NCLEX-RN
Communication and Documentation Questions
Extract:
Question 1 of 5
A client diagnosed with delirium anxiously states, 'Look at the spiders on the wall.' Which response by the nurse addresses the client's concerns therapeutically?
Correct Answer: C
Rationale: When hallucinations are present, the nurse should reinforce reality with the client while acknowledging the client's feelings as the correct option does. Eliminate options 1, 2, and 4 because they do not reinforce reality but rather support the legitimacy of the hallucination or that reinforces reality but does not address the client's feelings.
Question 2 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?
Correct Answer: C
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.
Question 3 of 5
A client has been using crutches to ambulate for 1 week and now 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'?
Correct Answer: A
Rationale: The correct option 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.
Question 4 of 5
A client who is experiencing paranoid thinking involving 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?
Correct Answer: A
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.
Question 5 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?
Correct Answer: D
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, stereotyping, and changing the subject are nontherapeutic techniques that block communication.