NCLEX-RN
Communication and Documentation Questions
Extract:
Question 1 of 5
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?
Correct Answer: D
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 primary health care provider can guarantee that a heart attack will not occur as option 3 seems to indicate.
Question 2 of 5
The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?
Correct Answer: A
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 bed rest.
Question 3 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?
Correct Answer: A
Rationale: 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 4 of 5
After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client's need to ambulate?
Correct Answer: A
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. Although 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.
Question 5 of 5
When responding to the call bell, the nurse finds the client lying on the floor beside the bed. After a thorough assessment and appropriate care, the nurse completes an incident report. How should the incident be described in the report?
Correct Answer: C
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. The correct option is the only option that describes the facts as observed by the nurse. All the remaining options are interpretations of the situation and are not factual data as observed by the nurse.