
 3. "The IV adds fluid into your bloodstream."
 4. "The IV catheter is an 18-gauge angiocatheter."
Rationale:
In option 3, the nurse uses simple terms to clearly inform the client about the IV's purpose. Option 1 is an unethical statement for the nurse
to make because the information is incorrect. Avoiding the client's feelings in option 2, blocks client communication regarding justifiable
fears and feelings related to the IV insertion. Option 4 is an unsuitable statement because the client potentially would not understand the
word "angiocatheter." Ignatavicius, Workman (2013), pp. 213-214; Potter et al (2013), pp. 320-322
Administration of an intravenous solution or medication provides immediate access to the vascular system. This is a benefit of
administering solutions or medications via this route, but it can also present a risk. Therefore, it is critical to ensure that the health care
provider's prescriptions are checked carefully and the correct solution or medication is administered as prescribed. Always follow the six
rights for medication administration.
34. A postoperative client displays signs of anxiety when the nurse explains that the intravenous (IV) line will need to be discontinued as a
result of an infiltration. Which appropriate statement should the nurse make to the client?
 1. "This will be a totally painless experience. It is nothing to worry about."
 2. "I'm sure it will be a real relief for you just as soon as I discontinue this IV for good."
 3. "Just relax and take a deep breath. This procedure will not take long, and it will be over soon."
 4. "I can see that you're anxious. Removal of the IV shouldn't be painful, but the IV will need to be restarted in another
location."
Rationale:
Option 4 addresses the client's anxiety and honestly informs the client that the IV may need to be restarted. This option uses the therapeutic
technique of giving information, and it also acknowledges the client's feelings. Although discontinuing an IV is a painless experience, it is
not therapeutic to tell a client not to worry. Option 2 does not acknowledge the client's feelings, and it does not tell the client that an
infiltrated IV may need to be restarted. Option 3 does not address the client's feelings. Ignatavicius, Workman (2013), p. 228; Potter et al
(2013), pp. 320-322
The nurse should avoid venipuncture and placing an intravenous line over an area of flexion to prevent infiltration.
Concepts: Clinical Judgment, Communication
35. A client who is scheduled for an abdominal peritoneoscopy tells the home care nurse, "The surgeon told me to restrict food and liquids for
at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this
procedure?" Which appropriate response should the nurse make to the client?
 1. "Any invasive procedure brings risk with it. You need to report any shoulder pain immediately."
 2. "You seem to understand the preparation very well. Are you having any concerns about the procedure?"
 3. "Trouble? There is never any trouble with this procedure. That's why the surgeon will use local anesthesia."
 4. "There are relatively few problems, especially if you are having local anesthesia, but vaginal bleeding should be reported
immediately."
Rationale:
Abdominal peritoneoscopy is performed to directly visualize the liver, gallbladder, spleen, and stomach after the insufflation of nitrous
oxide. During the procedure, a rigid laparoscope is inserted through a small incision in the abdomen. A microscope in the endoscope allows
for the visualization of the organs and provides a way to collect a specimen for biopsy or remove small tumors. The appropriate response is
the one that facilitates the expression of the client's feelings. Option 1 may increase the client's anxiety. In option 3, the nurse states that no
problems are associated with this procedure; this is close-ended and is incorrect. Although option 4 contains accurate information, the word
"immediately" can increase the client's anxiety. Chernecky, Berger (2013), pp. 705-706; Potter et al (2013), pp. 320-322
Following endoscopic procedures in which the throat is sprayed with an anesthetic, the nurse should monitor for the return of a gag reflex
before giving the client any oral substance. If the gag reflex has not returned and food or fluids are administered, the client could aspirate.
10
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Nutrition; Priority
Concepts: Communication, Nutrition
36. The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, "I really miss eating dinner with my
family." How should the nurse respond in order to reply to the client therapeutically?
 1. "What you are feeling is very common."
 2. "Tell me more about your family dinners."
 3. "In a few weeks, you may be allowed to eat."
 4. "You can sit down to dinner even if you do not eat."
Rationale:
The nurse assists the client with expressing feelings and dealing with the aspects of illness and treatment by clarifying and helping the client
to focus on and explore concerns. In option 1, the nurse characterizes and classifies the feelings on the basis of an assumption. Option 3
provides false hope and option 4 blocks communication by giving advice. Ignatavicius, Workman (2013), pp. 1348-1349; Potter et al
(2013), pp. 320-322
The delivery of hypertonic solutions into peripheral veins can cause sclerosis, phlebitis, or swelling, and the nurse should monitor for these
complications.
Concepts: Communication, Nutrition
37. A health care team has developed and initiated a refeeding program for a client. After breakfast, the client complains of fullness and
bloating. Which statement should the nurse make to the client?
 1. "Don't worry about it."
 2. "These are normal feelings and are temporary."
 3. "Focusing on your stomach will only make you feel worse."
 4. "I am so proud that you were able to eat all your breakfast."
Rationale:
The gastrointestinal tract takes time to adjust to unaccustomed intake. Option 2 directly addresses the client's feelings. Options 1 and 3
ignore the client's concern. Option 4 focuses on the nurse's feelings and ignores the client's concern. Lewis et al (2014), p. 902; Potter et al
(2013), pp. 320-322
The nurse should always use therapeutic communication techniques when communicating with a client. Additionally, the nurse should
consider cultural practices when planning client care.
Concepts: Communication, Professionalism
38. The nurse is developing a dietary plan with an anemic client. The client states, "My iron pills will have to do. I can't afford to buy any of
that fancy food." Which response by the nurse is appropriate?
 1. "This is very important, so pay attention."
 2. "Why don't you ask your family for help?"
 3. "Ground beef is not very expensive right now."
 4. "Would you like for me to check into some options for you?"
Rationale:
Option 4 validates the issue that the client has with financial income. The nurse offers assistance in a nonthreatening manner that will allow
the client to accept or decline. Options 1 and 3 block further communication with this client by placing the client's issues on hold. Option 2
is requesting an explanation by using the word, whyNix (2013), p. 153; Potter et al (2013), pp. 320-322
Hemoglobin determinations are important to monitor in a client with anemia.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Cultural Awareness; Priority
Concepts: Communication, Culture
39. When the nurse is providing care for a client who is not fluent in the English language, what is the initial nursing action?
 1. Determine the client's primary language.
 2. Obtain a translation dictionary for the client.
 3. Establish a means of communication using gestures and hand movements.
 4. Obtain a pad and paper so that the client can write and draw to express needs.
Rationale:
Language is the largest barrier for people who do not speak English or cannot communicate in English effectively. The nurse needs to
assess the client's ability to communicate. If the client is not fluent in English, the nurse should first determine his or her primary language.
Then a trained medical interpreter designated by the health care facility should be contacted for communication with the client to prevent
errors in communication that could lead to client harm. The client should not be expected to use a translation dictionary or use gestures and
hand movements because this could cause confusion and errors in communication. Writing or drawing needs on a pad of paper could also
cause confusion and lead to error. Ignatavicius, Workman (2013), p. 33
The nurse should always seek an agency-designated interpreter if a client does not speak or understand the English language. Having a
family member or other person interpret for the client can be a breach of confidentiality; additionally, it could lead to misinterpretation of
information and resultant errors.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Cultural Awareness; Priority
11
40. A Latino client unfamiliar with Western culture health care practices has been diagnosed with myasthenia gravis and is prescribed
neostigmine bromide (Prostigmin), 200 mg orally every 3 to 4 hours. The nurse is concerned that the client will not comply with the
medication regimen as prescribed. Which effective technique should the nurse use when teaching the client about the medication?
 1. Use a fluent translator.
 2. Touch the client while speaking.
 3. Avoid slang to explain a medical term.
 4. Have the client answer simply "yes" or "no" to questions.
Rationale:
The most effective technique is to use a translator (someone of the same language/culture) to explain the medication regimen. Touch is an
unacceptable practice in many cultures. Options 3 and 4 do not ensure client understanding of the medical regimen. Ignatavicius, Workman
(2013), p. 33; Jarvis (2012), pp. 45-47
Causes of myasthenia gravis include insufficient secretion of acetylcholine, excessive secretion of cholinesterase, and unresponsiveness of
the muscle fibers to acetylcholine.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Developmental Stages: Early Adulthood to Later
Adulthood; Priority Concepts: Adherence, Communication
41. After the surgical repair of a fractured hip, an older adult client has consistently refused to engage in ambulation as prescribed. Which
statement by the nurse will best encourage the client's need to ambulate?
 1. "What is it about getting out of bed that concerns you?"
 2. "If you are afraid of the pain, I can give you medication to help."
 3. "If you don't get up and start walking, your recovery will take much longer."
 4. "Being dependent on others must be a depressing for an active person like yourself."
Rationale:
Early ambulation during the postoperative period is very important to a client's health and recovery, but many different factors may be
contributing to the client's refusal to ambulate as prescribed. Asking an open-ended question that encourages a discussion about getting out
of bed is the best option available to allow the nurse to facilitate the client's plan of care. Pain may be a concern for the client, but again, the
nurse is making an unfounded assumption. While it is true that the recovery might be prolonged by not ambulating and the client may be
depressed, these statements make assumptions about the reason the client is refusing to comply with the plan of care. Ignatavicius,
Workman (2013), p. 99; Potter et al (2013), pp. 320-322
Effective communication with the client is a necessary factor in determining the underlying reasons for noncompliance with the plan of
care.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Developmental Stages: End-of-Life Care; Priority
42. The nurse is employed in a long-term care facility. What actions should the nurse implement to facilitate effective communication with an
older client?
 1. Use active listening.
 2. Use an authoritarian approach.
 3. Listen only for facts within the client's conversation.
 4. React to sensationalism within the client's conversation.
Rationale:
For effective communication, the nurse uses active listening and creates an environment in which the client feels comfortable expressing
feelings. An authoritarian approach is directive and not permissive and will not create an environment for verbal exchange from the client.
Reactiveness and listening only for facts are examples of inactive listening. Potter et al (2013), pp. 186, 320
The nurse should ask the client open-ended questions in order to obtain as much information as possible from the client.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Developmental Stages: Infancy to Adolescence;
Priority Concepts: Clinical Judgment, Development
43. A 4-year-old child who was recently hospitalized is brought to the clinic by his mother for a follow-up visit. The mother tells the nurse that
the child has begun to wet the bed ever since he was brought home from the hospital. The mother is concerned and asks the nurse what to
do. Which is the appropriate nursing response?
 1. "You need to discipline the child."
 2. "This is a normal occurrence after hospitalization."
 3. "The child probably has developed a urinary tract infection."
 4. "We will need to discuss this behavior with the health care provider."
Rationale:
Regression can occur in a preschooler, and it is most often a result of the stress of the hospitalization. It is best to accept the regression if it
occurs. Parents may be overconcerned about the regressive behavior, and they should be told that regression is normal after hospitalization.
It is premature to discuss the situation with the health care provider. Disciplining the child or responding that the child has a urinary tract
infection are inappropriate responses to the mother. Hockenberry, Wilson (2013), pp. 390, 500; McKinney et al (2013), p. 882
The hospitalized preschooler is typically quietly withdrawn, depressed, and uninterested in the environment, may become uncooperative,
refusing to eat or take medication, and repeatedly asks when the parents will be visiting.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Developmental Stages: Infancy to Adolescence;
Priority Concepts: Communication, Coping
12
44. A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What
question best demonstrates the nurse's ability to use therapeutic communication techniques to effectively assess the teenager's feelings
about using a cane?
 1. "How do you feel about needing a cane to walk?"
 2. "Do you have questions about ambulating with a cane?"
 3. "Are you worried about what your friends will think about your cane?"
 4. "What types of problems do you think you'll have ambulating with a cane?"
Rationale:
The nurse effectively uses therapeutic communication techniques when posing an open-ended question to elicit assessment data about how
the teenager feels about using a cane. The remaining options are closed-ended questions. Option 3 makes assumptions about how the
teenager feels while options 2 and 4 focus on the physical aspects of using the cane. Ignatavicius, Workman (2013), pp. 98, 1157-1158;
Potter et al (2013), pp. 320-322
The nurse should instruct the client using a cane to inspect the rubber tip on the cane regularly for worn places. A worn tip will need to be
replaced.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Antepartum; Priority
45. A client has some concerns regarding chorionic villus sampling (CVS) and states to the nurse, "I'm not sure I should have this test done."
Which appropriate response should the nurse make to the client?
 1. "It's your decision."
 2. "Tell me what concerns you have."
 3. "Don't worry. Everything will be fine."
 4. "Why don't you want to have this test?"
Rationale:
The nurse needs to gather more data and assist the client in exploring her feelings about the test. The nurse should not place the client's
feelings on hold or belittle the client's feelings. Options 1, 3, and 4 are communication blocks and are nontherapeutic. Option 2 addresses
the client's concerns. Pagana, Pagana (2013), pp. 253-255; Potter et al (2013), pp. 320-322
CVS is performed for the purpose of detecting genetic abnormalities.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Antepartum; Priority
46. A client states, "It will be so hard to wait for the results of this amniocentesis. I don't know what I will do if something goes wrong." Which
appropriate response should the nurse make to the client?
 1. "You sound concerned about this test."
 2. "You are in good hands; your health care provider is the best."
 3. "It's not good for your baby when you become upset or worry."
 4. "This test has been done for many years with few reported complications."
Rationale:
The nurse needs to gather more data and assist the client in exploring her feelings about the test. The nurse should not place the client's
feelings on hold or belittle the client's feelings. Options 2, 3, and 4 are incorrect. They do not focus on the client's feelings. McKinney et al
(2013), pp. 32, 306-308
Amniocentesis is performed to determine genetic disorders, metabolic defects, and fetal lung maturity.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Intrapartum; Priority
47. A client is admitted to the labor and delivery unit for a vaginal birth after cesarean (VBAC). The client, in early labor, expresses fear over
the upcoming labor pain and her ability to handle the contractions. Which therapeutic statements should the nurse make to the client? Select
all that apply.
 1. "Can you tell me more about your previous delivery?"
 2. "You should rest while you are in early labor, while you can."
 3. "You have fear about the pain of the contractions and the intensity of labor?"
 4. "Are you concerned about having another cesarean if your vaginal birth is unsuccessful?"
 5. "Why don't you ask the health care provider for an epidural once your contractions get stronger?"
Rationale:
The nurse should use therapeutic communication to help the client identify anxieties or beliefs about labor and its progress. Helping the
client to express fears and anxieties is the first step to managing them effectively, so the stress response does not slow her labor. Using
clarifying, paraphrasing, and reflecting will help the client express concerns. Options 1, 3, and 4 use those techniques. Giving advice or
failing to acknowledge feelings blocks communication. Option 2 fails to acknowledge feelings and gives advice; option 5 also gives advice.
McKinney et al (2013), pp. 30-31, 425
Therapeutic communication involves responding, as well as listening, and the nurse should use responses that facilitate rather than block
communication. These facilitative responses, often called communication techniques, focus on both the content of the message and the
feeling that accompanies the message.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Intrapartum; Priority
Concepts: Communication, Infection
13
48. A client who is in labor has human immunodeficiency virus (HIV) and says to the nurse, "I know I will have a sick-looking baby." Which
appropriate response should the nurse make?
 1. "You are very sick, but your baby may not be."
 2. "All babies are beautiful. I am sure your baby will be, too."
 3. "You have concerns about how HIV will affect your baby?"
 4. "There is no reason to worry. Our neonatal unit offers the latest treatments available."
Rationale:
Option 3 is the most therapeutic response, and it will elicit the best information. It addresses the therapeutic communication technique of
paraphrasing. Option 3 also is an open-ended response that will provide an opportunity for the client to verbalize her concerns. Parents need
to know that their baby will not look sick from HIV at birth and that there may be a period of uncertainty before it is known whether the
baby has acquired the infection. Options 1 and 2 provide false reassurances. The client should not be told that there is no reason to worry.
Lowdermilk, Perry, Cashion, Alden (2012), pp. 850-851; McKinney et al (2013), pp. 30-31, 629
Infants at risk for human immunodeficiency virus (HIV) infection need to receive all recommended immunizations at the regular schedule;
however, no live vaccines should be administered.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Anxiety,
Communication
49. The nurse is caring for an infant diagnosed with hyaline membrane disease. The infant will require the instillation of surfactant replacement
therapy via an endotracheal tube, and the parents will be present during the procedure. The father states that he is not sure about having this
done to his baby. Which statement by the nurse prior to performing the procedure will aid in preparing the parents?
 1. "Don't worry. We do this all the time."
 2. "You have concerns about this procedure for your baby?"
 3. "You have a wonderful health care provider who has made the right decision for your baby."
 4. "We are going to be busy with the baby, so why don't you wait outside during the procedure?"
Rationale:
In planning for this infant's care and the well-being of the parents, it will be important to apply the techniques of therapeutic
communication. By paraphrasing the father's concern, the message is restated in the nurse's own words. Option 1 is false reassurance, which
will block communication. Option 3 is a communication block that denies the parents the right to their opinion. Option 4 is inappropriate;
the parents have every right to be present at the procedure. Hockenberry, Wilson (2013), p. 270; McKinney et al (2013), pp. 30-31
Surfactant replacement therapy is usually prescribed for a newborn who is diagnosed with respiratory distress syndrome.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Client
Education, Communication
50. A new mother is trying to decide whether to have her baby boy circumcised. The nurse should make which statement to assist the mother
with making the decision?
 1. "I had my son circumcised, and I am so glad."
 2. "Circumcision is a difficult decision, but your health care provider is the best, and you know it's better to get it done now than
later."
 3. "You know they say it prevents cancer and sexually transmitted infections, so I would definitely have my son circumcised."
 4. "Circumcision is a difficult decision. There are various controversies surrounding circumcision. Here, read this pamphlet that
discusses the pros and cons, and we will talk about any questions that you have after you read it."
Rationale:
Informed decision making is the strategic point when answering this question. The nurse should provide educational materials and answer
questions pertaining to the education of the mother. Providing written information to the mother will give her the information she needs to
make an educated and informed decision. The nurse's personal thoughts and feelings should not be part of the educational process.
McKinney et al (2013), pp. 30-31, 518
The nurse should instruct the mother of a newborn who has been circumcised to monitor urine output and for signs of urinary retention.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority Concepts: Clinical
Judgment, Communication
51. The parents of a postterm infant ask the nurse, "Why does our baby have such a worried facial expression?" The nurse should make which
response to the parents?
 1. "I think you are right to be concerned."
 2. "In my experience, all babies look like that."
 3. "Have you decided on a name for your baby?"
 4. "You have concerns about the baby's worried facial expression?"
Rationale:
Paraphrasing is restating the parent's message in the nurse's own words. In option 1, the nurse is expressing approval, which can be harmful
to the nurse-parent relationship. In option 2, the nurse is offering false reassurance, and this type of response will block communication.
Option 3 reflects a communication block, because it avoids the parents' concern. Hockenberry, Wilson (2013), p. 256; McKinney et al
(2013), pp. 30-31
A postterm newborn is one who is born after 42 weeks of gestation.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Newborn; Priority
Concepts: Communication, Coping
14
52. The mother of a newborn with hydrocephalus is concerned about the complication of mental retardation. The mother states to the nurse,
"I'm not sure if I can care for my baby at home." Which therapeutic response should the nurse make to the mother?
 1. "All babies have individual needs."
 2. "Mothers instinctively know what is best for their babies."
 3. "You have concerns about your baby's condition and care?"
 4. "There is no reason to worry. You have a good pediatrician."
Rationale:
Paraphrasing is restating the mother's message in the nurse's own words. Option 3 demonstrates the therapeutic technique of paraphrasing.
In option 1, the nurse is minimizing the social needs involved with the baby's diagnosis, which is harmful for the nurse–parent relationship.
In options 2 and 4, the nurse is offering false reassurance, and these types of responses will block communication. Hockenberry, Wilson
(2013), pp. 969-970; McKinney et al (2013), pp. 30-31, 969-970
Hydrocephalus results in head enlargement and increased intracranial pressure.
Concepts: Communication, Development
53. During the discharge planning of a small-for-gestational-age (SGA) infant, the nurse makes an appointment for the infant to be evaluated by
a developmental specialist. The mother says to the nurse, "I am not sure that going to a specialist is necessary just because the baby is
small." The nurse should make which response to the mother?
 1. "Your baby is very small and needs to be evaluated by the developmental specialist."
 2. "A lot of parents have to have their babies evaluated by the developmental specialist."
 3. "I feel that it is the best thing for you to have the baby evaluated by the developmental specialist."
 4. "Would you like for me to clarify why I have made an appointment for your baby to be evaluated by the developmental
specialist?"
Rationale:
Small-for-gestational-age (SGA) infants are at risk for poor postnatal growth, as well as neurological and developmental handicaps. By
paraphrasing the mother's message, the nurse uses a therapeutic communication technique and addresses the mother's need for
understanding. Options 1, 2, and 3 are nontherapeutic responses. Options 1 and 2 provide advice from the nurse's viewpoint and opinion.
Option 3 is a generalized statement and does not address the mother's individual concern. McKinney et al (2013), pp. 30-31, 712
The SGA infant needs to be monitored closely for signs of hypoglycemia.
54. A new mother with diabetes mellitus questions the nurse about the need to perform a heel puncture for the frequent blood glucose screening
on her newborn infant. Which response should the nurse make to the mother?
 1. "The doctor prescribed them. It's only a little stick."
 2. "Try not to worry about them. They are covered by insurance."
 3. "It bothers you to have the infant stuck frequently. It is painful, but it is necessary to see what your infant's blood glucose is."
 4. "If you ask me, I would be much more concerned with your baby's breathing. Did you notice how the baby is breathing so
fast?"
Rationale:
Mothers are very concerned over any painful procedure performed on their infant. Option 3 reflects the perceived feelings of the mother,
validates that it is painful, and provides the correct rationale for the procedure. Most newborn infants of mothers with diabetes are
monitored regularly for several hours or until the glucose levels are stable. Options 1 and 2 avoid the client's concern. Option 4 would cause
concern in the mother. McKinney et al (2013), pp. 30-31, 494, 970-971
The newborn of a diabetic mother is at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, and
congenital anomalies.
Concepts: Development, Gas Exchange
55. A mother of an infant born at 42 weeks' gestation arrives at the neonatal intensive care unit to visit her infant. The mother notes that her
infant is on a mechanical ventilator and states, "I don't understand. I thought my baby would be fine. Why is my baby on this machine?"
What is an appropriate response by nurse?
 1. "Babies who are born postterm all need mechanical ventilation."
 2. "Your baby will need this machine until the lungs are fully developed."
 3. "Many postterm babies aspirate meconium, and the mechanical ventilator helps the baby breathe easier."
 4. "If the health care provider had delivered your baby a little earlier, the baby probably would not need this machine."
Rationale:
Postterm infants may experience meconium aspiration syndrome from the effects of anoxia in utero. Infants suffering from meconium
aspiration may require mechanical ventilator support. Option 1 is a closed-ended statement and incorrect and does not specifically respond
to the mother's question. Option 2 refers to the preterm infant who has immature lungs, which is not the issue in this question. Option 4
places blame on the health care provider, which is inappropriate. Hockenberry, Wilson (2013), pp. 256, 275; McKinney et al (2013), pp. 32,
711, 719-720
Aspiration can occur in utero or with the first breath of a newborn.
15
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Child Health: Metabolic/Endocrine; Priority
Concepts: Communication, Development
56. A 10-year-old child in remission from leukemia is upset over the appearance of cushingoid characteristics from long-term use of
corticosteroids, currently being administered every other day. Which therapeutic statements should the nurse make to the child about the
cushingoid appearance? Select all that apply.
 1. "I am sure it will be all right; they hardly look unusual."
 2. "Which manifestations of this condition do you find most troublesome?"
 3. "You should talk to the health care provider about the cushingoid characteristics."
 4. "The manifestations are lessened by taking the prednisone every other day instead of daily."
 5. "The cushingoid appearance will gradually disappear once the corticosteroids are tapered and discontinued."
Rationale:
The nurse should use therapeutic communication to help the client cope with these feelings. Using questioning and providing accurate
information will reassure the client about the cushingoid appearance. Options 2, 4, and 5 use those techniques. Giving advice or failing to
acknowledge feelings blocks communication. Option 1 fails to acknowledge feelings and option 3 is giving advice. Hockenberry, Wilson
(2013), p. 989
Facilitative nursing responses, often called communication techniques, focus on both the content of the message and the feeling that
accompanies the message.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Child Health: Neurological; Priority
Concepts: Communication, Intracranial Regulation
57. A mother says to the nurse, "I am afraid that my child might have another febrile seizure." Which therapeutic communication statement
is best for the nurse to make to the mother?
 1. "Tell me what frightens you the most about seizures."
 2. "Tylenol can prevent another seizure from occurring."
 3. "Most children will never experience a second seizure."
 4. "Why worry about something that you cannot control?"
Rationale:
Option 1 is the only response that is an open-ended statement and that provides the mother with an opportunity to express her feelings.
Options 2 and 3 are incorrect because the nurse is giving false reassurance that a seizure will not recur or that it can be prevented in this
child. Option 4 is incorrect because it blocks communication by giving a flippant response to an expressed fear. McKinney et al (2013), pp.
30-31, 1433
For the client experiencing a seizure, the nurse should ensure airway patency, have suction equipment and oxygen available, time the
seizure episode, place a pillow or folded blanket under the client's head, loosen restrictive clothing, remove eyeglasses if present, and clear
the area of any hazardous objects.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Oncology; Priority
58. During the nursing assessment, the client says, "My surgeon just told me that my cancer has spread, and I have less than 6 months to live."
Which nursing response would be therapeutic?
 1. "I am sorry. Would you like to discuss this with me some more?"
 2. "I am sorry. There are no easy answers in times like this, are there?"
 3. "I hope you'll focus on the fact that your doctor says you have 6 months to live and that you'll think of how you'd like to live."
 4. "I know it seems desperate, but there have been a lot of breakthroughs. Something might come along in a month or so to
change your status drastically."
Rationale:
The client has received very distressing news and is most likely still experiencing shock and denial. In option 1, the nurse invites the client
to ventilate feelings. Option 2 is social and expresses the nurse's feelings rather than the client's feelings. Option 3 is patronizing and
stereotypical. Option 4 provides social communication and false hope. Ignatavicius, Workman (2013), p. 419, Potter et al (2013), pp. 320-
322
The nurse should monitor the client's progression through the stages of grieving. Not all clients will progress in the same manner and may
progress from one stage to another in no logical order.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Endocrine; Priority
Concepts: Adherence, Communication
59. A client with diabetes mellitus says that it is very difficult to adhere to the diabetic treatment plan. The nurse interprets the client's concern
and responds appropriately with which response?
 1. "Let's check your blood glucose now."
 2. "Let's go over your diet again to be sure it contains foods you like."
 3. "Do you understand what noncompliance can mean to your future health?"
 4. "If you don't take your insulin, you will develop diabetic ketoacidosis (DKA)."
Rationale:
It is important to determine and deal with a client's concerns and to identify measures that will assist the client to comply with the diabetic
regimen. The nurse should determine if the client understands the diet and if the client's treatment plan maintains normalcy as much as is
possible with the lifestyle. Scare tactics as described in options 3 and 4 should not be used. Positive reinforcement is necessary instead of
focusing on negative behaviors. Option 1 does not address the subject of the question. Ignatavicius, Workman (2013), pp. 1438, 1451;
Potter et al (2013), pp. 320-322
16

Fasting blood glucose levels are used to help diagnose diabetes mellitus.
60. A client with hyperparathyroidism has just finished speaking with the health care provider about surgery. The client says to the nurse, "I'm
not sure that I want my neck cut open!" Which response should the nurse make to the client?
 1. "Can you tell me more about what you are thinking?"
 2. "I think you will feel much healthier postoperatively."
 3. "You are very ill. Your doctor has made the right decision."
 4. "There is no reason to worry. The surgeon is a wonderful doctor!"
Rationale:
Focusing on the client helps promote effective communication within a therapeutic relationship. Option 1 is paraphrasing the client's
message in the nurse's own words and allows the client and nurse to continue the discussion. The other options are blocks to communication
and are nontherapeutic. Ignatavicius, Workman (2013), pp. 1406-1407; Lewis et al (2014), p. 1206; Potter et al (2013), pp. 320-322
For the client with hyperparathyroidism, notify the health care provider immediately if a precipitous drop in the calcium level occurs; assess
for tingling and numbness in the face and extremities and for other signs of hypocalcemia.
61. A client with hyperaldosteronism has developed kidney failure and says to the nurse, "This means that I will die very soon." What is the
appropriate response for the nurse to make to the client?
 1. "You will do just fine."
 2. "What are you thinking about?"
 3. "You sound discouraged today."
 4. "I read that death is a beautiful experience."
Rationale:
Option 3 uses the therapeutic communication technique of reflection, and it both clarifies and encourages the further expression of the
client's feelings. Options 1 and 4 deny the client's concerns and provide false reassurance. Option 2 requests an explanation and does not
encourage the expression of feelings. Ignatavicius, Workman (2013), p. 1390; Potter et al (2013), pp. 320-322
The signs and symptoms of acute kidney injury are primarily caused by the retention of nitrogenous wastes, the retention of fluids, and the
inability of the kidneys to regulate electrolytes. Kidney failure affects all major body systems and may require dialysis to maintain life.
62. A client diagnosed with myxedema has changes in intellectual function, such as impaired memory, decreased attention span, and lethargy.
The client's husband, who is upset, shares his concerns with the nurse. Which statement by the nurse would be helpful to the client's
husband?
 1. "Would you like me to ask the doctor for a prescription for a stimulant?"
 2. "Give it time. I've seen dozens of clients with this problem who fully recover."
 3. "I don't blame you for being frustrated because the symptoms will only get worse."
 4. "It's obvious that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."
Rationale:
Using therapeutic communication techniques, the nurse acknowledges the husband's concerns and conveys that the client's symptoms are
common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal
within 2 weeks. Option 1 would not be helpful, and it also blocks further communication. Option 2 is not appropriate and offers false
reassurance. Option 3 is pessimistic and untrue. Ignatavicius, Workman (2013), p. 1404; Potter et al (2013), pp. 320-322
Myxedema is the most severe form of hypothyroidism characterized by swelling of the hands, face, feet, and periorbital tissues. At this
stage, the disease could lead to coma and death if left untreated.
Concepts: Communication, Glucose Regulation
63. A client with newly diagnosed type 1 diabetes mellitus has been seen for 3 consecutive days in the emergency department with
hyperglycemia. During the assessment, the client says to the nurse, "I'm sorry to keep bothering you every day, but I just can't give myself
those awful shots." Which therapeutic response should the nurse make?
 1. "I couldn't give myself a shot either."
 2. "You must learn to give yourself the shots."
 3. "Let me see if we can change your medication."
 4. "Has someone given you instructions on how to perform them?"
Rationale:
It is important to determine and deal with a client's underlying fear of self-injection. The nurse should determine whether a knowledge
deficit exists. Positive reinforcement should occur rather than focusing on negative behaviors. Demanding that the client perform a behavior
or skill is inappropriate. The nurse should not offer a change in regimen that cannot be accomplished. Ignatavicius, Workman (2013), p.
1434; Potter et al (2013), pp. 320-322
Common sites for the injection of insulin include the upper arm, abdomen, thighs, lower back, and buttocks.
17
64. The nurse requests that a client with diabetes mellitus ask their family members to attend an educational conference about the self-
administration of insulin. The client questions why they need to be included. How should the nurse answer this question?
 1. "Family members are at risk of developing diabetes."
 2. "Family members can take you to your appointments."
 3. "Nurses need someone to call and check on a client's progress."
 4. "Clients and families often work together to develop strategies for the management of diabetes."
Rationale:
Families and significant others may be included in diabetes education to assist with adjustments of the diabetic regimen. Having positive
family members involved will be a support to the client in assuming independent care. Ignatavicius, Workman (2013), p. 1456; Potter et al
(2013), pp. 320-322
Some chronic complications of diabetes mellitus include diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy.
65. A client with Addison's disease has developed melanosis and says to the nurse, "I hate these dark areas in my skin." Which appropriate
 1. "Picture them disappearing in your mind."
 2. "Don't think about them, they are not that bad."
 3. "You sound upset with the changes in your skin."
 4. "You need to ask the doctor about your skin changes."
Rationale:
Option 3 uses the therapeutic communication technique, reflection. It clarifies and encourages further expression of client's feelings.
Options 1, 2, and 4 avoid the client's concerns. Lewis et al (2014), pp. 1211-1212; Potter et al (2013), pp. 320-322
Observe for addisonian crisis caused by stress, infection, trauma, or surgery for the client with Addison's disease. Additionally, instruct the
client with Addison's disease in the need for lifelong glucocorticoid therapy.
66. The family of a client with myxedema is extremely distressed about how the disease is affecting the client's intellectual functions such as
impaired memory, inattentiveness, and lethargy. Which statement is appropriate for the nurse to make?
 1. "Try not to worry! I've taken care of similar clients before and most of them do well."
 2. "Would you like me to let the health care provider know about this so a tranquilizer can be prescribed?"
 3. "It sounds as though the disease is in the advanced stage and unfortunately the symptoms are irreversible."
 4. "I can see that you are concerned, but these symptoms are normal with myxedema and should improve with therapy."
Rationale:
The nurse acknowledges the family's concerns and relates that the behaviors presented by the client are classic neurological manifestations
associated with myxedema. With thyroid hormone therapy, these symptoms should decrease, and mentation usually returns to normal
within 2 weeks. Option 1 offers false reassurance and ignores the concerns of the family, thereby blocking further communication. Option 2
does not address concerns but instead requires the family to make a decision. This option is not appropriate and also indicates the nurse does
not understand the disease process. There is no indication that the myxedema is in an advanced stage. Lewis et al (2014), p. 1202; Potter et
al (2013), pp. 320-322
Myxedema is a severe and rare form of hypothyroidism characterized by swelling of the hands, face, feet, and periorbital tissues. At this
stage, the disease may lead to coma and death without immediate treatment.
Concepts: Communication, Thermoregulation
67. The nurse is monitoring a client for complications after thyroidectomy. The nurse notes that the client's voice is very hoarse. The client is
concerned about the hoarseness and asks the nurse about it. The nurse should make which response to alleviate the client's concern?
 1. "This complication is expected."
 2. "This problem is temporary and will probably subside in a few days."
 3. "It is best that you not talk at all until the problem is further evaluated."
 4. "Hoarseness and a weak voice may indicate permanent damage to the nerves."
Rationale:
Temporary hoarseness and a weak voice may occur if there has been unilateral injury to the laryngeal nerve during surgery. If hoarseness or
a weak voice is present, the client is reassured that the problem will probably subside in a few days. Unnecessary talking is discouraged to
minimize hoarseness. The statements in options 1, 3, and 4 will not alleviate the client's concern. Ignatavicius, Workman (2013), p. 1399;
Potter et al (2013), pp. 320-322
After a thyroidectomy, maintain the client in a semi-Fowler's position to assist in preventing edema in the operative site.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Gastrointestinal; Priority
18
68. A client has been told that he has hepatitis C and that the possibility of developing a chronic carrier state or liver cancer is very high. The
client says to the nurse "Am I going to die from this?" Which response should the nurse make to the client?
 1. "Here is a pamphlet on hepatitis C that explains the complications and prognosis."
 2. "Would you like to speak to a chaplain about your concerns, to get your affairs in order?"
 3. "You seem very upset. What did your health care provider tell you about these possibilities?"
 4. "If you take good care of yourself and follow your health care provider's prescriptions, everything will be okay."
Rationale:
The psychosocial needs of the client are best met when the nurse focuses the conversation on how the client is feeling and attempts to
encourage self-exploration and continued conversation. Option 1 places the client's concern on hold. Option 2 directs the client's concern to
another health care team member when it primarily should be addressed by the nurse. Option 4 is providing false reassurance. Ignatavicius,
The goals of treatment include resting the inflamed liver to reduce metabolic demands and increasing the blood supply, thus promoting
cellular regeneration and preventing complications.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Gastrointestinal; Priority
Concepts: Caregiving, Communication
69. During the admission assessment of a client admitted to the hospital for ruptured esophageal varices, the client says, "I deserve this. I
brought it on myself." Which therapeutic response should the nurse make to the client?
 1. "Would you like to talk to the chaplain?"
 2. "Is there some reason you feel you deserve this?"
 3. "Not all esophageal varices are caused by alcohol."
 4. "That is something to think about when you leave the hospital."
Rationale:
Ruptured esophageal varices are often a complication of cirrhosis of the liver, and the most common type of cirrhosis is caused by chronic
alcohol abuse. It is important to obtain an accurate history regarding the client's alcohol intake. If the client is ashamed or embarrassed, he
or she may not respond accurately. Option 2 is open-ended and allows the client to discuss his or her feelings about drinking. Option 1
blocks the nurse–client communication process. Options 3 and 4 are somewhat judgmental. Lewis et al (2014), pp. 1022-1023
Rupture and resultant hemorrhage of the esophageal varices are primary concerns because this is a life-threatening situation.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Respiratory; Priority
70. The nurse is caring for a client who has just experienced a pulmonary embolism. The client is restless and very anxious. Which approach
should the nurse use when communicating with this client?
 1. Explaining each treatment in great detail
 2. Giving simple, clear directions and explanations
 3. Having the family reinforce the nurse's directions
 4. Speaking very little to the client until the crisis is over
Rationale:
The client who has suffered pulmonary embolism is fearful and apprehensive. The nurse effectively communicates with this client by
staying with the client; providing simple, clear, and accurate information; and displaying a calm, efficient manner. Options 1, 3, and 4 will
produce more anxiety for the client and the family. Ignatavicius, Workman (2013), p. 669; Potter et al (2013), pp. 320-322
A pulmonary embolism is a life-threatening situation.
71. A health care provider prescribes a follow-up home care visit for an older adult client with emphysema. When the home care nurse arrives,
the client is smoking. Which statement by the nurse would be therapeutic?
 1. "Well, I can see you never got to the stop smoking clinic!"
 2. "I'm glad I caught you smoking! Now that your secret is out, let's decide what you are going to do."
 3. "I notice that you are smoking. Did you explore the stop smoking program at the senior citizens center?"
 4. "I wonder if you realize that you are slowly killing yourself. Why prolong the agony? You can just jump off the bridge!"
Rationale:
Clients with emphysema must avoid smoking and all airborne irritants. The nurse who observes a maladaptive behavior in a client should
not make judgmental comments and should instead explore an adaptive strategy with the client without being overly controlling. This will
place the decision making in the client's hands and provide an avenue for the client to share what may be expressions of frustration about an
inability to stop what is essentially a physiological addiction. Option 1 is an intrusive use of sarcastic humor that is degrading to the client.
Option 2 is a disciplinary remark and places a barrier between the nurse and the client within the therapeutic relationship. In Option 4, the
nurse preaches and is judgmental. Ignatavicius, Workman (2013), p. 621; Potter et al (2013), pp. 320-322
Emphysema occurs when there is abnormal permanent enlargement of air spaces distal to the terminal bronchioles, with destruction of
alveolar walls without obvious fibrosis.
19
72. The registered nurse (RN) is observing a new nurse care for a client with acute respiratory distress syndrome (ARDS) who is being
mechanically ventilated and is experiencing problems with communication. Which action by the new nurse indicates a need for further
teaching regarding fostering effective communication for this client?
 1. Express empathy for the client.
 2. Provide easy accessibility to a call light.
 3. Learn to read the client's body language.
 4. Tell the client that communication will be impossible until the tube is removed.
Rationale:
Although verbal communication is impossible for the intubated client, alternative means of communication should be tried. Alternative
means may include the use of an alphabet board or pencil and paper. The call light will at least enable the client to call for assistance.
Expressing empathy acknowledges that it is frustrating not to be able to speak. Learning to read the client's body language will ease the
client's efforts to communicate. Ignatavicius, Workman (2013), p. 679; Lewis et al (2014), pp. 1600, 1617
If a cause for an alarm on a mechanical ventilator cannot be determined, ventilate the client manually with a resuscitation bag until the
problem is corrected.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Cardiovascular; Priority
73. A client who is scheduled for permanent transvenous pacemaker insertion says to the nurse, "I know I need it, but I'm not sure this surgery
is a great idea." Which nursing response will best help the nurse assess the client's preoperative concerns?
 1. "How does your family feel about the surgery?"
 2. "Has anyone taught you about the procedure yet?"
 3. "You sound unnecessarily worried. Has anyone told you that the technology is quite advanced now?"
 4. "You sound uncertain about the procedure. Can you tell me more about what has you concerned?"
Rationale:
Anxiety is common in the client with the need for pacemaker insertion. This can be related to a fear of life-threatening dysrhythmias or of
the surgical procedure. Option 4 is the correct choice because it is open-ended and uses clarification as a communication technique to
explore the client's concerns. Option 1 is not indicated because it asks about the family and deflects attention away from the client's
concerns. Options 2 and 3 are closed ended and are not exploratory. Ignatavicius, Workman (2013), p. 741; Potter et al (2013), pp. 320-322
A pacemaker is a temporary or permanent device that provides electrical stimulation and maintains the heart rate when the client's intrinsic
pacemaker fails to provide a perfusing rhythm.
74. A client with superficial varicose veins says to the nurse, "I hate these things. They're so ugly. I wish I could get them to go away." Which
therapeutic response should the nurse make to the client?
 1. "You should try sclerotherapy. It's great."
 2. "There's not much you can do once you get them."
 3. "What have you been told about varicose veins and their management?"
 4. "I understand how you feel, but you know, they really don't look too bad."
Rationale:
The client expressing distress about physical appearance has a risk for an altered body image. The nurse assesses the client's knowledge and
self-management of the condition as a means of empowering the client and helping him or her adapt to the body change. Options 1, 2, and 4
are not therapeutic. Ignatavicius, Workman (2013), p. 805; Potter et al (2013), pp. 662-663
Varicose veins occur from the weakening and dilation of vein walls and incompetence of the valves inside the veins. The client may feel
pain in the legs with dull aching after standing, a feeling of fullness in the legs, and ankle edema.
75. A client was just told by the primary care health care provider that she will have an exercise stress test to evaluate the client's status after
recent episodes of severe chest pain. As the nurse enters the examining room, the client states, "Maybe I shouldn't bother going. I wonder if
I should just take more medication instead." Which therapeutic response should the nurse make to the client?
 1. "Can you tell me more about how you're feeling?"
 2. "Don't you really want to control your heart disease?"
 3. "Most people tolerate the procedure well without any complications."
 4. "Don't worry. Emergency equipment is available if it should be needed."
Rationale:
Anxiety and fear are often present before stress testing. The nurse should explore a client's feelings if concerns are expressed. Option 1 is
open ended and is the only choice that is phrased to engender trust and the sharing of concerns by the client. Options 2, 3, and 4 are
inappropriate statements and limit communication. Pagana, Pagana (2013), pp. 227-229; Potter et al (2013), pp. 320-322
A stress test is a noninvasive procedure that studies the heart during activity and detects and evaluates coronary artery disease. Treadmill
testing is the most commonly used mode of stress testing.
20
76. A client was just told by the primary care health care provider that he will have an exercise stress test performed to evaluate cardiac status
after recent episodes of increasingly severe chest pain. As the nurse enters the examining room, the client states, "Maybe I shouldn't bother
having this test. I wonder if I should just take more medication instead." The nurse should make which therapeutic response to the client?
 1. "Can you tell me more about how you're feeling?"
 2. "Don't you really want to control your heart disease?"
 3. "Most people tolerate the procedure well without any complications."
 4. "Don't worry. Emergency equipment is available during the test if it should be needed."
Rationale:
Anxiety and fear are often present before diagnostic testing. The nurse should explore a client's feelings and concerns. Option 1 is open-
ended and is the only option that is phrased to engender trust and sharing of concerns by the client. Options 2, 3, and 4 are nontherapeutic
statements, not questions, and therefore limit communication. Pagana, Pagana (2013), pp. 226-229; Potter et al (2013), pp. 320-322
For a cardiac stress test, the nurse should instruct the client to wear nonconstrictive, comfortable clothing and supportive rubber-soled shoes
for the exercise stress test.
Concepts: Client Education, Safety
77. A client is to have arterial blood gases drawn. While the nurse is performing Allen's test, the client says to the nurse, "What are you doing?
No one else has done that!" Which therapeutic response should the nurse make to the client?
 1. "I assure you that I am doing the correct procedure. I cannot account for what others do."
 2. "This step is crucial to safe blood withdrawal. I would not let anyone take my blood until they did this."
 3. "Oh? You have questions about this? You should insist that they all do this procedure before drawing up your blood."
 4. "This is a routine precautionary step that simply makes certain your circulation is intact before a blood sample is obtained."
Rationale:
Allen's test is performed to assess collateral circulation in the hand before drawing a radial artery blood specimen. The therapeutic response
provides information to the client. Option 1 is defensive and nontherapeutic in that it offers false reassurance. Option 2 identifies client
advocacy, but it is overly controlling and aggressive, and undermines treatment. Option 3 is aggressive, controlling, and nontherapeutic in
its disapproving stance. Pagana, Pagana (2013), p. 117; Potter et al (2013), pp. 320-322
Before an arterial blood gas (ABG) is drawn, the client should rest for 30 minutes to ensure accurate measurement of body oxygenation. If
the client is wearing oxygen, it should not be turned off unless the ABG sample is prescribed to be drawn with the client breathing room air.
Concepts: Communication, Perfusion
78. A client who has undergone successful femoral-popliteal bypass grafting of the leg says to the nurse, "I hope everything goes well after this
and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing." Which therapeutic response should the nurse make to
the client?
 1. "I can understand what you mean. I'd be nervous too if I were in your shoes."
 2. "This surgery is so successful that I wouldn't be concerned at all if I were you."
 3. "Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about."
 4. "Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens."
Rationale:
Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's
concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option
1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no
suggestions to empower the client. Lewis et al (2014), pp. 838-839
The client undergoing femoral-popliteal bypass grafting who is returning home should progressively return to his or her normal routine.
Additionally, the client should limit pushing or pulling objects for 6 weeks; maintain incision care and report signs of redness, swelling, or
discharge; avoid crossing the legs; use prescribed medications; and maintain the prescribed therapeutic diet.
Concepts: Communication, Perfusion
79. A client diagnosed with angina pectoris appears to be very anxious and states, "So, I had a heart attack, right?" Which response should the
nurse make to the client?
 1. "No. That is not why you are hospitalized."
 2. "No, but there could be some minimal damage to your heart."
 3. "No, and we will see to it that you do not have a heart attack."
 4. "No, but your health care provider wants to monitor and control or eliminate your pain."
Rationale:
Angina pectoris occurs as a result of an inadequate blood supply to the myocardium causing pain; managing the condition will help address
the client's pain. The nurse will want to correct the client's misconception regarding a heart attack while addressing the client's concerns.
Option 1 does not address the client's concerns. Option 2 is not correct because angina involves interrupted blood supply but does not result
in cardiac tissue damage. Neither the nurse nor the health care provider can guarantee that a heart attack will not occur as option 3 appears
to do. Ignatavicius, Workman (2013), pp. 835, 841; Potter et al (2013), pp. 320-322
By clarifying the client's condition with the client, the nurse will help minimize stress, which is a contributing factor of angina attacks.
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80. The rehabilitation nurse witnessed a postoperative client who had a coronary artery bypass graft and his spouse arguing after a rehabilitation
session. What would be an appropriate statement for the nurse to make to identify the feelings of the client?
 1. "You seem upset."
 2. "Oh, don't let this get you down."
 3. "It will seem better tomorrow. Now smile."
 4. "You shouldn't get upset. It'll affect your heart."
Rationale:
Acknowledging the client's feelings without inserting your own values or judgments is a method of therapeutic communication. Therapeutic
communication techniques assist with the flow of communication, and they always focus on the client. Option 1 is an open-ended statement
that allows the client to verbalize, which gives the nurse a direction or clarification of the client's true feelings. Options 2, 3, and 4 do not
encourage verbalization by the client. Ignatavicius, Workman (2013), pp. 850-851; Potter et al (2013), pp. 320-322
After arterial revascularization, the nurse should monitor for a sharp increase in pain because pain is frequently the first indicator of
postoperative graft occlusion. If signs of graft occlusion occur, notify the health care provider immediately.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Renal and Urinary; Priority
81. A client with polycystic kidney disease says to the nurse, "My father had this disease, and now me. I'm not sure about having children."
Which response should the nurse make to the client?
 1. "There is no reason to worry."
 2. "You are not sure about having children?"
 3. "I think you are making the right decision."
 4. "You should ask your doctor about your decision."
Rationale:
Option 2 involves reflecting or repeating the client's message and serves to encourage the client to elaborate on thoughts and feelings. In
option 1, the nurse is offering false reassurance. In option 3, the nurse is expressing approval, which can be harmful to a nurse-client
relationship. Option 4 devalues the client's right to an opinion by telling the client to ask the doctor. Lewis et al (2014), pp. 1082-1083;
Potter et al (2013), pp. 320-322
Polycystic kidney disease causes a cystic formation and hypertrophy of the kidneys, which leads to cystic rupture, infection, formation of
scar tissue, and damaged nephrons. There is no specific treatment, and the ultimate result of this disease is renal failure.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Renal and Urinary; Priority
Concepts: Cognition, Communication
82. A client with acute kidney injury has an elevated blood urea nitrogen (BUN). The client is experiencing difficulty remembering information
because of uremia. Which interventions should the nurse use when communicating with this client? Select all that apply.
 1. Give simple, clear directions.
 2. Include the family in discussions related to care.
 3. Give thorough, lengthy explanations of procedures.
 4. Explain treatments using understandable language.
 5. Use as many teaching methods as available to provide discharge instructions.
Rationale:
The client with acute kidney injury may have difficulty remembering information and instructions because of anxiety and the increased
level of the BUN. The nurse should avoid giving lengthy explanations about procedures because this information may not be remembered
by the client and could increase client anxiety. Communications should be clear, simple, and understandable. The family should be included
whenever possible. Using several methods for teaching can be overwhelming for the client. The nurse should assess the client's learning
needs and select a method that will facilitate learning. Ignatavicius, Workman (2013), pp. 1475, 1547; Potter et al (2013), pp. 329-330
Provide emotional support to the client who is having memory difficulties and allow the client the opportunity to express concerns and
fears.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Neurological; Priority
83. A client with myasthenia gravis is having difficulty with the motor aspects of speech. The client has difficulty forming words, and the voice
has a nasal tone. Which communication strategies should the nurse use when working with this client? Select all that apply.
 1. Use a letter board or picture board.
 2. Encourage the client to speak quickly.
 3. Ask questions requiring a yes or no response.
 4. Nod continuously while the client is speaking.
 5. Repeat what the client said to verify the message.
 6. Engage the client in lengthy discussions to strengthen the voice
Rationale:
The client with myasthenia gravis experiences dysphagia and a nasal quality to speech when the muscles of chewing and swallowing are
involved. The nurse listens attentively and verbally verifies what the client has said. Other helpful techniques are to ask questions requiring
a yes or no response and to develop alternative communication methods (letter board, picture board, pen and paper, flash cards).
Encouraging the client to speak quickly is incorrect and counterproductive. Continuous nodding may be distracting and is unnecessary.
Lengthy discussions will tire the client rather than strengthen the voice. Ignatavicius, Workman (2013), pp. 587, 990, 994
22

Causes of myasthenia gravis include insufficient secretion of acetylcholine, excessive secretion of cholinesterase, and unresponsiveness of
the muscle fibers to acetylcholine.
84. The nurse is collecting data from a client being admitted to the hospital who has right-sided weakness, aphasia, and urinary incontinence.
One of the client's family members states, "This is the end if this is a stroke." Which therapeutic response should the nurse make to the
family member?
 1. "A stroke does not mean the end."
 2. "These symptoms may be reversible."
 3. "You feel as if your family member is dying?"
 4. "Wait until the health care provider gets here to think like that."
Rationale:
Option 3 is a therapeutic response and allows for the family member to begin to cope and adapt to what is happening. By restating what was
said, the nurse is able to clarify the family member's feelings and begin to offer information that will help ease some of the fears they face at
the moment. Options 1 and 4 indicate disapproval and put the family member's feeling on hold. Option 2 provides false hope at this time.
Potter et al (2013), pp. 320-322
Swallowing difficulties may be a problem for the client who had a stroke.
Concepts: Communication, Functional Ability
85. While assisting a client with a spinal cord injury with activities of daily living, the client states, "I can't do this. I wish I were dead." Which
therapeutic response should the nurse make to the client?
 1. "Why do you say that?"
 2. "You wish you were dead?"
 3. "Let's wash your back now."
 4. "I'm sure you are frustrated, but things will work out just fine for you."
Rationale:
Clarifying is a therapeutic technique that involves restating what was said to obtain additional information. By asking "why" in option 1, the
nurse puts the client on the defensive. Option 3 changes the subject. In option 4, false reassurance is offered. Options 1, 3, and 4 are
nontherapeutic and block communication. Ignatavicius, Workman (2013), pp. 970, 973-974; Potter et al (2013), pp. 320-322
Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons. Loss of motor function, sensation, reflex
activity, and bowel and bladder control may result; therefore, the client is likely to feel a sense of loss of control.
Concepts: Communication, Intracranial Regulation
86. The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping
excessively. What is the best way for the nurse to explore subjects with the client regarding this behavior?
 1. Have the client express the feelings in writing.
 2. Have the health care provider speak to the client.
 3. Conduct a group discussion with the client's family.
 4. Ignore the behavior because it is expected in clients with trigeminal neuralgia.
Rationale:
Speaking can exacerbate the pain that occurs with trigeminal neuralgia. Having the client record feelings in writing will help the nurse gain
an understanding of the client's concerns without increasing the client's pain. Discussing the subject with the family will not provide insight
into the client's feelings. It is not in the client's best interest to refer the matter to the health care provider or to ignore the behavior. The
nurse should explore the client's concerns and offer support. Ignatavicius, Workman (2013), pp. 1000-1001; Potter et al (2013), pp. 320-322
The client with trigeminal neuralgia should be instructed to avoid hot or cold foods and fluids, be provided with small feedings of liquid and
soft foods, and be instructed to chew food on the unaffected side.
Concepts: Communication, Mobility
87. The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which therapeutic statement should the nurse
make to the client?
 1. "How could your home care nurse let this happen?"
 2. "Now that this problem is taken care of, I'm sure you'll be fine."
 3. "I have some time if you would like to talk about what happened to you."
 4. "I'm sure you now understand the importance of preventing this from occurring."
Rationale:
Option 3 encourages the client to discuss his or her feelings. Options 1 and 4 show disapproval, and option 2 provides false reassurance;
these are nontherapeutic techniques. Ignatavicius, Workman (2013), pp. 973-974; Potter et al (2013), pp. 320-322; Swearingen (2012), pp.
308-309
Autonomic dysreflexia occurs with spinal cord lesions or injuries above T6. If autonomic dysreflexia occurs, immediately place the client in
high Fowler's position.
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88. A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, "I'm no good to anyone. I might
as well be dead." Which response should the nurse make to the client?
 1. "You're not a useless person at all."
 2. "I'll ask the psychologist to see you about this."
 3. "You are feeling pretty bad about things right now."
 4. "It makes me uncomfortable when you talk this way."
Rationale:
Restating and reflecting keep the lines of communication open and encourage the client to expand on current feelings of unworthiness and
loss that require exploration. The nurse can block communication by showing discomfort and disapproval or postponing the discussion of
issues. Grief is a common reaction to a loss of function. The nurse facilitates grieving through open communication. Ignatavicius,
Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons.
Concepts: Functional Ability, Sexuality
89. A young adult client with a spinal cord injury tells the nurse, "It's so depressing that I'll never get to have sex again." What is the realistic
reply for the nurse to make to the client?
 1. "It must feel horrible to know you can never have sex again."
 2. "It's still possible to have a sexual relationship, but it will be different."
 3. "You're young, so you'll adapt to this more easily than if you were older."
 4. "Because of body reflexes, sexual functioning will be no different than before."
Rationale:
It is possible to have a sexual relationship after a spinal cord injury, but it is different than what the client will have experienced before the
injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm. Sexual counseling may
help the client adapt to changes in sexuality after a spinal cord injury. Ignatavicius, Workman (2013), pp. 974-975; Potter et al (2013), pp.
320-322
The complications associated with a spinal cord injury depend on the level of the injury. One complication is autonomic dysreflexia.
Autonomic dysreflexia occurs with spinal lesions above the level of T6.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Musculoskeletal; Priority
Concepts: Caregiving, Communication
90. The nurse develops a plan of care to facilitate effective communication for a client who will require a walker for ambulation. Which
intervention has highest priority?
 1. Directing the discussions so that teaching needs are met
 2. Focusing directly on the client's message regarding needs
 3. Reflecting only facts related to the client's expressed concerns
 4. Reacting to the client's responses in a matter of fact, professional manner
Rationale:
For effective communication, the nurse uses active listening and assesses for verbal and nonverbal communication to receive the client's
intended message, thus creating an environment in which the client feels comfortable expressing his or her feelings. An authoritarian
approach is directive and not permissive, and it is unlikely to create an environment for the free exchange of thoughts and ideas. Reflecting
facts only is a barrier to effective communication because subjective information can also provide a stimulus for effective communication.
Reacting enthusiastically can be an ineffective strategy for facilitating communication. Ignatavicius, Workman (2013), pp. 98, 1157; Potter
et al (2013), pp. 320-322
The nurse should use both verbal and nonverbal communication cues to interpret what the client is trying to express.
91. A client with a long leg cast who has been using crutches to ambulate for 1 week reports pain, fatigue, and frustration with crutch walking.
How should the nurse respond when the client states, "I feel like I will always be crippled"?
 1. "Tell me what makes this so bothersome for you."
 2. "I know how you feel. I had to use crutches before, too."
 3. "Why don't you take a couple of days off of work and rest?"
 4. "Just remember, you'll be done with the crutches in another month."
Rationale:
Option 1 demonstrates the therapeutic communication technique of clarification and validation and indicates that the nurse is dealing with
the client's problem from the client's perspective. Option 2 devalues the client's feelings and thus blocks communication. Option 3 gives
advice and is a communication block. Option 4 provides false reassurances because the client may not be done with the crutches in another
month. Additionally, it does not focus on the present problem. Ignatavicius, Workman (2013), pp. 1157-1158; Potter et al (2013), pp. 320-
322
The nurse should monitor for compartment syndrome in a client who has a cast. This is a condition in which pressure increases in a
confined anatomical space, leading to decreased blood flow, ischemia, and dysfunction of the tissues.
24
92. A client who is scheduled for surgery to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction
or if skin traction would be best to stabilize my fracture." Based on the client's statement, which response should the nurse make to the
client?
 1. "There is no reason to be concerned. I have seen lots of these procedures."
 2. "Skeletal traction is much more effective than skin traction in your situation."
 3. "You have concerns about skeletal versus skin traction for your type of fracture?"
 4. "Your fracture is very unstable. You will die if you don't have this surgery performed."
Rationale:
Option 3 exemplifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's
own words. Option 4 identifies a communication block that reflects a lack of the client's right to an opinion. It will also cause fear in the
client. In option 1 the nurse is offering a false reassurance, and this type of response will block communication. Option 2 is also a
communication block and reflects a lack of the client's right to an opinion. Ignatavicius, Workman (2013), pp. 1153-1154; Potter et al
(2013), pp. 320-322
Always use therapeutic communication techniques when communicating with a client and focus on the client's thoughts, feelings, concerns,
anxieties, and fears.
93. A health care provider has prescribed warm hydrotherapy to ease the pain associated with joint motion. The client says to the nurse, "I'm not
sure this procedure is the best treatment for me." Which response should the nurse make to the client?
 1. "The joint pain has made you very sick."
 2. "I know you are making the right decision."
 3. "Don't worry, your doctor treats all clients this way."
 4. "You have concerns about the treatment for your joints?"
Rationale:
Paraphrasing is restating the client's message in the nurse's own words. Option 4 uses this therapeutic communication technique. The nurse
does not address the client's concern in option 1. In option 2, the nurse is offering false reassurance and, therefore, blocks communication.
In option 3, the nurse is expressing the lack of the client's right to an option, which represents a block to communication. Ignatavicius,
Workman (2013), p. 341; Potter et al (2013), pp 320-322
Use open-ended questions when communicating with a client and always try to learn more about the client's concerns so they can be
addressed appropriately to meet the client's needs.
94. A female client with a long leg cast has been using crutches to assist ambulation for 1 week. She comes to the clinic with complaints of
pain, fatigue, and frustration with crutch walking and states that she has a "crippled leg." Which statement by the nurse is appropriate?
 1. "Tell me what is most bothersome for you."
 2. "I know how you feel; I had to use crutches before too."
 3. "Why don't you take a couple of days off work and rest."
 4. "Just remember, you'll be done with the crutches in another month or so."
Rationale:
Option 1 is correct because it is the therapeutic communication technique of clarification and validation and indicates that the nurse is
dealing with present client problems from his or her perspective. Option 2 devalues the client and thus blocks communication. Option 3
gives advice and is a communication block. Option 4 gives false reassurance because the client may not be done with the crutches in a
month, and it does not focus on the present problem. Ignatavicius, Workman (2013), p. 1157; Potter et al (2013), pp. 320-322
An accurate measurement of the client for crutches is important because an incorrect measurement could damage the brachial plexus.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Addiction,
Communication
95. The partner of a client who has an esophageal tube tells the nurse, "I thought having this tube down her nose the first time would convince
her to quit drinking." Which response to the statement should the nurse make?
 1. "I think you are a good person to stay with her."
 2. "Alcoholism is a disease that affects the whole family."
 3. "Have you discussed this subject at the Al-Anon meetings?"
 4. "You sound frustrated with dealing with her drinking problem."
Rationale:
In option 4, the nurse uses the therapeutic communication techniques of clarifying and focusing to assist the client's partner with expressing
feelings about the client's chronic illness. Showing approval (option 1), stereotyping (option 2), and changing the subject (option 3) are
nontherapeutic techniques that block communication. Perry, Potter, Ostendorf (2014), p. 639; Potter et al (2013), pp. 320-322
Alcohol abuse is an addiction and a relapse in behavior can occur. This can be very frustrating for families to understand and accept.
25
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Anxiety,
Communication
96. A client who has urticaria (hives) and pruritus is anxious and says to the nurse, "What am I going to do? I'm getting married next week, and
I'll probably be covered in this rash and itching like crazy." Which statement made by the nurse is the most therapeutic?
 1. "You're troubled that this will extend into your wedding?"
 2. "It's probably just due to prewedding jitters. You'll be fine."
 3. "The antihistamine will help a great deal, just you wait and see."
 4. "I hope your husband-to-be has a sense of humor and can laugh about this."
Rationale:
The therapeutic communication technique that the nurse uses in option 1 is reflection. In option 2, the nurse minimizes the client's anxiety
and fears. In option 3, the nurse talks about antihistamines and asks the client to "wait and see." This is nontherapeutic because the nurse is
making promises that may not be kept. In addition, the response is closed-ended and shuts off the client's expression of feelings. In option 4,
the nurse uses humor inappropriately and without sensitivity. Ignatavicius, Workman (2013), p. 472; Potter et al (2013), pp. 320-322
Antihistamines are used to treat the common cold, rhinitis, nausea and vomiting, motion sickness, urticaria, and as a sleep aid. These
medications can cause central nervous system depression if taken with alcohol, opioids, hypnotics, and barbiturates.
Communication
97. A client diagnosed with type 2 diabetes mellitus was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). Upon
discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. How should the nurse respond to
promote communication with the client?
 1. "Do you think you might need to go to the nursing home?"
 2. "You have concerns about the treatment of your condition?"
 3. "If you take the correct medications, I doubt this will happen again."
 4. "Don't worry. I'm sure your family will provide all the help you need."
Rationale:
The nurse should provide time and listen to the client's concerns while attempting to clarify the client's feelings as in option 2. Option 1 is
not an appropriate nursing response because it is making suggestions regarding care options without appropriately identifying the client's
true concerns. Options 3 and 4 provide inappropriate false hope and disregard the client's concerns. Ignatavicius, Workman (2013), pp.
1458-1459; Potter et al (2013), pp. 320-322
It is inappropriate to tell a client to "not worry" because it is a barrier to effective communication between the client and the nurse.
Communication
98. A client diagnosed with obsessive-compulsive disorder is upset and agitated, walking repeatedly around the nursing unit, following the
same route each time late into the night. The client asks the nurse working the evening shift to walk with him. Which response by the nurse
would be appropriate?
 1. "No, it is bedtime. Let me walk you back to your room."
 2. "Go to sleep now, but we can talk tomorrow afternoon."
 3. "I can see that you're upset. I will walk with you and talk for a while."
 4. "I'm sorry but I'm busy right now. Let me find someone else to do that with you."
Rationale:
The response in option 3 acknowledges the client's feelings and provides an avenue for release of the client's anxieties. Each of the incorrect
options identifies a block to communication. The wording of these options does not acknowledge the client's feelings. Stuart (2013), pp.
228, 231-232
Obsessive thoughts can involve issues of violence, aggression, sexual behavior, orderliness, or issues related to religion, and uncontrollably
can interrupt conscious thoughts and the ability to function.
Communication
99. A female client who was attacked outside a shopping mall is experiencing posttraumatic stress disorder. The client is visibly anxious about
shopping in general and specifically avoids crowds and parking lots. The client expresses concern about these events and tells the nurse how
upset she is about feeling this way. Which response should the nurse make to the client?
 1. "It's difficult now, but try not to worry so much."
 2. "Everything is going to be all right if you just give it more time."
 3. "I can see that you are upset about this. Can we talk some more about it?"
 4. "Why don't you just go back to a shopping mall and get it out of your system?"
Rationale:
Option 3 is most therapeutic because it does not contain a communication block. It indicates that the nurse is aware of the client's feelings
and promotes continued communication. Each of the incorrect options fails to acknowledge the client's concerns and does not invite further
communication. Stuart (2013), pp. 25-29, 228
After experiencing a psychologically traumatic event, the individual is prone to re-experience the event and have recurrent and intrusive
dreams or flashbacks; this is known as posttraumatic stress disorder.
26
Communication
100. The nurse is caring for a client who has a long history of antisocial and acting-out behavior. The client's behavior has included drug abuse,
numerous suicidal self-mutilation attempts, and prostitution. The client says to the nurse, "I'm ready to go straight now." Which response by
the nurse would be therapeutic?
 1. "Yeah, right. I've heard this from you before."
 2. "Tell me what you believe will be different this time."
 3. "I disagree. I have seen absolutely no changes in your life to support your claims."
 4. "That's so wonderful to hear! I will put in a good word for you with the health care provider ."
Rationale:
A client who has a long history of antisocial and acting-out behavior needs to demonstrate the motivation to change behavior, not just
verbalize that change will occur. The nurse would be therapeutic by assisting the client to look at the behaviors that indicate the motivation
to change. Option 2 is the only option that will accomplish this goal. Option 1 is insensitive and sarcastic. In option 3, the nurse disagrees
with the client. Option 4 jumps to a conclusion with no data gathering and provides a social response, not a therapeutic one. Stuart (2013),
pp. 25-29; Varcarolis (2013) p. 215
Antisocial personality disorder comprises a pattern of irresponsible and antisocial behavior, selfishness, an inability to maintain lasting
relationships, poor sexual adjustment, a failure to accept social norms, and a tendency toward irritability and aggressiveness.
Communication
101. The nurse is caring for a client who is divorced and is now homeless because she has just been evicted from her apartment because of
joblessness. The client says to the nurse, "I can't tell my son. He lives 80 miles away and barely gets by himself. I'm not his problem."
Which response by the nurse would be therapeutic?
 1. "What I'm hearing is that you don't want to be a burden to your son."
 2. "OK, let's call your ex-husband to see if he'll help you until you get on your feet."
 3. "You can come home with me. I have an extra bedroom you can use until you get back on your feet."
 4. "I could commit you to the mental health unit for a few days to get you a safe place to sleep and some food."
Rationale:
The therapeutic response is option 1. The nurse uses clarification, which attempts to put the client's ideas into words. In option 2, the nurse
implements an insensitive and intrusive action. In option 3, the nurse is very sympathetic, but the actions offered are not professional and
are social. In option 4, the nurse is again insensitive and offers a solution that may provide safety but strips the client of decision making.
Stuart (2013), pp. 25-29, 661
Homeless individuals or those from a lower socioeconomic group, minority group, or refugee group are at a greater risk for contracting
disease, including tuberculosis.
Communication
102. A client with a dissecting abdominal aortic aneurysm (AAA) is being prepared for surgery. The client asks the nurse, "Will I be OK?"
Based on the client's question, the nurse should make which response to the client?
 1. "I hope you will be fine."
 2. "Don't worry. You'll be fine."
 3. "You have to have this surgery."
 4. "Would you like to talk about the surgery?"
Rationale:
Option 4 is an open-ended question that allows the nurse to explore the client's feelings and fears. Option 1 blocks communication, as does
option 3. Option 2 offers false reassurance. The client wants and needs to talk about the impending surgery. Stuart (2013), pp. 25-29;
Varcarolis (2013) pp. 165-166
For the client scheduled for AAA repair, assess all peripheral pulses as a baseline for postoperative comparison.
Communication
103. A client with chronic pancreatitis is preparing for discharge from the hospital. While reviewing the discharge prescriptions with the nurse,
the client says, "I hope I can handle all this at home. It's a lot to remember." Which response should the nurse make to the client?
 1. "Oh, your sister can take care of it for you."
 2. "You seem to be nervous about going home."
 3. "I'm sure you can do it. You're a very smart person."
 4. "Maybe we should arrange for you to stay in the hospital one more day."
Rationale:
Option 2 uses the technique of attempting to reflect the client's feelings in words that encourage the client to verbalize his feelings. Options
1 and 3 devalue the client's feelings, and option 4 attempts to give advice. Lewis et al (2014), p. 1036; Potter et al (2013), pp. 320-322
Chronic pancreatitis is a continual inflammation and destruction of the pancreas, with scar tissue replacing pancreatic tissue.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Care
Coordination, Communication
27
104. The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because
she is not feeling well today. Which statement should the nurse use in response?
 1. "I am not allowed to buy groceries for clients."
 2. "Let's discuss how we can solve this problem."
 3. "Do you have any support systems for shopping?"
 4. "Nurses are professionals and do not run errands."
Rationale:
The nurse's duty is to help the client; but in helping the client, the nurse's first action is to finish the assessment and then find immediate and
long-term solutions to the problem. In option 1, the nurse uses a passive approach and hides behind policies and rules, even though this can
be true. In option 3, the nurse asks a closed-ended question, which is unlikely to further nurse–client communication. Option 4 is
inappropriate and indicates that the nurse thinks more of status than of helping the client. Potter et al (2013), pp. 320-322
Identify the local elder care services for the older client and assist the client in making contacts that will help meet his or her needs.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Caregiving,
Communication
105. The spouse of a dying client says to the nurse, "I don't think I can come anymore and watch her die. It's chewing me up too much!" Which
therapeutic response should the nurse make to the spouse?
 1. "It's hard to watch someone you love die. You've been here with your wife every day. Are you taking any time for yourself?"
 2. "Focus on your wife's pain rather than yours. I know it's hard, but this isn't about what's happening to you, you know."
 3. "I know it's hard for you, but she would know if you're not there, and you would feel so very guilty all of the rest of your
days."
 4. "I think you're making the right decision. Your wife knows you love her. You don't have to come every day. I'll take care of
her."
Rationale:
The most therapeutic response is the one that is empathetic and that reflects the nurse's understanding of the client's, in this case, the
husband's, stress and emotional pain. In the correct option, the nurse suggests that the client take time for himself. Option 2 is an example of
a nontherapeutic and judgmental attitude that places blame. Option 3 makes statements that the nurse cannot know are true (the client's wife
may not in fact know if the husband visits), and it predicts feelings of guilt, which is inappropriate. Option 4 fosters dependency and gives
advice, which is nontherapeutic. Stuart (2013), pp. 25-29; Varcarolis (2013), pp. 144-145
Respite care provides support to the caregiver(s) of the client requiring long-term care. This allows family members and significant others
involved in the client's care time to care for themselves.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Client
106. A 34-year-old schizophrenic client says to the nurse, "Since I've been taking this medication, I've noticed some problems performing
sexually. Is there any connection to the medication?" The nurse makes which therapeutic and accurate response to the client?
 1. "This medication is the most effective one for your condition and does not produce impotence. Nevertheless, I'll report your
complaint to the health care provider."
 2. "This medication produces a high occurrence of extrapyramidal side effects (EPS)], but sexual performance is not one of
them. Have you spoken to your health care provider?"
 3. "One of the side effects of this medication is that it produces impotence. I'll report this to your health care provider. There are
several other effective medications that your health care provider can select to help you."
 4. "You seem very troubled by this occurrence, yet at your age many men experience this difficulty. Have you checked with
your health care provider to determine if you have developed any physical problems?"
Rationale:
Counsel clients taking antipsychotic medications about the potential for sexual dysfunction as a side effect, and encourage them to report
problems. This will aid in establishing an effective treatment plan and, therefore, will promote client compliance with medication therapy.
Stuart (2013), pp. 25-29; Varcarolis (2013), p. 62
Counsel clients taking antipsychotic medications about the potential for sexual dysfunction as a side effect, and encourage them to report
problems. This will aid in establishing an effective treatment plan and, therefore, will promote client compliance with medication therapy.
107. The nurse is instructing a client with tuberculosis about the medication regimen. The client says to the nurse, "I'm really frightened about
the fatigue; do you think the medication will take it away?" Which statement should the nurse make to the client?
 1. "Don't worry, everything will work out."
 2. "The fatigue will be easier to deal with when you get used to it."
 3. "You must do what the doctor prescribed even if you are tired."
 4. "As long as you take the medication as directed, you will notice the fatigue diminishing as treatment progresses."
Rationale:
Fatigue can be frightening to the client. The nurse is realistic in offering a positive outlook for the client as long as he or she complies with
the medication regimen and suggests that fatigue will diminish as treatment progresses. The client's feelings are minimized when told not to
worry. The statement in option 2 is incorrect because the fatigue will diminish as treatment progresses. Option 3 blocks communication and
does not take the client's feelings into consideration. Ignatavicius, Workman (2013), pp. 657-658; Potter et al (2013), pp. 320-322
28

A multidrug approach is used in treating tuberculosis. The use of a multidrug regimen destroys organisms as quickly as possible and
minimizes the emergence of drug-resistant organisms.
Education, Mood and Affect
108. A client has undergone two electroconvulsive therapy (ECT) treatments during the past week and confides to the nurse, "I'm starting to feel
a little better, but it's scary too, because I'm having trouble remembering things now." Which response by the nurse is therapeutic?
 1. "Let's just hope you're forgetting bad things instead of good things!"
 2. "That does happen with ECT. It's just the price you pay for getting better, I suppose."
 3. "That's too bad. Maybe you should keep a diary so you will have a reference of events as they happen to you."
 4. "It must be disturbing to not be able to remember things. ECT causes a temporary memory loss, which many people recover
from within a few weeks."
Rationale:
Memory loss is an expected temporary effect of ECT. The client should be told that this might occur, and that memory usually returns
within a few weeks. Occasionally clients have memory loss that lasts up to 6 months. The nurse uses therapeutic communication techniques
that will focus on the client's concerns and do not block further communication. Stuart (2013), p. 599
Informed consent must be obtained from the client undergoing electroconvulsive therapy (ECT).
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Clinical
Judgment, Communication
109. A client tells the nurse, "I'm going to put an end to my misery." What is the therapeutic response by the nurse?
 1. "We all feel like that at times."
 2. "Why do you feel like you need to say that?"
 3. "Can you tell me more about what you plan to do?"
 4. "You feel like that now, but soon you'll regain your will to live."
Rationale:
All suicidal threats must be taken seriously, and their meaning must be thoroughly explored. Options 1 and 4 devalue the client. Option 2 is
incorrect because "why" questions request an explanation from the client when the client may not have one. Stuart (2013), pp. 25-29;
Varcarolis (2013) p. 441
Assess the client with depression for signs of suicide clues, and intervene to provide safety precautions as necessary.
Judgment, Psychosis
110. A client with a diagnosis of schizophrenia tells the nurse that there are voices outside the window telling him what to do all the time. The
client asks the nurse, "Can you hear them? What do you think I should tell them?" What is an appropriate response by the nurse?
 1. "Yes, I can hear them too."
 2. "What are the voices telling you?"
 3. "There are no voices, you are just ill."
 4. "Maybe they will go away if you ignore them."
Rationale:
When a client is experiencing an auditory hallucination, it is important initially to understand what the voices are saying or telling the client
to do. Suicidal or homicidal messages, if heard by the client, necessitate implementing priority measures. Options 1 and 4 are inappropriate
and do not reinforce reality. Option 3 is inappropriate because it is telling the client that he is "just ill." Varcarolis (2013) pp. 307-308
The nurse should avoid reacting to a client's hallucination as if it were real. The nurse should present reality to the client.
Judgment, Psychosis
111. A client who is demonstrating delusional thoughts says to the nurse, "Terrorists are sent here to kill me." Which response should the nurse
make to the client?
 1. "No one is going to kill you."
 2. "The medication is making you feel like this."
 3. "Do you feel afraid that people are trying to hurt you?"
 4. "What makes you think that terrorists were sent to hurt you?"
Rationale:
It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more
defensive, and the client may cling to the delusions even more. Medication may be prescribed to prevent the occurrence of delusions, not to
cause the delusions. Encouraging discussion regarding the delusion is inappropriate. Stuart (2013), pp. 25-29; Varcarolis (2013) p. 316
Encourage clients experiencing delusions to express feelings related to the delusions.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Cognition,
Safety
112. A home care nurse visits an older client at home. The client was found wandering the highway in her nightgown last night. Her daughter
who lives with her says to the nurse, "This wandering started last week, but this is the first time she got out of the house. She always seems
to do it around 10:00 p.m. What can I do?" Based on an evaluation of the situation, what is the nurse's therapeutic response?
29
 1. "This is a common occurrence in older adults. No need to worry."

 2. "Because this is the first time your mother has wandered out of the house, what has worked before this time?"
 3. "Try approaching your mother before it happens, so she doesn't wander. This could be seen as neglect, and you could be
prosecuted."
 4. "You need to consider a nursing home immediately. Put your mother's name in and when an empty bed comes up, let the
health care provider admit her. You can't handle this alone, and she could get killed!"
Rationale:
The nurse is most therapeutic if an accurate assessment of the situation is first made. The best response is the one that focuses on the
daughter's problem solving so that the nurse can then suggest strategies to try. Options 1 and 3 are inappropriate communication techniques.
Option 4 is histrionic and a too-early intervention based on inadequate information. Stuart (2013), pp. 25-29; Varcarolis (2013) p. 345
Dementia is a syndrome with progressive deterioration in intellectual functioning secondary to structural or functional changes.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority
113. A community health nurse visits a recently widowed retired military man. When the nurse visits, the ordinarily immaculate house is in
chaos, the client is disheveled and has an alcohol type of odor on his breath. Which therapeutic statement should the nurse make to the
client?
 1. "I can see this isn't a good time to visit."
 2. "You seem to be having a very troubling time."
 3. "Do you think your wife would want you to behave like this?"
 4. "What are you doing? How much are you drinking and for how long?"
Rationale:
The therapeutic statement is the one that helps the client explore his situation and express his feelings. Reflection, by telling the client that
the nurse feels that he is experiencing a troubled or difficult time, is empathic, and it will assist the client with beginning to ventilate his
feelings. Option 1 uses humor to avoid therapeutic intimacy and effective problem solving. Option 3 uses admonishment and tries to shame
the client, which is not therapeutic or professional. This social communication belittles the client, will likely cause anger, and may evoke
"acting out" by the client. Option 4 uses social communication. Stuart (2013), pp. 27-28
Therapeutic communication techniques should always be used when communicating with the client, family, or significant other.
114. A client says to the nurse, "I don't do anything right. I'm such a loser." Which therapeutic statement should the nurse make to the client?
 1. "Everything will get better."
 2. "You don't do anything right?"
 3. "You do things right all the time."
 4. "You are not a loser, you are sick."
Rationale:
Option 2 provides the client with the opportunity to verbalize. With this statement, the nurse can learn more about what the client really
means by the statement. Options 1, 3, and 4 are closed statements and do not encourage the client to explore further. Stuart (2013), pp. 21-
22; Varcarolis (2013), p. 118
Nontherapeutic communication techniques block the communication process and should never be used by the nurse in the communication
process.
115. During a preoperative assessment, the nurse notices that the client is crying softly. Based on this observation, which would be an
appropriate response?
 1. "You are crying. Tell me about your feelings."
 2. "You seem upset. I'll leave you alone for a while."
 3. "Don't be upset. You have the best surgeon in town."
 4. "Oh, honey, you don't need to worry. Everything will be OK."
Rationale:
Taking time to discuss the client's concerns is as important a nursing action in many instances as any intervention for physical care.
Therapeutic communication should focus on the client's nonverbal cues and encourage the client to express feelings or concerns about
surgery. Avoiding the client (option 2) and changing the subject (option 3) are also communication techniques that block therapeutic
communication with the client. False reassurance (option 4) blocks therapeutic communication with the client. Stuart (2013), pp. 25-29,
566
When communicating with a client, focus on the thoughts, feelings, concerns, anxieties, or fears of the client.
116. An English-speaking Hispanic man with a newly applied long leg cast has a right proximal fractured tibia. During rounds at night, the nurse
finds the client restless, withdrawn, and quiet. Which nursing statement would be appropriate?
 1. "Are you uncomfortable?"
 2. "Tell me what you are feeling."
30
 3. "You'll feel better in the morning."

 4. "I'll get your pain medication right away."
Rationale:
Option 2 is open-ended and makes no assumptions about the client's psychological or emotional state. Option 1 is incorrect because males
in traditional standard Hispanic cultures practice "machismo" in which stoicism is valued, so this client may deny any pain when asked.
False reassurance is never therapeutic, which makes option 3 incorrect. Option 4 is incorrect because an assessment is necessary before
administering medication for pain. Giger (2013), pp. 214-215; Potter et al (2013), pp. 321-322, 969
The concept of machismo (manliness) may predominate in the Hispanic culture. The nurse must be aware of these types of culture issues, so
that culturally competent care can be provided.
Concepts: Communication, Interpersonal Violence
117. A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2
months ago, she still feels "as though the rape just happened yesterday." How should the nurse respond?
 1. "In reality, the rape did not just occur. It has been over 2 months now."
 2. "What can you do to alleviate some of your fears about being assaulted again?"
 3. "In time, our goal will be to help you move on from these strong feelings about your rape."
 4. "Tell me more about those aspects of the rape that cause you to feel like the rape just occurred."
Rationale:
Option 4 allows for the client to express her ideas and feelings more fully and portrays a unhurried, nonjudgmental, supportive attitude.
Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe care environment.
Although option 1 is true, it immediately blocks communication. Option 2 places the problem solving totally on the client. Option 3 places
the client's feelings on hold. Fortinash, Holoday-Worret (2012), pp. 71-74, 549; Stuart (2013), pp. 747-748
For the client who is a victim of rape, rape trauma syndrome may occur. The client may experience sleep disturbances; nightmares; loss of
appetite; fears; anxiety; phobias; suspicion; a decrease in activities and motivation; disruptions in relationships with the partner, family, or
friends; self-blame, guilt, and shame; lowered self-esteem; feelings of worthlessness; and somatic complaints.
118. The nurse is caring for a client with delirium who has become physically abusive. Which statement should the nurse make to the client?
 1. "If you hit me, I am putting you into restraints."
 2. "You are not to hit me or anyone else. Tell me how you feel."
 3. "The seclusion room is empty and that's where you will need to be if you threaten to hit me or anyone else."
 4. "I will call the health care provider to prescribe a shot for you if you continue to threaten to hit me or anyone else."
Rationale:
If the client's behavior becomes physically abusive, the nurse first sets limits on the behavior by saying, "You are not to hit me or anyone
else. Tell me how you feel." Options 1, 3, and 4 threaten the client and are a violation of the client's rights. Stuart (2013), pp. 25-29;
Varcarolis (2013), pp. 334-335
Forms of acting out include physical and verbal attacks, such as yelling and swearing, and self-injurious behaviors, such as cutting oneself,
banging the head, punching oneself, manipulation, substance abuse, promiscuous sexual behaviors, and suicide attempts. The nurse should
recognize these behaviors and intervene appropriately.
119. The home care nurse visits an older client who lives with her husband in a four-bedroom home. The client states, "I am such a bother to my
husband. He has to do all the heavy work now that my arthritis has gotten worse. When I say we should move to a smaller place, he
explodes." After interpretation of the client's statement, which response by the nurse would be therapeutic?
 1. "I keep noticing bruises on your body, and a month ago you suffered a cracked rib."
 2. "A four bedroom house! It really sounds like you need to sell to me! Why not let me speak to him?"
 3. "Sounds as if he doesn't want to sell, so why pressure him? He's the one who does all the work."
 4. "He explodes? Does he always take his anger out on you? Tell him he'll have to deal with me next time!"
Rationale:
The client has verbalized feelings of being a "bother." This is often a classic sign of spousal abuse. Verbalizing the nurse's observation
(reflection) without making any judgmental statements is a facilitative technique that will allow the client to share her situation, her
feelings, and any fears. If the client is able to respond to the nurse, it will open the door for the nurse to intervene with the couple. In option
2, the nurse uses sarcastic humor, which is belittling to the client. In addition, the nurse's suggested intervention removes control from the
client and probably would add to the client's feelings of powerlessness. In option 3, the nurse patronizes the client and does not hear the
verbal cues that the client is giving. In option 4, the nurse again uses sarcasm and humor that belittle the client. Stuart (2013), pp. 25-29;
Varcarolis (2013) pp. 408-409, 413
The occurrence of spousal abuse is an example of a crisis.
120. The nurse suspects that a female client is a victim of physical abuse. Which statement is likely to encourage the client to confide in the
nurse?
31
 1. "You've got a huge bruise on your face. Did your husband hit you?"
 2. "That looks very sore. I don't know how people can do that to one another."
 3. "If your boyfriend has hit you, you can take him to court or get a restraining order for that."
 4. "I sometimes see women who have been hurt by their boyfriends or husbands. Did anyone hit you?"
Rationale:
Women must be asked in a caring and nonthreatening manner about violence in their lives. Options 1 and 3 are very confrontational, and
option 3 is based on the nurse's assumption that the client wants a restraining order. Option 2 is incorrect because it is a highly judgmental
statement on the nurse's part. The nurse must avoid judgment of the victim or suspected victim's situation. It can take a great deal of time for
a woman to admit that there is in fact abuse, and the nurse must avoid becoming another controller in the woman's life. Only option 4
allows the client the option of rejecting or accepting further intervention on the part of the nurse because the nurse is making an indirect,
general statement. Stuart (2013), pp. 25-29; Varcarolis (2013), p. 404
Victims of abuse may attempt to dismiss injuries as accidental, and abusers may prevent victims from receiving proper medical care to
avoid discovery.
Concepts: Communication, Mood and Affect
121. A client with a diagnosis of depression says to the nurse, "I should have died. I've always been a failure." Which therapeutic response
should the nurse make to the client?
 1. "I see a lot of positive things in you."
 2. "You still have a great deal to live for."
 3. "Feeling like a failure is part of your illness."
 4. "You've been feeling like a failure for some time now?"
Rationale:
Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of
the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate the
exploration of the client's expressed feelings. Fortinash, Holoday-Worret (2012), pp. 71-74, 504; Varcarolis (2013), p. 253
Any client with depression needs to be carefully assessed for a risk for suicide.
122. The nurse is caring for a client diagnosed with depression who appears anxious and withdrawn. Which statement is appropriate for the nurse
to make when initially initiating conversation?
 1. "Do you feel like talking today?"
 2. "You are wearing your new shoes."
 3. "It appears that talking makes you anxious."
 4. "Can you tell me how you are feeling today?"
Rationale:
When a depressed client is mute or silent, the nurse should use the communication technique of making observations. A statement such as,
"You are wearing your new shoes" is an appropriate statement to make to the client because it is open ended and nonthreatening. When the
client is not ready to talk, direct questions or statements such as options 1, 3, and 4 can often raise the client's anxiety level. Fortinash,
Holoday-Worret (2012), pp. 35, 71-74; Stuart (2013), p. 22
Depression may be mild, moderate, or severe. Treatment may include counseling, antidepressant medication, or electroconvulsive therapy.
123. The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a
family member states, "I don't think that this ECT will be helpful, especially since it makes people's memory worse." What form of
communication should the nurse implement to address the family member's concern?
 1. Ask other family members and the client if they think that ECT makes people worse.
 2. Immediately reassure the client and family that ECT will help and that the memory loss is only temporary.
 3. Involve the family member in a dialogue to ascertain how the family member arrived at this conclusion.
 4. Reinforce with the client and the family member that depression causes more memory impairment than ECT.
Rationale:
In option 3, the nurse is looking for data to assist with clarifying information about the procedure with the family which is necessary in
order to deal effectively with their concerns. Option 1 may place family members on the defensive and promote conflict among them.
Option 2 does not acknowledge the family member's statement and concerns. Option 4 addresses content clarification but not the
assessment process, and it is not the most therapeutic action. Fortinash, Holoday-Worret (2012), pp. 71-74, 286; Stuart (2013), pp. 596-597,
600
Electroconvulsive therapy (ECT) may be prescribed to treat depression. It consists of inducing a seizure by passing an electrical current
through the brain via electrodes attached to the temples. ECT is not a permanent cure. It is true that some clients experience temporary
memory loss, but it usually centers on the time period around the treatment itself.
32
124. A 26-year-old client is being successfully treated for a first episode of depression. The client says to the nurse, "My mother and
grandmother were always getting depressed, so I guess I inherited it. Will I be like them and get sick again?" The nurse makes which
therapeutic response to the client?
 1. "There is a higher incidence of depression with family history and in women, but that does not mean that you are affected.
You're doing quite well now. Let's talk about the plans you have now that you are cured."
 2. "Although your mother and grandmother got depressed, it doesn't mean you will. You are very different from them. Your
early treatment will guarantee a cure. Shall we discuss why you identify so heavily with the female members of your family?"
 3. "Although some people with depression experience only one episode in their lifetime or may not become depressed for 2
years or more, there is a chance of experiencing a second episode within 6 months. Knowing when you're becoming
depressed and obtaining immediate treatment are important. It seems as if you have some concerns about your illness."
 4. "We now know that if clients are treated early with medication for a first episode of depression, they will never experience
another depressive episode again. Let's talk about your concerns and make a list of all the worries you are experiencing, shall
we?"
Rationale:
The correct answer is factual and provides anticipatory guidance by teaching the client that early recognition of depressive symptoms allows
treatment to reduce the course of the illness. This information also reduces the client's fears and anxieties arising from the concern that the
illness will be as incapacitating as it was for the client's mother and grandmother. The nurse is using the therapeutic communication
technique of focusing to assess relevant client needs, achieve clearer thinking, and enhance expression of feelings. There is a high
probability that this client will experience another episode of depression in the future. This client has not been cured. Options 1, 2, and 4 all
address a cure for this client and therefore provide inaccurate information. Stuart (2013), pp. 25-29, 293-294
Monitor the client with depression for general hygiene and self-care deficits; deficits may indicate worsening depression.
125. On the second day of hospitalization, a client with depression comes to the dayroom dressed neatly in slacks and a blouse, with hair combed
back in a ponytail. Which statement should the nurse make to the client?
 1. "Wow, you look terrific!"
 2. "This is a first-time event!"
 3. "You must be feeling better today."
 4. "I notice that you are dressed and that your hair is combed."
Rationale:
Accomplishments of clients with depression should be recognized appropriately without flattery or excessive praise. Appropriate
recognition (rather than overly enthusiastic insincerity) increases the likelihood that the client will continue positive behavior. Insincerity
can be perceived as ridicule. The nurse's response should state the actual client behavior that recognizes the client's accomplishment. Stuart
(2013), pp. 296-297; Varcarolis (2013), pp. 120-122, 260
Cognitive therapy may be used for clients with depression. This type of therapy is based on exploring the client's subjective experience.
126. The nurse is caring for a depressed older adult client who asks, "What do you think I should do about my home? My son thinks I should sell
it and move into something smaller now that I'm alone." Which response by the nurse is therapeutic?
 1. "I believe your son is well intending but this is something only you can decide."
 2. "I agree with your son. As you age, you will find that smaller one-floor living is best."
 3. "Why not wait until you're feeling less depressed to make such an important decision? You've only been on your medication
for 4 months."
 4. "What would you like to do? Do you feel you'd be happier in a smaller place? As your depression lifts, you'll be better able to
decide what is best for you."
Rationale:
The therapeutic response is the one that makes the assumption that the client will make her own decisions. This approach provides the client
with a sense of personal empowerment that will relieve the client's powerlessness. If the client is still very depressed, decision making is
difficult. Option 1 is incorrect because the nurse provides a social, not a therapeutic, response, which may undermine the client's
confidence, sense of support, and mutuality. Option 2 is incorrect because the nurse agrees with the client's son and makes a judgment that
is unprofessional and not therapeutic. Option 3 is incorrect because the nurse provides procrastination and avoidance as models for problem
solving. Stuart (2013), pp. 25-29; Varcarolis (2013) pp. 258-259
The increased dependency that older adults may experience can lead to hopelessness, helplessness, lowered sense of self-control, and
decreased self-esteem and self-worth; these changes can interfere with daily functioning and lead to depression.
127. A client with a diagnosis of depression says to the nurse, "My daughter is hateful to me." What is the appropriate nursing response?
 1. "Your daughter is not hateful to you."
 2. "Your daughter must be awful to live with."
 3. "Your daughter will be punished for being so hateful."
 4. "It sounds like you are having a rough time right now with your daughter."
Rationale:
The nurse should use therapeutic communication techniques when responding to a client's comment. In options 1, 2, and 3, the nurse is
33
criticizing the client and others and is putting others down. Option 4 exemplifies the therapeutic response of reflection. Stuart (2013), pp.
25-29; Varcarolis (2013) p. 257
Monitor the client's nonverbal communication because this can provide important cues regarding the client's feelings.
128. A client diagnosed with depression says to the nurse, "I don't want to live anymore, now that my child is gone." Which statement is a
therapeutic nursing response?
 1. "Anyone would be sad."
 2. "I understand what you mean."
 3. "Your child's death is no reason to want to die."
 4. "The death of your child must be very difficult for you. Tell me more about how you are feeling."
Rationale:
Options 1, 2, and 3 are nontherapeutic nursing responses. In these responses, the nurse uses avoidance and puts down the client's expressed
feelings to avoid having to deal with the painful feelings. In option 4, the nurse encourages the client to further express feelings. Stuart
(2013), pp. 25-29; Varcarolis (2013) p. 257
The nurse's role in the grief and loss process includes communicating with the client, family members, and significant other and
encouraging the expression of feelings.
129. An older client says to the home-care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this
house, ready to plan our activities for the day." Which is the most therapeutic nursing response?
 1. "It must be hard to accept that she has passed away."
 2. "Are you saying that she made all of the social plans for you?"
 3. "Focus on the fact that her suffering is over and that she had a good life with you."
 4. "Try to focus on the fact that you have three wonderful children and that you and your wife loved one another for years."
Rationale:
The most therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and facilitates expression
of feelings, option 1. The statements in the remaining options are not therapeutic and do not encourage expression of feelings. Stuart
(2013), pp. 25-29
Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review
what was said.
Concepts: Communication, Palliation
130. A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of
pain but is quiet and isolative. Which nursing actions are therapeutic? Select all that apply.
 1. Sit by the client's bed and hold the client's hand.
 2. Reminisce with the client and share a humorous story that the client enjoys.
 3. State, "What can I do that might make you feel more comfortable today?"
 4. State, "Just think, you will soon be in a better place; where you will not be in pain."
 5. State, "I noticed you grimacing earlier when I walked in your room, are you in pain?"
 6. State, "It must be very frustrating to be in pain and not be able to get complete relief from your pain."
Rationale:
Sitting by the bed and holding the client's hand is an example of silence. Reminiscing promotes active listening. Asking the client what
might be done to make them more comfortable provides an offering of self and shows empathy. Asking the client about grimacing seeks
validation. Asking about the lack of pain relief is a technique of empathy and offers the client an opportunity to discuss pain control. Telling
the client "Just think, you will soon be in a better place where you will not be in pain," can be viewed as offering false reassurance. It can
also be viewed as making an assumption (life after death) that the client may not share. Potter et al (2013), pp. 965, 986; Varcarolis (2013),
pp. 120-122
Therapeutic communication techniques can help the nurse learn more about the client and their situation. Using nontherapeutic
communication techniques can lead to mistrust and a lack of needed information.
131. A client says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them
told me she had other clients besides me! I'm very sick, but the nurses don't care!" Which statement from the nurse is therapeutic?
 1. "I think you are being very impatient. The nurses come as quickly as they can."
 2. "I can hear your anger. That nurse had no right to speak to you that way. I will report her."
 3. "You poor thing! I'm so sorry this happened to you. That nurse should be fired immediately."
 4. "It's hard to be in bed and to have to ask for help. You feel that the nurses do not seem to care?"
Rationale:
Empathy is a term that describes the nurse's capacity to enter into the life of another person and to perceive how the client is feeling and
what meaning this has for the client. In option 4, the nurse displays empathy and shares perceptions. The sharing of perceptions asks the
34
client to validate the nurse's understanding of what the client is feeling and thinking. It opens the door for the client to share concerns, fears,
and anxieties. In option 1, the nurse is assertive and also defends the nursing staff. In option 2, the nurse expresses the client's frustration by
labeling the client's feelings as angry and disapproving of the nursing staff. This is splitting, and it is nontherapeutic. Option 3 is a social
response, and it is demeaning to the client. Stuart (2013), pp. 32-33, 38; Varcarolis (2013), pp. 144-145
The nurse should encourage the client to share thoughts and feelings. This will assist to uncover other feelings, anxieties, or fears the client
is having.
132. The nurse is caring for a client who says, "I don't want to talk with you because you're only the nurse. I'll wait for my doctor." What should
the nurse say in response to the client?
 1. "I'm angry with the way you dismissed me."
 2. "I understand. So should I call your health care provider?"
 3. "Your health care provider directs me in your nursing care."
 4. "So then, you would prefer to speak with your health care provider?"
Rationale:
The nurse uses techniques of therapeutic communication to reflect the client's statement (option 2), redirect feelings back to the client for
validation, and focus on the client's desire to talk with the doctor. Options 1 and 3 are nontherapeutic responses and are defensive responses.
Option 4 reinforces the client's behavior and does not encourage client expression of feelings. Fortinash, Holoday-Worret (2012), pp. 71-
74; Stuart (2013), pp. 27-28
Communication includes both verbal and nonverbal expression. Anxiety in the nurse or client may impede communication.
133. The client angrily tells the nurse that the health care provider (HCP) purposefully provided incorrect information. Which response to the
client would hinder therapeutic communication?
 1. "I'm certain that the HCP would not lie to you."
 2. "I'm not sure what information you are referring to."
 3. "Can you describe the information that you are referring to?"
 4. "Do you think it would be helpful to talk to your doctor about this?"
Rationale:
Option 1 hinders communication by disagreeing with the client. This technique could make the client defensive and block further
communication. Options 2 and 3 attempt to clarify the information to which the client is referring. Option 4 attempts to explore whether the
client is comfortable talking to the HCP about this issue and encourages direct confrontation. Fortinash, Holoday-Worret (2012), pp. 71-74,
77, 80; Stuart (2013), p. 24
Agreeing or disagreeing with the client is a nontherapeutic communication technique.
134. The client tells the nurse, "I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What
happens if something goes wrong after I go home?" Which statement by the nurse is therapeutic?
 1. "Don't worry about the details. This procedure is done all the time and generally without any problems. You'll be fine!"
 2. "They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I'll come."
 3. "Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can't be too
careful."
 4. "You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and
your family?"
Rationale:
The client has verbalized concerns. In option 4, the nurse uses reflection to direct the client's feelings and concerns. In option 1, the nurse
provides false reassurance and then minimizes the client's concerns. In option 2, the nurse is ventilating the nurse's own anger, frustration,
and powerlessness. In addition the nurse is trying to problem solve for the client but is overly controlling and takes the decision making out
of the client's hands. In option 3, the nurse is projecting the client's own fears, and the problem solving suggested by the nurse will increase
fear and anxiety in the client. Fortinash, Holoday-Worret (2012), pp. 71-74; Stuart (2013), pp. 30-31
Communication with the client needs to be goal directed and based on the client's concerns.
135. The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse–client relationship. Which
intervention is representative of this phase of the relationship?
 1. The nurse and client determine the contract for time.
 2. The client is encouraged to make use of all services depending on need.
 3. The client begins to identify with the nurse, and trust and rapport are maintained.
 4. The nurse focuses on facilitating the safe expression of feelings on the part of the client.
Rationale:
In the orientation (introductory phase) of the therapeutic nurse–client relationship, the client and nurse meet and determine the contract for
35
time, such as how often to meet, the length of the meetings, and when termination is anticipated to occur. Utilizing services, identification
with the nurse, and expression of feelings are appropriate for the working phase of the therapeutic nurse–client relationship. Stuart (2013),
p. 19
Acceptance, trust, and boundaries are established in the orientation (introductory) phase of the therapeutic nurse–client relationship.
136. An older client is admitted to the hospital after falling from a chair at home. During the night the nurse wakes the client to perform a
neurological assessment. The client states, "I'm so scared. Where am I? What's happening?" Based on the client's statement, the nurse makes
which response?
 1. "Hold my hand. Try to wake up and tell me your name."
 2. "You're in the hospital after a fall. Do you feel frightened?"
 3. "You fell and hit your head. Your family brought you here."
 4. "There's no reason to be scared, you're safe here in the hospital."
Rationale:
The communication technique of reflecting involves using the client's own words or feelings when responding. In option 2, the nurse gives
information to the client as well as reflects feelings. In option 1, the nurse attempts to calm the client but blocks communication by
changing the subject and beginning the neurological assessment. In option 3, the nurse gives information but does not deal with the client's
emotional need. In option 4, the nurse does not provide complete information to the client. Ignatavicius, Workman (2013), p. 919; Potter et
al (2013), pp. 320-322
The nurse should orient a client who is frequently confused to date, time, and place.
137. A client says to the nurse, "What good does it do to be assertive, when people only say no anyway?" Which response by the nurse is
therapeutic?
 1. "Hold on now! It's the thought that counts, so to speak."
 2. "You're right, of course. We teach it because it is probably the best way to communicate."
 3. "The purpose of being assertive is to express one's feelings openly without causing hurt or anger."
 4. "Now just a minute! Assertiveness isn't a strong-arm tactic; it's an appropriate way of being in the world."
Rationale:
Responsible assertiveness provides clients with the skill to stand up for their personal and professional rights and to express their thoughts
and beliefs directly, honestly, and appropriately in a manner that will not violate the rights of others. Option 2 is not therapeutic because the
nurse agrees with the client. Options 1 and 4 are also incorrect because the nurse is aggressive and nontherapeutic. Stuart (2013), p. 574;
The nurse should assist the client to use assertive techniques rather than manipulative techniques to meet needs.
138. A prison client, who killed an abusive spouse, is eligible for parole and asks the nurse, "Do you think I have a chance of being paroled?"
Which nursing response would be therapeutic?
 1. "Do you think you do?"
 2. "If I were you, I would not build up too much hope. Simply having a firm plan in place will not help your case."
 3. "You have a promise of employment and regaining your children already lined up. I believe that the parole board will view
your problem solving as a positive criterion."
 4. "Let me respond by telling you that most parole applications are denied the first time. Nevertheless, I have learned your good
conduct record will be seriously considered."
Rationale:
One of the criteria that the parole board will investigate is the client's ability to engage in strategic planning. The fact that the client has
plans for employment and regaining custody of the children will be viewed in a positive way as an example of changed behavior. In option
1, the nurse is using a confrontational question that seems somewhat sardonic and is not therapeutic. In option 2, the nurse is giving an
opinion that is not therapeutic and is unprofessional. In option 4, the nurse is giving inaccurate information. Stuart (2013), p. 662-663;
Use therapeutic communication techniques to respond to a client. Respond by validating the client's concerns and remaining neutral.
139. The nurse employed in a prison is caring for a client who is recuperating in the prison infirmary. The client says, "You have beautiful eyes
and you smell nice, nurse." Which nursing response or action would be therapeutic?
 1. "Thank you for noticing."
 2. "Do you think you are being appropriate?"
 3. "I'm not here to discuss my eyes or how I smell."
 4. Say nothing in order to extinguish the client's inappropriate behavior.
Rationale:
A client in prison is knowledgeable about the rules for behavior in the correctional setting. Many clients will test the nurse's capacity to be
36
victimized and will make inappropriate statements. These behaviors need to be verbally confronted directly and then carefully documented
in the client's chart. Option 1 is a social response that can be misinterpreted by the client. Option 2 is confrontational but also judgmental
and provides an opening for a regressive struggle. Option 4 can also be misinterpreted as the nurse's wanting or liking the client's comments.
Stuart (2013), pp. 662-663; Varcarolis (2013) pp. 120-122
Present reality to clients who are speaking or acting inappropriately or are experiencing hallucinations.
140. The nurse is assigned to care for a hospitalized client with a diagnosis of depression. When the nurse enters the client's room, which would
be the appropriate statement?
 1. "You look nice this morning."
 2. "I like the way you did your hair."
 3. "You are wearing a new dress this morning."
 4. "Don't worry. Things will look up for you."
Rationale:
When depressed, a client sees the negative side of everything. Neutral comments such as that identified in option 3 will avoid negative
interpretations. The client can interpret the statement in option 1 as, "I didn't look nice yesterday morning." The statement in option 2 can be
thought of as something done to please the nurse. For example, the client may think "If I did my hair another way, maybe he or she will not
like it." The client should not be told "not to worry and that things will look up." This statement tends to minimize the client's feelings of
guilt and worthlessness because the client cannot "look up or snap out of it" at this time. Stuart (2013), pp. 25-29; Varcarolis (2013) pp.
258-259
Clients who have depression and have not responded to other antidepressant therapies, including electroconvulsive therapy, may be
prescribed a monoamine oxidase inhibitor (MAOI).
141. A client in the mental health unit says to the evening nurse, "The staff members of the day shift let me smoke two cigarettes." Knowing that
the policy is one cigarette per shift, the nurse appropriately responds by making which statement?
 1. "The day shift is always breaking the rules."
 2. "I'll speak to the day shift about the smoking rules."
 3. "The policy is one cigarette, which we will follow."
 4. "The day shift should not allow you to smoke two cigarettes."
Rationale:
Option 3 is the most appropriate response because it provides the client with a clear and direct response regarding the rules in the unit. In
options 1, 2, and 4, the nurse is criticizing others and putting others down in front of the client. Stuart (2013), pp. 25-29
On admission to the mental health unit, the nurse should provide the client with the unit rules and privileges that are allowed.
142. A client has surgery to treat a mitral valve prolapse. The client states, "If I can't do anything, I might as well be dead." Which response
should the nurse make to the client?
 1. "You aren't better off dead."
 2. "You should be more positive."
 3. "Let's talk more about the way you feel."
 4. "It is normal to be depressed after surgery."
Rationale:
Option 3 focuses on the client and encourages the client to share his feelings. Options 1, 2, and 4 will block the communication process.
Lewis et al (2014), p. 822; Potter et al (2013), pp. 320-322
Prophylactic antibiotics may be prescribed prior to invasive procedures for the client with mitral valve prolapse to prevent the development
of infection.
143. A client with obesity says to the clinic nurse, "I'm not sure that attending my Weight Watchers support group is the best thing for me to do."
 1. "Weight Watchers has been successful for many of our clients in the past."
 2. "Your doctor has decided that you should give Weight Watchers a chance."
 3. "You have concerns about attending the Weight Watchers support group?"
 4. "I feel certain that you have made the right decision by giving Weight Watchers a try."
Rationale:
In option 3, the nurse has restated the client's message in an open-ended question. Option 1 represents a block to communication and is
impersonal. Option 2 devalues the client, implying that the doctor knows best. In option 4 the nurse is expressing approval, which can be
detrimental to the nurse-client relationship. Lewis et al (2014), p. 915; Potter et al (2013), pp. 320-322
37

Use open-ended questions to obtain information about the client's feelings and concerns; allow time for the client to ask questions and
express feelings.
144. The nurse enters the room of a client who begins to discuss his anger toward his spouse following an argument on the telephone. Which
statement by the nurse is a barrier to effective communication with the client?
 1. "You seem quite upset."
 2. "You had an argument with your wife?"
 3. "Every couple has their share of arguments."
 4. "Would you like to talk about this incident?"
Rationale:
Option 3 is a stereotypical comment. Such comments imply a lack of understanding of a client's uniqueness and create or maintain distance
between the nurse and the client. Option 1 acknowledges the client's distress; option 2 attempts to obtain further information; and option 4
provides an opportunity for the client to discuss feelings. Stuart (2013), pp. 30-31; Varcarolis (2013), p. 402
The nurse should always listen to the client in order to establish a trusting nurse-client relationship, which will enhance the treatment
experience for the client overall.
145. A client is admitted to the mental health unit with a diagnosis of anxiety disorder. The client says to the nurse, "I came in to get away from
the pressure at home." Which nursing response is best to use in this introductory meeting with the client?
 1. "I'm glad you came into the hospital at this time."
 2. "We will be able to help you here in the hospital."
 3. "What are your feelings about being hospitalized?"
 4. "Can you tell me what made you feel overwhelmed at home?"
Rationale:
Option 4 seeks to obtain further specific information from the client regarding stresses that led to the client's hospitalization by offering a
general lead. Obtaining information is an important aspect of the nursing assessment when the client is initially hospitalized. Option 1 is
giving approval or praise, which may hinder the client's learning process because the client may seek to gain the nurse's approval rather than
focus on learning coping behaviors. Stuart (2013), p. 219; Varcarolis (2013), pp. 120-122
During hospitalization, the client with an anxiety disorder should be assisted in identifying the thoughts that arouse the anxiety and identify
the basis for these thoughts.
146. A client with Parkinson's disease expresses embarrassment because of tremors and drooling and states that he no longer wants to be seen in
public. Which response should the nurse make to the client?
 1. "Don't worry. Lots of people have disabilities."
 2. "You shouldn't feel that way; it's not that noticeable."
 3. "You should just ignore the people who are staring at you."
 4. "It must be difficult for you. Would you like to talk about your concerns?"
Rationale:
The correct response focuses on the client's concerns. Options 1 and 2 devalue the client's feelings and offer false reassurance. Option 3
offers advice. Devaluing feelings, giving advice, and offering false reassurance are blocks to effective communication. Ignatavicius,
Workman (2013), pp. 945-946; Potter et al (2013), pp. 320-322
The debilitation that occurs in Parkinson's disease can result in falls, self-care deficits, failure of body systems, and depression. Mental
deterioration occurs late in the disease.
147. A client is admitted to the hospital with a bowel obstruction as a result of a recurrent malignancy, and the health care provider inserts an
intestinal tube. After the procedure, the client asks the nurse, "Do you think this is worth all this trouble?" What should be the response by
the nurse?
 1. "Let's give this tube a chance."
 2. To stay with the client and be silent
 3. "Are you wondering whether you are going to get better?"
 4. "I remember a case similar to yours, and the tube relieved the obstruction."
Rationale:
The nurse uses therapeutic communication tools to assist a client with a chronic terminal illness to express feelings. The nurse listens
attentively to the client and uses clarifying and focusing to assist the client with expressing feelings. Changing the subject (option 1),
responding with inappropriate silence (option 2), and offering false reassurance (option 4) are not therapeutic communication techniques.
Ignatavicius, Workman (2013), p. 1254; Mosby's dictionary of medicine, nursing & health professions (2013), p. 1146; Potter et al (2013),
pp. 320-322
38

An intestinal tube may be used to drain and decompress the small intestine. One type of intestinal tube is a Miller-Abbott tube in which one
lumen leads to a balloon that is filled with a special substance as soon as it is in the stomach; the second lumen is for irrigation and
drainage.
Concepts: Communication, Psychosis
148. The nurse is caring for a client diagnosed with delirium who states, "Look at the spiders on the wall." How should the nurse respond?
 1. "Would you like me to kill the spiders for you?"
 2. "While there may be spiders on the wall, they are not going to hurt you."
 3. "I know that you are frightened, but I do not see any spiders on the wall."
 4. "You are having a hallucination; I'm sure there are no spiders in this room."
Rationale:
When hallucinations are present, the nurse should reinforce reality with the client while acknowledging their feelings as option 3 does.
Options 1 and 2 do not reinforce reality but rather support the legitimacy of the hallucination. Option 4 reinforces reality but does not
address the client's feelings. Fortinash, Holoday-Worret (2012), pp. 71-74, 275; Varcarolis, Halter (2013), p. 315
If the client is hallucinating, ask the client to describe the hallucinations. Avoid reacting to the hallucination as if it were real.
149. The nurse is caring for a client with schizophrenia and documents that the client is experiencing poverty of speech. The nurse documents
this finding based on which observation?
 1. The client remains quiet.
 2. The client stops talking in the middle of a sentence.
 3. Speech is restricted in amount and ranges from brief to monosyllabic 1-word answers.
 4. Speech is adequate in amount but conveys little information because of vagueness, empty repetitions, or use of stereotypes or
obscure phrases.
Rationale:
Poverty of speech is speech that is restricted in amount and ranges from brief to monosyllabic 1-word answers. Blocking is when the client
stops talking in the middle of a sentence and remains quiet. Poverty of content of speech is speech that is adequate in amount but conveys
little information because of vagueness, empty repetitions, or use of stereotypes or obscure phrases. Stuart (2013), p. 349
Initiate one-on-one interaction with a client with schizophrenia and progress to small group interaction as tolerated.
150. A client with paranoia tells the nurse that she will not attend the group therapy session because a student nurse has been sent to spy on her.
 1. "Come to therapy with me; I'll protect you."
 2. "If you attend group therapy, I'll take you for a walk."
 3. "What makes you think the student is spying on you?"
 4. "Student nurses attend group therapy as part of their education."
Rationale:
Option 4 gives the client a clear statement of reality. Options 1, 2, and 3 are nontherapeutic because they imply that there is something to be
suspicious of, and this reinforces the client's delusion. Stuart (2013), pp. 25-29; Varcarolis (2013), p. 315
A paranoid disorder can be described as a concrete delusional system characterized by persecutory and grandiose beliefs.
151. A client experiencing delusions is taken to the laboratory for routine blood work and while in the laboratory begins shouting, "You're all
vampires. Get me out of here." Based on the client's behavior, the nurse should make which therapeutic response to the client?
 1. "OK, I'll take you out of here."
 2. "I'll leave until you calm down."
 3. "What makes you think they are vampires?"
 4. "It must be scary to think others want to hurt you."
Rationale:
This response helps the client focus on the emotion underlying the delusion but does not argue with it. A danger in directly attempting to
change the client's mind is that the delusion may then in fact be even more strongly held. Options 1, 2, and 3 are inappropriate responses.
Varcarolis (2013) p. 315
Delusions and hallucinations may be noted in certain disorders, including severe depression, alcohol or drug withdrawal, and schizophrenia.
152. The psychiatric nurse is sitting with several clients in the dayroom. A client who has been experiencing delusions and hallucinations states
to the nurse, "That television is talking only to me." Which therapeutic response should the nurse make to the client?
 1. "Televisions don't talk."
39
 2. "What is the television saying?"

 3. "The television is on for everyone."
 4. "The television is not talking to you."
Rationale:
The most therapeutic response is the one that provides reality for the client. In options 1, 2, and 4, the nurse feeds into the client's delusions
or hallucinations and denies the client the opportunity to see reality. This does not provide a healthy response toward growth. Varcarolis
(2013) pp. 315-316
Maintain reality with the client and encourage the client to express feelings.
153. A client with paranoia says to the nurse, "The FBI is trying to harm me." Which response by the nurse would be appropriate?
 1. "The FBI is not going to harm you."
 2. "You are in the hospital, so you are safe from the FBI."
 3. "You're having auditory hallucinations at this time; the FBI will not hurt you."
 4. "I don't know about the FBI trying to harm you, but thinking that must be frightening."
Rationale:
When caring for the client with altered thought processes, it is important to remember that the client cannot logically discuss illogical
material but perhaps can discuss feelings. The best response is option 4, because it reinforces reality therapeutically and addresses the
client's feelings. Stuart (2013), pp. 25-29; Varcarolis (2013), p. 315
During a hallucination, attempt to engage the client's attention through a concrete activity. Avoid reacting to the hallucination as if it were
real.
154. A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. Tell them to be quiet." Looking at the
nurse, the client says, "Can't you hear them shouting at me?" What is the nurse's best response?
 1. "How often are you hearing voices?"
 2. "If you took your medications, you wouldn't be hearing voices."
 3. "The voices aren't real. Go to the day room and watch television."
 4. "I don't hear the voices, but I can see you how upsetting it must be for you."
Rationale:
Hallucinations are real to the client who is experiencing them. The brain is not processing stimuli accurately. The client who is hallucinating
may also be experiencing anxiety, fear, loneliness, and low self-esteem. The content of the hallucination is more important than the
frequency of occurrence. The nurse should not negate the client's experience, but rather offer his or her own perception and try to
understand what the voices are saying or telling the individual to do. Eliminate any option that attempts to assess is a judgmental,
disapproving, and nontherapeutic response; or rejects the client's feelings and negates the client's experience. Varcarolis (2013), pp. 318,
320
Assist the client with schizophrenia who has difficulty expressing feelings verbally to use alternative means to express feelings, such as
through music, art therapy, or writing.
155. The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard
here all week, and this is my day of rest. I'll get up at 11:30." What is the nurse's best response?
 1. "You have to get up right now. Those are the unit rules."
 2. "Let me know if you change your mind, and I'll get you something to eat."
 3. "I'm sorry you feel this way. I believe you are experiencing a religious delusion."
 4. "Your doctor expects you to participate in all the activities while you are a client here."
Rationale:
Delusions are false fixed beliefs, and it is never useful to argue with the client regarding the content of the delusion. This can intensify the
client's retention of the irrational beliefs. Once a client describes his or her delusion, do not dwell on it. Rather, focus the conversation on
more reality-based topics. The correct option reinforces caring. Option 1 is rigid and is directly challenging to this client's delusion. Using
the nontherapeutic technique of interpreting described in option 3 may be construed as challenging to the client. The expectation to
"participate in all activities" is not realistic. Stuart (2013), pp. 25-29; Varcarolis (2013), pp. 305, 321
Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and
open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing
acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal
encouragement, and summarizing.
156. A client who is experiencing suicidal thoughts greets the nurse with the following statement, "It just doesn't seem worth it anymore. Why
not just end it all?" Which response should the nurse make to further assess the client?
 1. "Did you sleep at all last night?"
40
 2. "Tell me what you mean by that."

 3. "I know you have had a stressful night."
 4. "I'm sure that your family is worried about you."
Rationale:
Option 2 allows the client the opportunity to tell the nurse more about what his or her current thoughts are. Option 1 changes the subject and
may block communication. Although option 3 offers empathy to the client, it does not further assess the client. Option 4 is false reassurance
and may block communication. Fortinash, Holoday-Worret (2012), pp. 71-74, 512; Varcarolis (2013), pp. 436, 440-441
The nurse should develop a contract with the suicide client that is written, dated, and signed, and that indicates alternative behavior at times
of suicidal thoughts.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Health Care
Law, Interpersonal Violence
157. A client states, "I have decided to stop blaming myself and to mobilize my depression like my doctor said. I intend to take my son's rifle and
shoot my husband and his new girlfriend tonight while they're working late at the office." Which is the appropriate nursing response?
 1. "I will need to report your intentions to the law and to your husband.."
 2. "I will respect your confidentiality, but I am going to commit you immediately."
 3. "How can you come to the conclusion that this is how to mobilize your depression? This is not an appropriate decision."
 4. "I disagree with your conclusion that this is the way to mobilize your depression. Nevertheless, I will respect your
confidentiality."
Rationale:
Any clear threats by psychiatric clients to harm specific people must be reported to the authorities (law enforcement) and the intended
victims by mental health care providers and psychotherapists. Option 2 contains a contradictory message and inaccurate information. Option
3 uses a judgmental attitude and is overly controlling. Option 4 is incorrect. The client has a specific plan for homicide, which includes the
potential victims, the method, the time, and the place. With such high lethality, the nurse is responsible for taking appropriate action. Stuart
(2013), p. 581; Varcarolis (2013) pp. 456-457
The nurse is required to report a case of suspected child or elder abuse to legal authorities. Additionally a threat by a client to commit a
homicidal act must be reported to legal authorities.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority Concepts: Interpersonal
Violence, Professionalism
158. The nurse is caring for a 12-year-old client who has been physically and sexually abused by her father. The father angrily approaches the
nurse and says, "I'm taking my daughter home. She's told me what you people are up to, and we're out of here!" Which therapeutic response
should the nurse make?
 1. "Your daughter will remain here until the doctor discharges her. I'll call hospital security and the police if you attempt to take
her."
 2. "Try to listen to me, please. If you are insistent and do take your daughter from this unit, the police will most certainly order
you to bring her back again."
 3. "Your daughter is ill and needs to be here. I know you want to help her to recover and that you will work to help everyone
straighten out the circumstances that caused this."
 4. "You seem very upset. Let's talk at the nurse's station. I know you're very concerned and that you want to help your daughter.
It will be best if you agree to let your daughter stay here for now."
Rationale:
When a suspected abused child is admitted to the hospital for further evaluation and protection, the health care provider will usually work
with the parents so that they will agree to the admission. If the parents refuse to do this, the hospital can request an immediate court order to
retain the child for a specific length of time. In option 1, the nurse is angry and verbally abusive. It is clear that the nurse has decided that
the father is guilty of child abuse. In addition, the nurse is aggressive and challenging; this may antagonize the father and cause the nurse to
become a victim of violence as well. In option 2, the command to listen is somewhat demanding. Option 3 seems somewhat pompous and
lecturing. Fortinash, Holoday-Worret (2012), pp. 71-74, 541; Swearingen (2012), pp. 569-570
Nurses are legally required to report all cases of suspected child abuse to the appropriate local or state agency. A safe environment must be
provided for the victim.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Pharmacology: Hematological Medications;
Priority Concepts: Communication, Professionalism
159. A client who is being treated with warfarin (Coumadin) to prevent postoperative thromboembolism says to the nurse, "I'm not sure that I
want to be on a drug that can cause so many side effects." Which response should the nurse make to the client?
 1. "I understand that you have concerns, but the medication prevents you from having problems that can kill you, so the side
effects are really a small price to pay."
 2. "Your concerns are very real, but the health care provider must weigh the side effects against the seriousness of your illness.
The side effects are little enough if the drug can save your life."
 3. "I understand that you have concerns, but the medication has been used for some time at this dosage and had very few, if any,
problems. But I would like to hear all of your concerns. Let's discuss this some more."
 4. "You make an excellent point that I would urge you to discuss with your health care provider. It is, after all, your body and
your decision, not your health care provider's. But I would like to hear all of your concerns. Let's discuss this some more."
Rationale:
Option 3 is the only therapeutic response and focuses on the client's feelings. Option 1 begins by acknowledging the client's concerns but is
less appropriate in its use of the word kill, which would only increase the client's anxiety. In addition, it patronizes the client's feelings and
41
medical risks. This approach can be demeaning and demoralizing to clients. Option 2 validates the client's concerns and then minimizes and
negates them by placing the decision out of the client's hands and into the health care provider's. In addition, it could frighten the client by
stating that the illness is so serious that side effects are not a consideration. Option 4 makes a judgment (use of the word excellent suggests
approval). It also contains language that undermines the health care provider's authority by making the innuendo that the health care
provider is insensitive to the client's concerns and risks. Hodgson, Kizior (2014), pp. 1262-1263; Potter et al (2013), pp. 320-322
Use therapeutic communication techniques and open-ended questions to obtain information about the client's symptoms and concerns; allow
time for the client to ask questions.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Leadership/Management: Ethical/Legal; Priority
160. The nurse supervisor tells an evening nurse, "I need you to work tonight because half of the staff has been stressed out and has called in
sick." Which would be the therapeutic response by the single-parent evening nurse who must return home to the babysitter?
 1. "I'm so sorry but I just can't work for you tonight. I am stressed out, too."
 2. "I'm out of here at 11:00 p.m.! I guess you'll just have to take charge tonight."
 3. "I cannot work for you. My daughter is with a baby-sitter who needs to leave at midnight."
 4. "I'm sorry to hear that but I just can't work for you tonight. Let me help you by calling for some staff to come in."
Rationale:
Assertive techniques include using the word "I", looking the other person directly in the eye, relinquishing apologetic behavior, using a
serious expression when speaking, and letting feelings show. Option 3 identifies appropriate use of assertiveness techniques. Option 1 is
apologetic and identifies an association of feelings. Option 2 is aggressive and challenging. Option 4 is apologetic, and then the nurse offers
to do the supervisor's job. Potter et al (2013), pp. 317, 741
Assertive techniques can be a mode of resolution if used effectively.
Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Cultural Awareness; Priority
Concepts: Caregiving, Culture
161. The nurse is caring for an older Orthodox Jewish client of the opposite sex whose condition is terminal. The nurse is implementing a plan of
care and wishes to communicate this plan with the client and family. The nurse should be aware of what end-of-life religious practices when
planning and communicating with the client and family? Select all that apply.
 1. The client may demonstrate a high level of anxiety.
 2. Religious laws are suspended during times of severe illness.
 3. During the process of dying, visitors and conversation should be kept to a minimum.
 4. Family members may not shake hands or make direct eye contact with members of the opposite sex.
 5. Clients that are of the Orthodox Jewish faith are usually very quiet and do not express what they are thinking or feeling.
Rationale:
Outward expressions of anxiety are commonly seen among Orthodox Jewish members, especially older individuals. The Orthodox Jew
strictly follows the laws of Judaism, however, during times of severe illness, Jewish laws are not observed if doing so will endanger the
client's health. In the Orthodox Jewish faith, members generally will not shake hands or make direct eye contact with members of the
opposite sex. During times of illness or death, the Orthodox Jewish community including family and friends will frequently visit and are
considered the nucleus of the Jewish culture. Clients of the Orthodox Jewish faith are generally very verbal about what they are feeling,
especially in the older population. Giger (2013), p. 512-513, 518
If an autopsy is performed on a client who is an Orthodox Jew, all parts of the body that are removed need to be buried with the body.
Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Fundamental Skills: Cultural Awareness; Priority
Concepts: Communication, Reproduction
162. The nurse is planning care for a non-English speaking client who is in early labor. Which interventions should the nurse plan to implement
for this client? Select all that apply.
 1. Enlist a family member to perform as the interpreter.
 2. Plan to address the questions looking directly at the interpreter.
 3. Arrange for a phone interpreter if one is not available in the hospital.
 4. Assess what language the client speaks, reads, or verbally understands.
 5. Inquire through the hospital interpretation services if a female interpreter is available.
Rationale:
The nurse should begin by assessing what language the client speaks, reads, or verbally understands to ensure adequate communication. A
female interpreter is preferred over a male interpreter. If no one in the hospital is able to interpret, a phone interpreter should be arranged.
Family members may not be the best interpreters because they may interpret selectively, adding or subtracting information as they see fit.
Questions should be directed to the client not the interpreter. McKinney et al (2013), pp. 335, 337
Non–English speaking clients feel a loss of control over their situation if no health care provider is present who speaks their language.
Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Maternity: Antepartum; Priority
163. A pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat
regular meals." Based on the client's statement, what is the best response for the nurse to make?
 1. "I'll have the doctor review your diet history."
 2. "Can you tell me more about what you are eating?"
 3. "It does not matter anymore how much weight you gain."
42
 4. "If you do not eat regular meals, you will hurt your baby."
Rationale:
It is important for the nurse to obtain additional information from the client. In option 2, the nurse is using the therapeutic communication
tool of validation and clarification to obtain more information. The other options will block communication. Option 1 is avoiding the issue,
and option 3 provides false reassurance. Option 4 devalues the client and shows disapproval. McKinney et al (2013), pp. 30-31, 614
Nutrition is a basic need that must be met for all clients. Nurses must have the knowledge required to educate and care for healthy clients
and for clients with nutritional needs or disorders requiring alterations in dietary measures.
Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Respiratory; Priority
164. A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for
communication should the nurse determine may be the best for the client?
 1. Use a picture or word board.
 2. Have the family interpret needs.
 3. Devise a system of hand signals.
 4. Use a pad of paper and a pencil.
Rationale:
The client with an endotracheal tube in place cannot speak, so the nurse devises an alternative communication system with the client. The
use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. The family
does not need to bear the burden of communicating the client's needs, and they may not understand them either. The use of hand signals
may not be a reliable method because it may not meet all needs, and it is subject to misinterpretation. A pad of paper and a pencil is an
acceptable alternative, but it requires more client effort and time. Ignatavicius, Workman (2013), p. 679
A resuscitation (Ambu) bag must be kept at the bedside of a client with an endotracheal tube or a tracheostomy tube at all times.
Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Adult Health: Cardiovascular; Priority
165. The nurse enters the room of a client who has had a myocardial infarction (MI) and finds the client quietly crying. After determining that
there is no physiological reason for the client's distress, how should the nurse best respond?
 1. "Do you want me to call your daughter?"
 2. "Can you tell me a little about what has you so upset?"
 3. "Try not to be so upset. Psychological stress is bad for your heart."
 4. "I understand how you feel. I'd cry, too, if I had a major heart attack."
Rationale:
Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and
facilitating communication using therapeutic communication techniques. Option 2 provides the client with an opportunity to express
concerns. Options 1, 3, and 4 do not address the client's feelings or promote client verbalization. Ignatavicius, Workman (2013), pp. 835,
841; Potter et al (2013), pp. 320-322
Cardiac rehabilitation is the process of actively assisting the client with cardiac disease to achieve and maintain a vital and productive life
within the limitations of the heart disease.
Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Mental Health; Priority
166. The nurse is caring for a client who has been diagnosed with schizophrenia. The client is unable to speak, although there is no known
pathological dysfunction. What type of dysfunctional communication is the client experiencing?
 1. Mutism
 2. Verbigeration
 3. Pressured speech
 4. Poverty of speech
Rationale:
Mutism is the absence of verbal speech. The client does not communicate verbally despite an intact physical and structural ability to speak.
Verbigeration is the purposeless repetition of words or phrases. Pressured speech refers to a rapidity of speech that reflects the client's
racing thoughts. Poverty of speech involves diminished amounts of speech or monotonic replies. Stuart (2013), p. 362; Varcarolis (2013), p.
305
Clients with schizophrenia may experience hallucinations. For a client with hallucinations, safety is the first priority; the nurse should
ensure that the client does not have an auditory command telling him or her to harm self or others.
Level of Cognitive Ability: Evaluating; Client Needs: Psychosocial Integrity; Content Area: Pharmacology: Psychiatric Medications; Priority
Concepts: Clinical Judgment, Psychosis
167. A client with a psychotic disorder has been taking an antipsychotic medication. After 6 weeks of therapy with this medication, the client
returns to the health care clinic for follow-up. The nurse documents a therapeutic response when the nurse notes which objective finding?
 1. A tense facial expression
 2. An inability to concentrate
 3. An increase in muscle strength
 4. A well-groomed and neat appearance
43
Rationale:
If the client is taking an antipsychotic medication, the nurse evaluates for a therapeutic response by noting the client's interest in her
surroundings, improvement in self-care, increased ability to concentrate, and a relaxed facial expression. Options 1 and 2 indicate a
response that is not therapeutic. Option 3 is unrelated to the action of this medication. Lehne (2013), p. 349; Varcarolis (2013), p. 320
Inform the client that a full therapeutic effect of an antipsychotic medication may not be evident for 3 to 6 weeks after initiation of therapy;
however, an observable therapeutic response may be apparent after 7 to 10 days.
Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Adult Health: Cardiovascular; Priority
Concepts: Functional Ability, Gas Exchange
168. The nurse is assessing the client with left-sided heart failure. The client states that he needs to use three pillows under the head and upper
torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?
 1. Orthopnea
 2. Dyspnea at rest
 3. Dyspnea on exertion
 4. Paroxysmal nocturnal dyspnea
Rationale:
Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with
the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume
a "three-point" position while upright and use pillows to support the head and upper torso at night. Paroxysmal nocturnal dyspnea is a
severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
Ignatavicius, Workman (2013), pp. 551, 614
Signs of left-sided heart failure are evident in the pulmonary system. Signs of right-sided heart failure are evident in the systemic
circulation.
Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Critical Care: Emergency Situations; Priority
Concepts: Clinical Judgment, Tissue Integrity
169. The ambulatory care nurse has given first aid to a client with a burn on the lower leg. The area is reddened and has weeping blisters present.
What should the nurse document is the depth of the client's burn?
 1. Full thickness
 2. Partial thickness
 3. Deep full thickness
 4. Moderate partial thickness
Rationale:
Partial-thickness burns are bright pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals
on its own, usually within a week. Moderate partial-thickness burns are also reddened but have weeping blisters. A waxy, white color
characterizes full-thickness burns. Full-thickness and deep full-thickness burns are associated with insensitivity to pain and cold.
Ignatavicius, Workman (2013), pp. 514-515
Clients with severe nutritionally deficient conditions such as acquired immunodeficiency syndrome, cancer, burn injuries, malnutrition, or
clients receiving chemotherapy may benefit from total parenteral nutrition.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Fundamental Skills: Diagnostic Tests; Priority
170. The nurse is sending an arterial blood gas (ABG) specimen to the laboratory for analysis. Which pieces of information should the nurse
write on the laboratory requisition? Select all that apply.
 1. Ventilator settings
 2. A list of client allergies
 3. The client's temperature
 4. The date and time the specimen was drawn
 5. Any supplemental oxygen the client is receiving
 6. Extremity from which the specimen was obtained
Rationale:
An ABG requisition usually contains information about the date and time the specimen was drawn, the client's temperature, whether the
specimen was drawn on room air or using supplemental oxygen, and the ventilator settings if the client is on a mechanical ventilator. The
client's allergies and the extremity from which the specimen was drawn do not have a direct bearing on the laboratory results. In some
health care facilities, ABG analysis is done at the bedside. If the client has an arterial catheter, continuous ABG monitoring is possible via
sensor or electrode. Chernecky, Berger (2013), pp. 212-213; Pagana, Pagana (2013), pp. 117-118
An arterial blood gas (ABG) specimen must be placed on ice unless it will be analyzed in less than 1 minute.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Intrapartum; Priority
Concepts: Development, Perfusion
171. A client in labor is at 40 weeks' gestation. The nurse checks the fetal heart rate (FHR) for a baseline rate and tells the client that the baby's
heart rate is within normal limits. Which FHR finding does the nurse then document?
 1. 90 beats per minute
44

Rationale:
The normal fetal heart rate (FHR) ranges from 120 to 160 beats per minute; therefore, option 2 is the only correct option. McKinney et al
(2013), p. 372
To determine the baseline FHR, measure the FHR between contractions.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Adult Health: Respiratory; Priority
172. A client has impaired verbal communication as a result of a temporary tracheostomy following a laryngectomy (radical neck dissection). In
planning for communication with this client, which methods should the nurse use for this particular client? Select all that apply.
 1. Use of a word board
 2. Use of a picture board
 3. Use of a pencil and paper
 4. Use of hand or finger signals
 5. Nodding and shaking the head for yes and no
Rationale:
Following laryngectomy, the client should not be asked to nod or shake the head, because it is painful for the client. The use of eye blink or
hand or finger signals is acceptable. Other helpful methods include the use of a pencil and paper, a word or picture board, flash cards, a
magic slate, or a computer. Ignatavicius, Workman (2013), p. 593
Following laryngectomy, the client is placed in a semi-Fowler's or Fowler's position to maintain a patent airway and minimize edema.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Adult Health: Cardiovascular; Priority
Concepts: Clinical Judgment, Clotting
173. A client has developed thrombophlebitis in the left leg. Which intervention should the nurse document in the client's plan of care while the
client is on bedrest?
 1. Elevating the left leg
 2. Keeping the left leg flat
 3. Engaging in activity as tolerated
 4. Maintaining bathroom privileges
Rationale:
The nurse plans to elevate the affected extremity because this facilitates venous return by using gravity to improve blood return to the heart,
decreases venous pressure, and helps relieve edema and pain. Option 2 does not facilitate venous return and thus is not indicated for a client
with thrombophlebitis. Options 3 and 4 are unsuitable activities for a client on bedrest. Ignatavicius, Workman (2013), p. 800
Thrombophlebitis is an inflammation of a vein, often accompanied by clot formation that can present serious circulatory problems.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Adult Health: Cardiovascular; Priority
Concepts: Clinical Judgment, Perfusion
174. The nurse assesses a client with chronic arterial insufficiency. The client complains of leg pain and cramping after walking three blocks,
which is relieved when the client stops and rests. How should the nurse correctly document this on the client record?
 1. Venous insufficiency
 2. Deep vein thrombosis
 3. Arterial-venous shunting
 4. Intermittent claudication
Rationale:
Intermittent claudication is a classic symptom of peripheral vascular disease, also known by other names, including peripheral arterial
disease and chronic arterial insufficiency. Intermittent claudication is described as a cramp-like pain that occurs with exercise and is
relieved by rest. Intermittent claudication is caused by ischemia and is reproducible; that is, a predictable amount of exercise causes the pain
each time. The data in the question are not characteristic of the conditions noted in options 1, 2, or 3. Ignatavicius, Workman (2013), p. 786
Instruct the client with peripheral arterial disease to inspect the skin on the extremities daily and to report any signs of skin breakdown to
the health care provider.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Adult Health: Neurological; Priority
Concepts: Clinical Judgment, Intracranial Regulation
175. The nurse has a prescription to institute aneurysm precautions for a client with a cerebral aneurysm. Which item should the nurse document
on the plan of care for this client?
 1. Limit out-of-bed activities to twice daily.
 2. Allow the client to read and watch television.
 3. Encourage the client to take his or her own daily bath.
 4. Instruct the client to not strain with bowel movements.
Rationale:
Any activity that increases the blood pressure (BP) or impedes venous flow from the brain is prohibited, such as pushing, pulling, sneezing,
coughing, or straining. The nurse documents that the client is instructed to avoid straining with bowel movements. Aneurysm precautions
usually include placing the client on bedrest in a quiet setting. Lights are kept dim to minimize environmental stimulation. The nurse
45
provides all physical care to minimize increases in the BP. For the same reason, visitors, radio, television, and reading materials are
prohibited or limited. Stimulants such as caffeine and nicotine are also prohibited. Ignatavicius, Workman (2013), pp. 1014-1015
For a cerebral aneurysm, bedrest is maintained with the head of the bed elevated 30 to 45 degrees (semi-Fowler's to Fowler's position) to
prevent pressure on the aneurysm site.
176. The nurse is in the room with a client when a seizure begins. The client's entire body becomes rigid, and the muscles in all four extremities
alternate between relaxation and contraction. Following the seizure, which type of seizure should the nurse document that the client had
experienced?
 1. Partial seizure
 2. Absence seizure
 3. Tonic-clonic seizure
 4. Complex partial seizure
Rationale:
Tonic-clonic seizures are characterized by body rigidity (tonic phase) followed by rhythmic jerky contraction and relaxation of all body
muscles, especially those of the extremities (clonic phase). Absence seizures are characterized by a sudden lapse of consciousness for
approximately 2 to 10 seconds and a blank facial expression. There are two types of complex partial seizures: complex partial seizures with
automatisms and partial seizures evolving into generalized seizures. Complex partial seizures with automatisms include purposeless
repetitive activities such as lip smacking, chewing, or patting the body. Partial seizures evolving into a generalized seizure begin locally and
then spread through the body. Ignatavicius, Workman (2013), p. 932
If a seizure occurs in a client, time the seizure and note the type, character, and progression of the movements during the seizure.
177. The clinic nurse is providing follow-up care to a client with this type of device. The nurse documents that the client is in which
device? Refer to figure.
 1. A halo vest
 2. A hip spica cast
 3. A body jacket cast
 4. Gardner-Wells tongs
Rationale:
The halo vest is used to treat cervical fractures. The halo vest or jacket has a ring that is fixed to the skull with pins. This ring is then
attached to the vest or jacket by rods. This device provides the traction required to maintain cervical alignment and allows early
mobilization and rehabilitation. A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to
one or both lower extremities. A body jacket cast is applied to the upper torso. Skull tong traction involves the use of one of a variety of
tongs (Gardner-Wells, Crutchfield, Vinke, or Barton). These tongs are drilled into the skull or placed below the scalp and attached to ropes,
pulleys, or weights. This type of traction is used for cervical vertebrae fractures and involves the use of special beds or turning frames to
facilitate nursing care. Ignatavicius, Workman (2013), pp. 971-972, 975
For the client with a halo vest, notify the health care provider if redness, swelling, drainage, open areas, pain, tenderness, or a clicking
sound occurs from the pin sites.
178. The nurse notes that a client's eyes are continuously moving back and forth within the eye sockets. What disorder should the nurse
document in the medical record that the client has?
 1. Ataxia
 2. Nystagmus
 3. Pronator drift
 4. Hyperreflexia
Rationale:
Nystagmus is characterized by fine involuntary eye movements. Ataxia is a disturbance in gait. Pronator drift occurs when a client cannot
46
maintain the hands in a supinated position with the arms extended and eyes closed. This assessment technique may be done to detect small
changes in muscle strength that might not otherwise be noted. Hyperreflexia is an excessive reflex action. Ignatavicius, Workman (2013),
pp. 979, 1047
In a gaze nystagmus evaluation, the client's eyes are examined as the client looks straight ahead, 30 degrees to each side, upward and
downward. Any spontaneous nystagmus—an involuntary, rhythmic, rapid twitching of the eyeballs—represents a problem with the
vestibular system.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Adult Health: Musculoskeletal; Priority
Concepts: Clinical Judgment, Mobility
179. The nurse is providing care to a client with this type of cast. Which type of cast applied should the nurse document in client's electronic
health record (EHR)? Refer to figure.
 1. Short leg cast

 2. Long leg cast
 3. Hip spica cast
 4. Body jacket cast
Rationale:
A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If
only one lower extremity is included, it is called a single hip spica; if two are included, it is called a double hip spica. Short and long leg
casts are applied to the leg. A body jacket cast is applied to the upper torso. Lewis et al (2014), p. 1516
If a hip spica cast is placed, the cast edges around the perineum and buttocks may need to be covered with waterproof tape.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Critical Care: Medications and Intravenous
Therapy; Priority Concepts: Clinical Judgment, Tissue Integrity
180. The nurse assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, swollen, and not infusing. Which condition
should the nurse document?
 1. Phlebitis
 2. Infection
 3. Infiltration
 4. Thrombosis
Rationale:
The infusion stops when the pressure in the tissue exceeds the pressure in the tubing. The pallor, coolness, and swelling of the IV site are
the result of IV fluid infusing into the subcutaneous tissue. An IV site is infiltrated when it becomes dislodged from the vein and is lying in
subcutaneous tissue, so the nurse concludes that the IV is infiltrated. The nurse needs to remove the infiltrated catheter and insert a new IV.
All the remaining options are likely to be accompanied by warmth at the site. Options 1 and 2 also involve the site appearance as reddened.
Ignatavicius, Workman (2013), p. 228
Insert an infusion catheter at a distal site to provide the option of proceeding up the extremity if the vein is ruptured or infiltration occurs;
for example, if infiltration occurs from the antecubital vein, the lower veins in the same arm usually cannot be used for further puncture
sites.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Mental Health; Priority Concepts: Clinical
Judgment, Safety
181. The nurse employed in a mental health unit is caring for a client who has been placed in seclusion. The nurse is documenting care provided
to the client and addresses which items in the client's record?
 1. Vital signs, reason for the procedure, and date and time
 2. Vital signs, toileting, and checking the client based on protocol time frame, such as every 15 minutes
 3. Ambulating, toileting, and checking the client based on protocol time frame, such as every 15 minutes
 4. Vital signs, toileting, feeding and fluid intake, and checking the client based on protocol time frame, such as every 15 minutes
47
Rationale:
The client in seclusion is assessed continuously or at least every 15 minutes, or according to agency protocol. Vital signs, toileting needs,
and food and fluid intake are assessed. Option 1 contains client documentation that would precede seclusion. Options 2 and 3 are not
complete in terms of identification of physiological needs. Varcarolis (2013), pp. 85-86
The client in seclusion needs constant one-to-one supervision.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Mental Health; Priority
182. A client who is experiencing paranoid thinking involving his food being poisoned is admitted to the mental health unit. Which
communication technique should the nurse use to encourage the client to communicate his fears?
 1. Open-ended questions and silence
 2. Offering personal opinions about the need to eat
 3. Verbalizing reasons why the client may choose not to eat
 4. Focusing on self-disclosure of the nurse's own food preferences
Rationale:
Open-ended questions and silence are strategies that are used to encourage clients to discuss their feelings in a descriptive manner. Options
2 and 3 are not helpful to the client because they do not encourage the expression of personal feelings. Option 4 is not a client-centered
intervention. Fortinash, Holoday-Worret (2012), pp. 71-74; Varcarolis, Halter (2013), pp. 120-123
Avoid whispering in the presence of a client who is paranoid because this will intensify his or her feelings of paranoia.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Mental Health; Priority Concepts: Mood and
Affect, Safety
183. A nursing student says to the psychiatric nurse, "Now that the client is responding to the antidepressant, the suicidal risk is over." After
analyzing this statement, how should the psychiatric nurse respond?
 1. "I disagree. Your comment reflects a lack of knowledge that this disease runs in families."
 2. "I agree. Clients who want to kill themselves are only suicidal for a limited time. No one can feel self-destructive forever."
 3. "I agree. The suicidal threats were really attention-seeking. Continuing to provide attention would reinforce the client's use of
manipulation."
 4. "I disagree. Suicides occur within about 3 months after improvement begins because the client now has the energy to carry
out the suicidal intentions."
Rationale:
The facts presented by the psychiatric nurse in the correct option are accurate. Most suicides do occur within 3 months after the beginning
of the improvement when the client has the energy to carry out the suicidal intentions. It is critical to assess for the continuation of suicidal
ideation. Options 1, 2, and 3 are inaccurate statements. Stuart (2013), p. 337
It is critical for the nurse to assess a client's suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm
exists.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Pharmacology: Respiratory Medications; Priority
184. A client states to the nurse, "My urine has turned red-orange since I started taking this rifampin (Rifadin). Should I stop taking it?" Which
 1. "You are correct to report this happening because this medication discolors your urine and the condition can be harmful, so
you must stop this medication immediately."
 2. "You are correct to report this happening, but this medication can discolor your urine, and this is not harmful. It will
disappear if this medication should be discontinued."
 3. "This is not an important side effect, and you don't need to worry about such a small occurrence. Please concentrate on the
serious ones I have written down for you."
 4. "This never happens with the administration of this medication. Perhaps it is a result of interacting with another medication
you have been taking. I'll check immediately with your health care provider."
Rationale:
Rifampin is an antitubercular medication and can cause the client's urine to turn a harmless red-orange. This condition disappears when the
medication is discontinued. Options 1, 3, and 4 are inappropriate and nontherapeutic nursing responses to the client. Lehne (2013), pp.
1123-1124; Stuart (2013), pp. 25-29
Rifampin (Rifadin) should be used with caution in clients with hepatic dysfunction or alcoholism because of the risk of hepatoxicity.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Pharmacology: Psychiatric Medications; Priority
Concepts: Anxiety, Mood and Affect
185. Immediately after taking a routine evening dose of alprazolam (Xanax), a client says, "I'm not sure I should have taken that stuff." Which
appropriate statement should the nurse make to the client?
 1. "Anxiety is expected with any new experience."
 2. "You are afraid of the media claims about this medication."
 3. "Your depression will fade once the medication begins to work."
 4. "Let's talk about how you feel about alprazolam (Xanax) for a while."
Rationale:
The nurse should focus on determining the reason for the client's concern. Cliché responses (option 1) do not express concern. The nurse
48
would add anxiety to the client by mentioning media concerns. Alprazolam (Xanax) is used to treat anxiety, not depression. Hodgson,
Kizior (2014), p. 38; Potter et al (2013), pp. 320-322
Use therapeutic communication techniques instead of clichés when communicating with the client.
Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Adult Health: Neurological; Priority
Concepts: Clinical Judgment, Fluid and Electrolyte Balance
186. Immediately after taking a routine evening dose of alprazolam (Xanax), a client says, "I'm not sure I should have taken that stuff." Which
appropriate statement should the nurse make to the client?
 1. Positive Cullen's sign

 2. Positive Babinski's reflex
 3. Positive Chvostek's sign
 4. Positive Trousseau's sign
Rationale:
Chvostek's sign and Trousseau's sign may be elicited in hypocalcemic clients. Tapping at the level of the facial nerve may result in
ipsilateral twitching of the eye, cheek, and lip, and this is called Chvostek's sign. Cullen's sign is ecchymosis around the umbilicus.
Babinski's reflex may be elicited when the sole of the foot is stroked. Trousseau's sign refers to carpopedal spasm that is induced by
inflating a blood pressure cuff on the hypocalcemic client's arm. Lewis et al (2014), pp. 300, 1144
Monitor cardiovascular, respiratory, neuromuscular, and gastrointestinal status for the client with hypocalcemia, and place the client on a
cardiac monitor when appropriate.
Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Adult Health: Oncology; Priority
187. The nurse is caring for a client who had a laryngectomy for laryngeal cancer. The client will be using an artificial larynx, and the nurse has
provided instructions to the client and client's wife regarding the use of the device. Which statement by the client's wife indicates an
understanding of the use of the artificial larynx?
 1. "He will need to place the device into his tracheostomy."
 2. "He will need to swallow air in order for the device to work."
 3. "He will need to hold the device along the side of his neck to speak."
 4. "He will need to speak into the device like a microphone to make it work."
Rationale:
The artificial larynx is an electronic device that assists the client after laryngectomy to produce speech. There are 2 types; one is held at the
side of the neck and the other is inserted into the mouth. The vibration produces a mechanical-sounding speech that is monotone in quality
but is intelligible. Options 1, 2, and 4 are incorrect. Lewis et al (2014), pp. 516-517
For the client who has undergone a laryngectomy, place the client in a semi-Fowler's or Fowler's position to maintain a patent airway and
minimize edema.
49

Integrated Process - Communication and Documentation

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Integrated Process - Communication and Documentation

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INTEGRATED PROCESS: Communication and Documentation

 1. "I gave the wrong dose of the medication."

Priority Nursing Tip:

Priority Nursing Tip:

Priority Nursing Tip:

Priority Nursing Tip:

 1. "This is a common occurrence in older adults. No need to worry."

 3. "You'll feel better in the morning."

Priority Nursing Tip:

Priority Nursing Tip:

 2. "What is the television saying?"

 2. "Tell me what you mean by that."

 4. 200 beats per minute

 1. Short leg cast

 1. Positive Cullen's sign

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