Which assessment finding is the most critical and needs to be addressed first?

Questions 52

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Communication in Nursing Practice Questions Questions

Question 1 of 9

Which assessment finding is the most critical and needs to be addressed first?

Correct Answer: A

Rationale: The correct answer is A because tracheal deviation after a pulmonary resection indicates a life-threatening condition like tension pneumothorax. This condition requires immediate intervention to prevent respiratory distress and potential cardiovascular collapse. Tracheal deviation is a red flag sign that signals a medical emergency. Options B, C, and D are important but not as urgent as tracheal deviation. Decreased urinary output in a bladder cancer patient could indicate renal dysfunction, dysrhythmias in a patient with non-Hodgkin lymphoma may need further evaluation, and severe abdominal pain post-bowel resection could signal complications but are not as immediately life-threatening as tracheal deviation.

Question 2 of 9

The nurse plans to delegate a client's personal hygiene to a nursing assistant. Which statement if made by the nurse to the nursing assistant is assertive?

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. The statement in choice C is assertive because it clearly states the task, timeline, and expectation without being aggressive or demeaning. 2. It communicates the need for assistance with the client's bath and sets a clear priority. 3. It provides a specific instruction for the nursing assistant to assist the client immediately and then take a break. 4. This approach demonstrates effective delegation and ensures the client's needs are met promptly and respectfully. Summary: A: This choice is not assertive as it presents a conditional statement and implies a personal sacrifice by the nurse if the task is not completed. B: This choice is aggressive and threatening, which is not appropriate in a professional setting. D: This choice is directive but lacks consideration for the nursing assistant's well-being and does not communicate the urgency of the task for the client.

Question 3 of 9

Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?

Correct Answer: A

Rationale: Step-by-step rationale for the correct answer, A: 1. Monitoring the access site during administration allows for early detection of extravasation. 2. Early detection can prevent serious tissue damage and complications. 3. As Mr. L has a tracheostomy and partial laryngectomy, his airway is compromised, making prevention of extravasation crucial. 4. This action is within the nurse's scope of practice and promotes patient safety. Summary: - Choice B is incorrect as delaying treatment can impact Mr. L's health. - Choice C is not directly related to preventing extravasation. - Choice D, though important, does not directly address preventing extravasation during administration.

Question 4 of 9

The nurse discusses smoking cessation with a client. Which action, if taken by the nurse, would most likely result in a behavior change?

Correct Answer: C

Rationale: The correct answer is C: The nurse should collaborate with the client to develop an individualized plan of action. This is the most likely action to result in a behavior change because it involves actively involving the client in the process, taking into account their unique needs, preferences, and circumstances. By collaborating with the client, the nurse can tailor the smoking cessation plan to be more personalized and therefore more effective. Choice A (contact the national telephone quitline) may be helpful but lacks individualization. Choice B (recommend nicotine replacement and behavioral interventions) is a good approach but may not address the client's specific needs. Choice D (implement a strategy validated by research) is important but may not be as effective if it does not consider the client's individual factors. Overall, choice C is the best option as it promotes client engagement and customization for a higher chance of successful behavior change.

Question 5 of 9

When a patient states, "My son hasn't been to see me in months," the nurse's best verbal response is:

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Reflective listening: Restating the patient's statement shows empathy and understanding. 2. Open-ended question: Encourages patient to share more without assumptions. 3. Non-judgmental: Neutral tone promotes trust and openness. 4. Validates patient's feelings: Acknowledges patient's concerns without dismissing them. Summary: A: Provides false reassurance, does not address the patient's feelings. C: Shifts focus to the nurse, not patient-centered. D: Implies judgment, may shut down communication.

Question 6 of 9

Which are examples of a nurse who is communicating responsibly? (Select all that apply)

Correct Answer: B

Rationale: The correct answer is B because helping a client communicate about discontinuing chemotherapy shows responsible communication. This action respects the client's autonomy and involves them in decision-making. This choice prioritizes the client's well-being and supports open and honest communication. Incorrect choices: A: Using profanity is unprofessional and disrespectful, violating ethical standards. C: While using interpersonal strategies to help a client cope is important, it doesn't specifically address responsible communication. D: Sharing a client's health information without consent breaches confidentiality and violates privacy rights.

Question 7 of 9

A Hispanic patient approaches the Asian nurse and, standing very close, touches the nurse's shoulder during their conversation. The nurse begins to step back to 18 to 24 inches, while smiling and nodding to the patient. This situation is most likely an example of:

Correct Answer: D

Rationale: The correct answer is D: a difference in culturally learned personal space of the nurse and the patient. This is because different cultures have varying norms regarding personal space. In this scenario, the Hispanic patient touching the Asian nurse's shoulder and standing very close suggests a cultural difference in personal space expectations. The nurse stepping back to establish a distance of 18 to 24 inches is a respectful response to accommodate the patient's cultural norm. It demonstrates cultural competence and understanding. Explanation for why the other choices are incorrect: A: the nurse's need to maintain a professional role rather than a social role - This choice does not address the cultural aspect of personal space and assumes the nurse's response is solely professional. B: a patient's attempt to keep the nurse's attention - This choice does not consider the cultural factor influencing the patient's behavior. C: a nurse's need to establish a more appropriate location for conversation - This choice does not acknowledge the cultural difference in personal space as the primary reason for the nurse

Question 8 of 9

The nurse greets a patient who is admitted to the hospital. Which action by the nurse displays warmth and concern?

Correct Answer: A

Rationale: The correct answer is A because using a soft and relaxed tone of voice conveys warmth and concern, making the patient feel welcomed and cared for. It helps build rapport and comfort. Maintaining a distance of 6 to 8 feet (B) may create a sense of coldness and detachment. Avoiding attentive behaviors (C) will make the patient feel neglected and uncared for. Engaging in verbal exchange without physical contact (D) lacks the personal touch needed to show warmth and concern.

Question 9 of 9

Which assessment finding is the most critical and needs to be addressed first?

Correct Answer: A

Rationale: The correct answer is A because tracheal deviation after a pulmonary resection indicates a life-threatening condition like tension pneumothorax. This condition requires immediate intervention to prevent respiratory distress and potential cardiovascular collapse. Tracheal deviation is a red flag sign that signals a medical emergency. Options B, C, and D are important but not as urgent as tracheal deviation. Decreased urinary output in a bladder cancer patient could indicate renal dysfunction, dysrhythmias in a patient with non-Hodgkin lymphoma may need further evaluation, and severe abdominal pain post-bowel resection could signal complications but are not as immediately life-threatening as tracheal deviation.

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