A teenaged client is discharged from the hospital after surgery with i

Communication and Documentation

Home / Nursing & Allied Health Certifications / NCLEX RN / Nursing Process

Question 1 of 5.

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?

A. How do you feel about needing a cane to walk?'

B. Do you have questions about ambulating with a cane?'

C. Are you worried about what your friends will think about your cane?'

D. What types of problems do you think you'll have ambulating with a cane?'

Explanation: 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, and options 2 and 4 focus on the physical aspects of using the cane.

Question 2 of 5.

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?

A. The nurse and client determine the contract for time.

B. The client is encouraged to make use of all services depending on need.

C. The client begins to identify with the nurse, and trust and rapport are maintained.

D. The nurse focuses on facilitating the therapeutic expression of the client's feelings.

Explanation: In the orientation (introductory phase) of the therapeutic nurse-client relationship, the client and nurse meet and determine the contract for 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.

Question 3 of 5.

The partner of a client who has an esophageal tube introduced for a second time tells the nurse, 'I thought having this tube down the nose the first time would convince anyone to quit drinking.' Which response to the statement should the nurse make?

A. I think you are a good person to stay with her.'

B. Alcoholism is a disease that affects the whole family.'

C. Have you discussed this subject at the Al-Anon meetings?'

D. You sound frustrated dealing with such a drinking problem.'

Explanation: 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, stereotyping, and changing the subject are nontherapeutic techniques that block communication.

Question 4 of 5.

The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?

A. Do you have concerns about managing your condition?'

B. Do you think you might need to go to the nursing home?'

C. If you take the correct medications, I doubt this will happen again.'

D. Don't worry. I'm sure your family will provide all the help you need.'

Explanation: The nurse should provide time and listen to the client's concerns while attempting to clarify the client's feelings as in the correct option. Option 2 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.

Question 5 of 5.

The nurse assesses the client's peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document?

A. Phlebitis

B. Infection

C. Infiltration

D. Thrombosis

Explanation: 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.