NUR2101 Exam 2 Review

Exam 2 Exam Review

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Question 1

Question 1 - Rationale

Correct Answer

The nurse should establish eye contact and maintain during active listening. It demonstrates interest in what the client is saying.

• Focus on the speaker
• Use open-ended questions

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Question 2

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make?

Question 2 - Rationale

Correct Answer

“I decline the opportunity at this time.” This is assertive form of communication because it contains “I” statement and is clear and firm.

• Aggressive – Uses “you” statements, verbally abusive, controlling.
• Assertive – Honest and clear communication, advocates for self, uses “I”.
• Passive – Avoids conflict, anxious, hesitates to stand up for self.
• Passive – aggressive – Acts out anger in indirect ways, feels powerless and resentful, sarcastic.

Question 2 - Rationale

Incorrect Answers

“It’s just not the right time for me to do this.” This statement shifts the responsibility back onto those who offered the nurse the opportunity to chair the committee, and it could make them react defensively. “Everyone knows there are others who can chair this committee better than me.” This statement express self-doubt and reluctance, not assertiveness, and it does not clearly express the nurse’s thoughts about declining to chair a committee. “Can you tell me why you chose me?” This statement changes the subject and does not clearly express the nurse’s thoughts about declining a chair committee.

Question 3

A nurse is assessing a client who came to the ER reporting chest pain. The client tells the nurse that they have hearing loss and forgot to bring their hearing aids with them. Which of the following actions should the nurse take to improve communication with the client?

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Question 3 - Rationale

Correct Answers

Move the client to a quiet area or private room The nurse should reduce environmental noise as much as possible to enhance communication with this client. Speak at a slower pace is correct. Speaking at a slower pace might help the client to be able to better understand and communicate with the nurse. Speak at a slower pace Speaking at a slower pace might help the client to be able to better understand and communicate with the nurse. Avoid using medical terminology The nurse should avoid using medical terminology. These words are unfamiliar and can impede communication with all clients. Strategies for visually impaired:

• Use clock when identifying where items are placed.
• Identify self when entering and before doing any procedures.
• Let client know when leaving.
• Have materials printed in large print.

Strategies for hearing impaired:

• Speak into “good” ear or talk on the “good” side.
• Stand in front of client (They may read lips).
• Speak clearly and slowly.

Question 3 - Rationale

Incorrect Answers

Delay the assessment until the client's family member brings the hearing aid The nurse needs to prioritize the assessment of a client who reports chest pain. Chest pain can be a manifestation of a myocardial infarction. The nurse should not wait till the client has their hearing aid. The nurse needs to implement other strategies while waiting for the family to bring the hearing aid. Have a sign language interpreter translate the communication with the client Not all clients who have hearing loss know or communicate with sign language. Stand next to the client when talking The nurse should stand in front of the client when they are talking.

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Question 4

Question 4 - Rationale

Correct Answer

Performing hand hygiene before, during, and after direct contact with the client The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after patient care procedures.

Question 4 - Rationale

Incorrect Answers

Changing the client's bed linens each day While changing linens helps maintain a clean environment, it does not stop the transmission of infection. Encouraging the client to consume a high-protein diet A diet high in protein can help the patient fight the infection, but it does not prevent its transmission. Placing the client in a room with positive-pressure airflow Placing the patient in a positive pressure airflow room will not prevent the transmission of infection. Positive-pressure airflow keeps pathogens from entering the patient’s room. This is a strategy for patients who have immune-system compromise. Types of Transmission based precautions:

• Airborne: (TB) – negative pressure, N95 mask
• Droplet: (Flu) – surgical mask
• Contact: (MRSA, VRE, C-Diff) – gown
• Standard precautions – use for everyone.

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Question 5

Question 5 - Rationale

Correct Answer

“The client was lying on the floor next to his bed.” In an incident report, the nurse should only document what she actually witnessed, along with the date, time, place, and any other actual facts about the incident.

Question 5 - Rationale

Incorrect Answers

“The client attempted to climb over the side rails and fell.” Speculation about actions the nurse did not witness is not part of an incident report. “The client was restless and trying to get out of bed all evening.” Speculation or information about the client’s previous behavior is not part of an incident report. . “The presence of a bed alarm could have prevented the client from falling.” Information about preventive measures is not part of an incident report. The facility’s risk managers can later determine procedures to implement to prevent such incidents in the future.

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Question 6

Question 6 - Rationale

Correct Answer

Psychomotor Learning Deals with skills. For a psychomotor skill to be acquired, the patient needs to have the knowledge, physical ability, and attitude to learn the skills. Examples include insulin administration and blood sugar testing.

Question 6 - Rationale

Incorrect Answers

Affective Learning Learning includes a patient’s feelings, attitudes, opinions, and values. Includes active listening and responding with a consistent value system. Examples include discussion and role play. Cognitive Learning Learning includes what the patient knows and understands. The cognitive domain includes acquisition of knowledge, comprehension, or ability to understand, application, analysis, synthesis, and evaluation. Motivational Learning Learning because there is a need to learn something.

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Question 7

Question 7 - Rationale

Correct Answer

Move any clients in the immediate area. Remember RACE

• Rescue
• Activate
• Contain
• Extinquish

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Question 8

Question 8 - Rationale

Correct Answer

Move any clients in the immediate area Fall prevention strategies:

• Movement/ bed alarm
• Non-skid shoes/ grippy socks
• Clearing clutter from floors/ trip hazards
• Bed in low position/ wheels locked

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Question 9

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Question 10

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Question 11

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Question 12

Question 12 - Rationale

Correct Answers

Determine if the client feels dizzy Feeling dizzy is a subjective response to orthostatic hypotension. Obtaining feedback from the client provides a quick evaluation of the client's tolerance of the transfer.

Question 12 - Rationale

Incorrect Answers

Obtain a blood pressure Although a blood pressure reading may indicate the presence of hypotension, the blood pressure should be obtained before and after a transfer to allow a comparison to conclude that hypotension is orthostatic hypotension. Monitor for bradycardia If the patient is experiencing orthostatic hypotension, the heart rate will increase and not decrease. Allow the client to adjust to the change in position This is not an assessment. This is a safe intervention for a client who is experiencing orthostatic hypotension.

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Question 13

Question 13 - Rationale

Correct Answers

Post a turning schedule at Mr. Roger's bedside A turning schedule will help ensure Mr. Rogers is repositioned in a timely manner which will help prevent skin breakdown.

Question 13 - Rationale

Incorrect Answers

Reposition Mr. Rogers at least twice every shift Repositioning should occur at least every 2 hours. Vigorously massage the bony prominences to induce blood flow Vigorous massage should be avoided because it may damage capillaries. Log roll Mr. Rogers when turning Log rolling Mr. Rogers is not necessary and will not prevent pressure ulcers.

• How often should we turn clients? (2 hours)
• Pad bony prominences (Sacrum, heels, shoulder blades)

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Question 14

Question 14 - Rationale

Correct Answers

Encouraging the client to perform the exercises independently Active range-of-motion exercises require the client to complete the exercises independently. Active range-of-motion exercises require muscle contraction that eventually improves muscle strength.

Question 14 - Rationale

Incorrect Answers

Assisting the client who is able to complete the exercise through all planes of movement When a client needs assistance to complete these exercises it is called active assistive range-of-motion exercises, not active range-of-motion exercises. Providing a warm bath before the exercises Although a warm bath may relax the client, reducing stiffness, it is not a required or unique action associated with implementing range-of-motion exercises. Demonstrating how to do the exercises This is not unique to providing active range-of-motion exercises. Explaining what is to be done and why should be implemented before providing all nursing care.