TEST BANK for Arnold & Boggs Interpersonal Relationships 1st Edition by Mallette, Yonge, Arnold & Bo

TEST BANK

TEST BANK

Part I: Theoretical Foundations and Contemporary Dynamics in Person-Centred Relationships and Communication Chapter

1. Historical Perspectives and Contemporary Dynamics

Chapter

2. Clarity and Safety in Communication

Chapter

3. Professional Guides for Nursing Communication

Chapter

4. Clinical Judgement: Critical Thinking and Ethical Decision Making

Part II: Essential Communication Competencies Chapter

5. Developing Person-Centred Communication Skills

Chapter

6. Variation in Communication Styles

Chapter

7. Cultural Contexts and Communication

Chapter 8. Engaging With Humility: Authentic Interpersonal Communication in Partnership: With Indigenous Peoples Chapter

9. Communicating in Groups

Part III: Relationship Skills in Health Communication Chapter

10. Self-Concept in Professional Interpersonal Relationships

Chapter

11. Developing Person-Centred Therapeutic Relationships

Chapter

12. Bridges and Barriers in Therapeutic Relationships

Chapter

13. Communicating With Families

Part IV: Communication for Health Promotion and Disease Prevention Chapter

14. Resolving Conflicts Between Nurse and People Receiving Care

Chapter

15. Communication Strategies for Health Promotion and Disease Prevention

Chapter

16. Communication in Health Teaching and Coaching

Chapter

17. Communication in Stressful Situations

Part V: Accommodating People With Special Communication Needs Chapter

18. Communicating With People With Communication Disorders

Chapter

19. Communicating With Children

Chapter

20. Communicating With Older People

Chapter

21. Communicating With People in Crisis

Chapter

22. Communication Approaches in Palliative Care

Part VI: Collaborative Professional Communication Chapter

23. Role Relationship Communication Within Nursing

Chapter

24. Interprofessional Communication

Chapter

25. Communicating for Continuity of Care

Chapter

26. e-Documentation in Health Information Technology Systems

Chapter

27. Digital Health and Communication Technology

MULTIPLE CHOICE

9. When describing nursing to a group of nursing students, the nursing instructor lists all of the following characteristics of nursing except a. historically nursing is as old as mankind. b. nursing was originally practiced informally by religious orders dedicated to care of the sick. c. nursing was later practiced in the home by female caregivers with no formal education. d. nursing has always been identifiable as a distinct occupation.

ANS: A

Historically, nursing is as old as mankind. Originally practiced informally by religious orders dedicated to care of the sick and later in the home by female caregivers with no formal education, nursing was not identifiable as a distinct occupation until the 1854 Crimean war.

There, Florence Nightingale’s Notes on Nursing introduced the world to the functional roles of professional nursing and the need for formal education.

DIF: Cognitive Level: Comprehension REF: p. 1 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

10. The nursing profession’s first nurse researcher, who served as an early advocate for high-quality care and used statistical data to document the need for handwashing in preventing infection, was a. Abraham Maslow. b. Martha Rogers. c. Hildegard Peplau. d. Florence Nightingale.

ANS: D

An early advocate for high-quality care, Florence Nightingale’s use of statistical data to document the need for handwashing in preventing infection marks her as the profession’s first nurse researcher.

DIF: Cognitive Level: Knowledge REF: p. 1 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

11. Today, professional nursing education begins at the a. undergraduate level. b. graduate level. c. advanced practice level. d. administrative level.

ANS: A

Today, professional nursing education begins at the undergraduate level, with a growing number of nurses choosing graduate studies to support differentiated practice roles and/or research opportunities. Nurses are prepared to function as advanced practice nurse practitioners, administrators, and educators.

DIF: Cognitive Level: Comprehension REF: p. 2 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

12. Nursing’s metaparadigm, or worldview, distinguishes the nursing profession from other disciplines and emphasizes its unique functional characteristics. The four key concepts that form the foundation for all nursing theories are a. caring, compassion, health promotion, and education. b. respect, integrity, honesty, and advocacy. c. person, environment, health, and nursing. d. nursing, teaching, caring, and health promotion.

ANS: C

Individual nursing theories represent different interpretations of the phenomenon of nursing, but central constructs—person, environment, health, and nursing—are found in all theories and models. They are referred to as nursing’s metaparadigm.

DIF: Cognitive Level: Knowledge REF: p. 2 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

13. When admitting a client to the medical-surgical unit, the nurse asks the client about cultural issues. The nurse is demonstrating use of the concept of a. person. b. environment. c. health. d. nursing.

ANS: B

The concept of environment includes all cultural, developmental, and social determinants that influence a client’s health perceptions and behavior. A person is defined as the recipient of nursing care, having unique bio-psycho-social and spiritual dimensions. The word health derives from the word whole. Health is a multidimensional concept, having physical, psychological, sociocultural, developmental, and spiritual characteristics. The World Health Organization (WHO, 1946) defines health as “a state of complete physical, mental, social well-being, not merely the absence of disease or infirmity.” Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people.

DIF: Cognitive Level: Application REF: p. 3 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

14. A young mother tells the nurse, “I’m worried because my son needs a blood transfusion. I don’t know what to do, because blood transfusions cause AIDS.” Which central nursing construct is represented in this situation? a. Environment

b. Caring c. Health d. Person ANS: D

The concept of environment includes all cultural, developmental, and social determinants that influence a client’s health perceptions and behavior. Caring is not one of the four central nursing constructs. The word health derives from the word whole. Health is a multidimensional concept, having physical, psychological, sociocultural, developmental, and spiritual characteristics. The World Health Organization (WHO, 1946) defines health as “a state of complete physical, mental, social well-being, not merely the absence of disease or infirmity.” Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Person is defined as the recipient of nursing care, having unique bio-psycho-social and spiritual dimensions.

DIF: Cognitive Level: Application REF: p. 2 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

15. The nurse performs a dressing change using sterile technique. This is an example of which pattern of knowledge? a. Empirical b. Personal c. Aesthetic d. Ethical ANS: A

Empirical knowledge is the scientific rationale for skilled nursing interventions. Personal ways of knowing allow the nurse to understand and treat each individual as a unique person.

Aesthetic ways of knowing allow the nurse to connect in different and more meaningful ways.

Ethical ways of knowing refer to the moral aspects of nursing.

DIF: Cognitive Level: Comprehension REF: p. 5 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care

16. The nurse-client relationship as described by Hildegard Peplau a. would not be useful in a short-stay unit. b. allows personal and social growth to occur only for the client. c. facilitates the identification and accomplishment of therapeutic goals. d. focuses on maintaining a personal relationship between the nurse and client.

ANS: C

Hildegard Peplau offers the best-known nursing model for the study of interpersonal relationships in health care. Her model describes how the nurse-client relationship can facilitate the identification and accomplishment of therapeutic goals to enhance client and family well-being. In contemporary practice, Peplau’s framework is more applicable today in longer term relationships, and in settings such as rehabilitation centers, long-term care, and nursing homes. Despite the brevity of the alliances in acute care settings, basic principles of being a participant observer in the relationship, building rapport, developing a working partnership, and terminating a relationship remain relevant.

DIF: Cognitive Level: Knowledge REF: p. 10 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

17. The identification phase of the nurse-client relationship a. sets the stage for the rest of the relationship. b. correlates with the assessment phase of the nursing process. c. focuses on therapeutic goals to enhance client and family well-being. d. uses community resources to help resolve health care issues.

ANS: C

Hildegard Peplau offers the best-known nursing model for the study of interpersonal relationships in health care. Her model describes how the nurse-client relationship can facilitate the identification and accomplishment of therapeutic goals to enhance client and family well-being.

DIF: Cognitive Level: Knowledge REF: p. 10 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care

18. Abraham Maslow's needs theory is a framework that a. begins with meeting basic psychosocial needs first. b. ensures essential needs are satisfied, then people move into higher physiological areas of development. c. proposes that people are motivated to meet their needs in a descending order. d. nurses use to prioritize client needs and develop relevant nursing approaches.

ANS: D

Abraham Maslow's needs theory is a framework that nurses use to prioritize client needs and develop relevant nursing approaches. Maslow's model proposes that people are motivated to meet their needs in an ascending order beginning with meeting basic survival needs. As essential needs are satisfied, people move into higher psychosocial areas of development.

DIF: Cognitive Level: Application REF: p. 10 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

19. Which of the following statements about communication theory is true? a. Primates are able to learn new languages to share ideas and feelings. b. Concepts include only verbal communication. c. Perceptions are clarified through feedback. d. Past experience does not influence communication.

ANS: C

Feedback is the only way to know that one’s perceptions about meanings are valid. Human communication is unique. Only human beings have large vocabularies and are capable of learning new languages as a means of sharing their ideas and feelings. Communication includes language, gestures, and symbols to convey intended meaning, exchange ideas and feelings, and to share significant life experience. To encode a message appropriately requires a clear understanding of the receiver’s mental frame of reference (e.g., feelings, personal agendas, past experiences) and knowledge of its purpose or intent of the communication.

DIF: Cognitive Level: Knowledge REF: p. 7 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

20. In the circular transactional model of communication, a. questions are framed in order to recognize the context of the message. b. people take only complementary roles in the communication. c. the context of the communication is unimportant. d. the purpose of communication is to influence the receiver.

ANS: A

A circular model expands linear models to include the context of the communication, feedback loops, and validation. With this model, the sender and receiver construct a mental picture of the other, which influences the message and includes perceptions of the other person’s attitude and potential reaction to the message.

DIF: Cognitive Level: Comprehension REF: p. 8 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

21. The nurse recognizes that feedback loops a. do not allow for correction of original information. b. are solely based on the General Systems Theory. c. do not allow for validation of information. d. allow the human system to correct its original information.

ANS: D

Feedback (from the receiver or the environment) allows the system to correct or maintain its original information. Feedback loops (from the receiver, or the environment) validate the information, or allow the human system to correct its original information. General Systems Theory, initially described by Ludwig von Bertalanffy (1968), focuses on process and interconnected relationships comprising the “whole.”

DIF: Cognitive Level: Knowledge REF: p. 8 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

22. Which of the following statements best represents therapeutic communication when a student discovers a client crying in bed? a. “I am the nurse who will be doing your treatments today.” b. “Will you listen to me so I can help you get better?” c. “This is what is going to happen during surgery.” d. “Can we talk about what seems to be bothering you?”

ANS: D

Asking about what is bothering the client is goal directed. Its purpose is to promote client well-being. “I am the nurse who will be doing your treatments today” is a statement of fact, and it ignores the client’s emotional needs. “Will you listen to me so I can help you get better?” is not goal directed and does not involve mutuality. “This is what is going to happen during surgery” is simply one way. It does not engage the client in a therapeutic manner.

DIF: Cognitive Level: Application REF: p. 10 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

23. The central constructs of person, environment, health, and nursing are found in all nursing theories and models and are referred to as a. telehealth. b. the medical model. c. nursing’s metaparadigm. d. five core areas of competency.

ANS: C

Individual nursing theories represent different interpretations of the phenomenon of nursing, but central constructs—person, environment, health, and nursing—are found in all theories and models. They are referred to as nursing’s metaparadigm. These constructs are the “metalanguage” of nursing, and together they act as basic building blocks for the discipline of professional nursing. Telehealth is fast becoming an integral part of the health care system, used both as a live interactive mechanism (particularly in remote areas, where there is a scarcity of health care providers) and as a way to track clinical data. Two important outcomes are reduced health costs and increased access to care. During the last century, the bulk of professional care was delivered in acute care settings, based on the disease-focused medical model. Switching to today’s community focus recognizes the fact that chronic medical conditions account for most of today’s care, with most being treated in the community. The IOM report Health professions education: A bridge to quality (2003) calls for the restructuring of clinical education responsive to the 21st century health system transformation goals of providing the highest quality and safest medical care possible. This report identified five core areas of competency required to cross the bridge to quality.

DIF: Cognitive Level: Comprehension REF: p. 4 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The discipline of nursing has “a unique perspective, a distinct way of viewing all phenomena,

which ultimately defines and limits the nature of its inquiry,” related to (Select all that apply.) a. principles and laws that govern the life processes, well-being, and optimum functioning of human beings, sick or well. b. patterning of human behavior in interaction with the environment in critical life situations. c. processes by which positive changes in health status are affected. d. processes by which negative changes in health status are affected. e. patterning of human behavior in interaction with the environment in every life situation. f. principles and laws that govern the life processes, well-being, and optimum functioning of human beings, in relation to wellness only.

ANS: A, B, C

Donaldson and Crowley characterize the discipline of nursing as having "a unique perspective, a distinct way of viewing all phenomena, which ultimately defines and limits the nature of its inquiry," related to "Principles and laws that govern the life processes, well-being, and optimum functioning of human beings, sick or well; patterning of human behavior in interaction with the environment in critical life situations; and processes by which positive changes in health status are affected."

DIF: Cognitive Level: Application REF: p. 2 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Chapter 2: Professional Guides for Nursing Communication Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. The nurse demonstrates effective communication by ensuring all of the following except a. two-way exchange of information among clients and health providers. b. making sure that unilateral information is exchanged between clients and nurses. c. making sure that the expectations and responsibilities of all are clearly understood. d. recognizing that effective communication is an active process for all involved.

ANS: B

Effective communication is defined as a two-way exchange of information among clients and health providers ensuring that the expectations and responsibilities of all are clearly understood. It is an active process for all involved.

DIF: Cognitive Level: Knowledge REF: p. 23 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. A preoperative assessment shows that a client’s hemoglobin level is dropping. The anesthetist

orders 3 units of blood to be administered. The nurse administers the first unit before discovering that the client is a Jehovah’s Witness, as documented in the record. This is an example of a. professional conduct. b. a negligent act. c. physical abuse. d. breaching client confidentiality.

ANS: B

The nurse was negligent by not checking the record and by failure to obtain written consent from the client for the procedure. This is an example of misconduct, not professional conduct.

The nurse did not intend to physically harm the patient. The nurse did not breach client confidentiality.

DIF: Cognitive Level: Application REF: pp. 28-29 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. Which of the following is a violation of client confidentiality? Reporting a. certain communicable diseases. b. child abuse. c. gunshot wounds. d. client data to a colleague in a nonprofessional setting.

ANS: D

Releasing information to people not directly involved in the client’s care is a breach of confidentiality. Certain communicable or sexually transmitted diseases, child and elder abuse, and the potential for serious harm to another individual are considered exceptions to sharing of confidential information.

DIF: Cognitive Level: Knowledge REF: p. 37 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. A 16-year-old trauma victim arrives in the emergency department with a life-threatening

condition and requires emergency surgery. The nurse knows that a. a parent/guardian must give consent. b. the client can give consent if she provides proof of emancipation. c. the client must first be evaluated for competency before obtaining consent. d. surgery can be performed without consent.

ANS: D

Surgery can be performed without consent because it is a life-threatening emergency.

Normally parents or a guardian must give consent, but in a life-threatening emergency medical care can be administered without consent. Providing proof of emancipation is not necessary in a life-threatening situation. The client does not need to first be evaluated for competency in a life-threatening situation.

DIF: Cognitive Level: Application REF: p. 38 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. In regard to informed consent, which of the following statements is true? a. Only legally incompetent adults can give consent. b. Only parents can give consent for minor children. c. It is not required that the client be told about costs and alternatives to treatment. d. Consent must be voluntary.

ANS: D

For legal consent to be valid, it must be voluntary. Only legally competent adults can give consent. Parents or legal guardians can give consent for minor children. Clients must have full disclosure about risks/benefits, including costs and alternatives.

DIF: Cognitive Level: Knowledge REF: p. 37 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. The client has a living will in which he states he does not want to be kept alive by artificial

means. The client’s family wants to disregard the client’s wishes and have him maintained on artificial life support. The most appropriate initial course of action for the nurse would be to a. tell the family that they have no legal rights. b. tell the family that they have the right to override the living will because the patient cannot speak. c. report the situation to the hospital ethics committee. d. allow the family to verbalize their feelings and concerns, while maintaining the role of client advocate.

ANS: D

Allowing the family to verbalize their feelings and concerns is the most appropriate action at the time to help the family deal with their loss and come to terms with their family member’s wishes. Telling the family that they have no legal rights would not be supportive and might create hostility. The family does not have the right to override a living will. It is not the most appropriate initial course of action to report the situation to the hospital ethics committee.

According to the American Nurses Association Code of Ethics for Nurses, the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

DIF: Cognitive Level: Analysis REF: p. 27 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care 7. The nurse collects both objective and subjective data. An example of subjective data is a. BP 140/80. b. skin color jaundiced. c. “I have a headache.” d. history of seizures.

ANS: C

Subjective data refers to the client’s perception of data and what the client or family says about the data. Objective data refers to data that are directly observable or verifiable through physical examination or tests. Blood pressure recording is objective. Jaundiced skin color observation by the nurse is objective data. A history of seizures is objective data.

DIF: Cognitive Level: Knowledge REF: p. 33 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. The nurse observes a client pacing the floor. The nurse validates an inference when speaking

to the client by stating, a. “You are anxious, so let’s talk about it.” b. “Let’s try some deep breathing to help you relax.” c. “You seem anxious. Will you tell me what is going on?” d. “Clients who pace usually need to talk to a physician. Should I call yours?”

ANS: C

The nurse has inferred that the client is anxious but needs to ask further questions to validate the information. A nurse should not make assumptions without first confirming that the inference is correct. Deep breathing exercise is an intervention; it is not validating an inference.

DIF: Cognitive Level: Application REF: p. 33 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. A client who is scheduled for a bilateral inguinal hernia repair the next day is observed pacing

the unit. After validating that the client is anxious about his upcoming surgery because he is afraid of pain, a relevant nursing diagnosis would be a. anxiety related to surgery. b. pain related to anxiety about surgery as evidenced by pacing. c. anxiety related to fear of postoperative pain as evidenced by pacing.

d. pacing related to fear of postoperative pain.

ANS: C

Anxiety is the problem to be addressed. Related to connects the problem to the etiology (fear of pain). The third part of the statement identifies the clinical evidence (pacing) that supports the diagnosis. There are three parts to a nursing diagnosis, and the anxiety is related specifically to fear of pain after surgery. The problem to be addressed is the anxiety, not the pain, at this time. “Pacing related to fear of postoperative pain” contains only two parts to this statement. Pacing is the evidence, not the problem.

DIF: Cognitive Level: Application REF: p. 33 TOP: Step of the Nursing Process: Nursing Diagnosis MSC: Client Needs: Management of Care 10. Which of the following is an outcome for a client with a broken leg? a. Client will develop an ambulation program within 1 month. b. Encourage client to ambulate with cast using crutches. c. Client asks, “When will I walk again?” d. Client experiences alteration in mobility related to a broken leg.

ANS: A

Outcomes are goals that are measurable, achievable, and client centered. Ambulation is a nursing intervention. A question from the client is not an outcome; it is a question. “Client experiences alteration in mobility related to a broken leg” is part of a nursing diagnosis.

DIF: Cognitive Level: Application REF: pp. 34-35 TOP: Step of the Nursing Process: Outcome Identification MSC: Client Needs: Physiological Integrity 11. The nurse is teaching a client who is alert and oriented about the drug warfarin. When

teaching the client about this drug, the nurse emphasizes the need to be consistent with Vitamin K intake, which is found primarily in green leafy vegetables. When the client’s spouse comes to visit, the client states, “I can no longer consume green leafy vegetables.”

This is an example of what type of failure caused by a communication problem? a. System failure b. Reception failure c. Transmission failure d. Global aphasia ANS: B

Communication problems occur when there are failures in one or more categories: the system, the transmission, or in the reception. Reception failures occur when channels exist and necessary information is sent, but the recipient misinterprets the message. System failures occur when the necessary channels of communication are absent or not functioning.

Transmission failures occur when the channels exist but the message is never sent or is not clearly sent.

DIF: Cognitive Level: Analysis REF: p. 23 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 12. When setting goals with a client, the nurse demonstrates which step of the nursing process?

a. b. c. d.

Assessment Planning Implementation Evaluation

ANS: B

Outcome identification occurs during the planning phase. Goals are identified during planning, not assessment. Nursing interventions are performed during the implementation phase. During evaluation, goal achievement is evaluated.

DIF: Cognitive Level: Knowledge REF: p. 35 TOP: Step of the Nursing Process: Outcome Identification and Planning MSC: Client Needs: Management of Care 13. When the nurse identifies a health problem or alteration in a client’s health status that requires

a nursing intervention, the nurse is performing which step of the nursing process? a. Diagnosis b. Planning c. Intervention d. Evaluation ANS: A

The nursing diagnosis consists of three parts: (1) problem, (2) etiology, and (3) evidence. The problem is a statement identifying a health problem or alteration in a client’s health status requiring nursing intervention. Planning occurs after problem identification. Interventions occur during implementation. The effectiveness of the interventions is evaluated in the evaluation phase.

DIF: Cognitive Level: Knowledge REF: p. 33 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Management of Care 14. When evaluating the client’s progress toward goal achievement, the nurse should ask which of

the following questions? a. “Did the client tell the truth?” b. “Were the goals realistic?” c. “Did the physician diagnose the client’s condition correctly?” d. “Was the length of stay too short?”

ANS: B

The goals need to be realistic and achievable in the time frame allotted for the interventions to be effective. Validation of information occurs in the assessment phase. Medical diagnosis is not part of the nursing process. The nurse needs to work within the time frame allotted.

DIF: Cognitive Level: Comprehension REF: p. 34 TOP: Step of the Nursing Process: Evaluation MSC: Client Needs: Management of Care 15. The plan of care serves as the structural framework for a. maintaining confidentiality. b. attaining self-actualization. c. maintaining therapeutic communication.

d. providing safe, high-quality care.

ANS: D

The plan of care plan serves as the structural framework for providing safe, high-quality care.

Its purpose is to provide continuity and supply a basis for interventions and documentation of client progress. Each plan of care should be individualized to reflect client values, clinical needs, and preferences. Confidentiality is defined as providing only the information needed to provide care for the client to other health professionals who are directly involved in the care of the client. The nurse can use Maslow’s hierarchy of needs to prioritize goals and objectives.

Therapeutic communication helps the nurse use the nursing process.

DIF: Cognitive Level: Comprehension REF: p. 35 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 16. The nurse is caring for a client whose health has suddenly worsened. The nurse calls the

health care provider. What is the best example of the nurse communicating to the health care provider using the situation part of SBAR communication? a. “The patient has developed dyspnea with audible crackles in the lungs bilaterally; oxygen saturation is 86% on room air.” b. “The patient has chronic obstructive pulmonary disease due to a long-term history of smoking.” c. “I am concerned that the patient is exhibiting signs of a pulmonary embolus due to a sudden drop in oxygenation.” d. “I would like for you to order a STAT chest x-ray because the patient has suddenly developed shortness of breath with hypoxia.”

ANS: A

Situation: What is going on with the client? Background: What is key information/context?

Assessment: What do I think the problem is? Recommendation: What do I want to be done?

DIF: Cognitive Level: Analysis REF: p. 24 TOP: Step of the Nursing Process: All phases of the nursing process MSC: Client Needs: Management of Care 17. During a routine visit, the nurse notes that a child has several bruises at various stages of

healing. The child reports having fallen down. Failure to report these findings is an example of a. negligence. b. reasonable prudence. c. maintenance of confidentiality. d. HIPAA regulation.

ANS: A

Failing to report suspected physical or sexual child abuse is an example of a negligent act.

Reasonable prudence is a nursing action that a reasonably prudent nurse would perform. In a situation where a child has several bruises, confidentiality must be breached. HIPAA regulations protect the privacy of client records.

DIF: Cognitive Level: Application REF: p. 37 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care

MULTIPLE RESPONSE 1. When practicing effective and correct communication, the nurse should (Select all that apply.) a. speak in a clear voice. b. be concise when providing client education. c. be concrete when communicating with clients. d. focus entirely on abstract communication techniques with clients. e. ensure that communication with clients is complete. f. provide courteous communication when interacting with clients.

ANS: A, B, C, E, F

Effective and correct communication is: clear, concise, concrete, complete, and courteous.

DIF: Cognitive Level: Analysis REF: p. 23 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

Chapter 3: Clinical Judgment and Ethical Decision Making Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following types of thinking reflects the nursing process? a. Habits b. Inquiry c. Mnemonic d. Practice ANS: B

More structured methods of thinking, such as inquiry, have been developed in disciplines related to nursing. Repetitive practice does not reflect the nursing process. Memorizing does not reflect the nursing process.

DIF: Cognitive Level: Knowledge REF: p. 40 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. Which of the following personality characteristics is a barrier to critical thinking? a. Accepting change b. Being open minded c. Stereotyping d. Going with the flow ANS: C

Stereotyping is a cognitive barrier to critical thinking because it interferes with the ability to treat a client as an individual. Critical thinkers recognize that priorities change continually.

Being open minded is the ability to consider alternatives. Being flexible is a bridge to critical thinking, not a barrier.

DIF: Cognitive Level: Comprehension REF: p. 46 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. The ethical decision-making model where good is defined as maximum welfare or happiness

is known as the a. utilitarian model. b. human rights based model. c. duty-based model. d. Kant’s model.

ANS: A

The utilitarian model is also known as the goal-based model, where the duties of the nurse are determined by what will achieve maximum welfare. In the human rights model, the client has basic rights, including the right to refuse care. In the duty-based model, rightness is determined by moral worth. The duty-based model is based on Kant’s philosophy.

DIF: Cognitive Level: Knowledge REF: p. 41 TOP: Step of the Nursing Process: All phases

MSC: Client Needs: Management of Care 4. Which of the following case examples represents the ethical concept of distributive justice? a. A famous baseball player receives a heart transplant. b. An older adult who has government insurance is denied standard cancer treatment. c. During a visit to his physician’s office, a client demands antibiotics for his cold

and is given a prescription. d. A client suffering from cirrhosis of the liver is placed on a transplant list.

ANS: B

The decision to deny expensive treatments or to deny acute care to clients older than a certain age because of scarce treatment resources is an example of the concept of distributive justice.

A famous baseball player who receives a heart transplant could be an example of the concept of social worth. A client demanding antibiotics for his cold during a physician’s office visit is an example of the concept of unnecessary treatment. A client who suffers from cirrhosis and who is placed on a transplant list is an example of justice, being fair or impartial.

DIF: Cognitive Level: Analysis REF: pp. 43-44 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. Personal values are defined as a. values shaped by family, religious beliefs, and years of experience. b. altruism. c. two values that are in conflict. d. values determined by commitment.

ANS: A

We all have a personal value system developed over a lifetime that has been extensively shaped by our family, our religious beliefs, and our years of life experiences. Altruism is a core value of professional nursing. Cognitive dissonance refers to two conflicting values.

Value intensity refers to the amount of an individual’s commitment to values.

DIF: Cognitive Level: Knowledge REF: p. 46 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. A nurse values autonomy and self-determination as well as the preservation of life. This is an

example of a. conceptions of the ideal. b. cognitive dissonance. c. operative values. d. commitment.

ANS: B

Cognitive dissonance refers to the mental discomfort felt when there is a discrepancy between what an individual already believes and some new information that does not go along with that view. It refers to the holding of two or more conflicting values at the same time.

Conceptions of the ideal are conceived values. Operative values do not refer to conflicting values. Commitment refers to value intensity.

DIF:

Cognitive Level: Application

REF: p. 46

TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. Which of the following statements is true about the critical thinking process? a. It is a linear process. b. The skills are inborn. c. It is goal directed. d. It assists nurses to criticize the health care system.

ANS: C

The process of critical thinking is systematic, organized, and goal directed. As critical thinkers, nurses are able to explore all aspects of a complex clinical situation. Critical thinking is a circular process. Critical thinking is a learned skill that teaches you how to “think about your thinking.” Critical thinking is clinical judgment, not criticism.

DIF: Cognitive Level: Comprehension REF: p. 49 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 8. Which of the following best describes the critical thinking skills of a novice nurse and an

expert nurse? a. The expert nurse is able to diagnose faster than the novice nurse. b. The expert nurse does not need to question and reassess like the novice nurse. c. The novice nurse uses past knowledge, whereas the expert nurse stays in the here and now. d. The expert nurse organizes data more efficiently than the novice nurse.

ANS: D

The novice nurse collects lots of facts but does not logically organize them. Novice nurses tend to jump too quickly to a diagnosis without recognizing the need to obtain more facts. The expert nurse constantly questions and reassesses. The expert nurse compares new information with prior knowledge, while the novice nurse makes fewer connections to past knowledge.

DIF: Cognitive Level: Comprehension REF: p. 45 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. A client with schizophrenia has been stabilized on long-acting haloperidol, an antipsychotic

medication that is administered by injection every 3 weeks. The physician switches the medication to Seroquel, a new antipsychotic oral medication that is administered twice a day.

The client complains that he cannot afford the new medication and will not be able to remember to take it. The physician replies, “I can’t help that; I have to treat you the way I think is best.” The client’s nurse may experience a. paternalism. b. cognitive dissonance. c. nonmaleficence. d. moral distress.

ANS: D

Moral distress results when the nurse knows what is right but is bound to do otherwise because of legal or institutional constraints. Paternalism is making decisions for clients based on what is thought best for them. Cognitive dissonance occurs when there are two conflicting values. Nonmaleficence is avoiding actions that bring harm to another person.

DIF: Cognitive Level: Application REF: p. 47 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. Characteristics of a critical thinker include all but which of the following? a. Haphazardly seeking solutions b. Anticipating consequences c. Considering alternative solutions d. Revising actions based on new input ANS: A

This is an example of a negative style question. “Haphazardly seeking solutions” is correct because a characteristic of a critical thinker is to systematically seek solutions, not to haphazardly seek solutions. All of the other options are characteristics of a critical thinker.

DIF: Cognitive Level: Knowledge REF: p. 45 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. The best method for nurse educators to teach professional values is a. reading the ANA code. b. laissez-faire. c. role modeling. d. values clarification.

ANS: C

Nursing education helps a nurse to acquire a professional value system. In nursing school, the student nurse begins to take on some of the values of the nursing profession. Often, professional values are transmitted by tradition in nursing classes and clinical experiences.

They are modeled by expert nurses and assimilated as part of the role socialization process during the years spent as a student and new graduate. Professional values are stated in the ANA code, but the best way to transmit them is by role modeling. Professional values are transmitted by tradition and assimilated in the role socialization process. Values clarification helps a nurse to identify and prioritize values.

DIF: Cognitive Level: Knowledge REF: p. 49 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 12. Which of the following describes the first step in acquisition of a value? a. There must be pride in and happiness with the choice. b. The value must be acted upon in a pattern of behavior consistent with the choice. c. The value should be the result of conscious choice. d. The value must be chosen after careful consideration of each alternative.

ANS: C

Professional values acquisition should be the result of conscious choice. This is the first step in values acquisition. The value must be acted upon in a pattern of behavior consistent with the choice, which occurs during the seventh criteria for acquisition of a value. Pride and happiness with the choice occurs during the fourth criteria for acquisition of a value. Careful consideration of each alternative occurs during the third criteria for acquisition of a value.

DIF: Cognitive Level: Knowledge REF: p. 49 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 13. The client’s values a. must coincide with those of the nurse. b. are only considered during assessment. c. influence the nurse’s interventions. d. are not influenced by culture.

ANS: C

In the planning phase, it is important to identify and understand the client’s value system as the foundation for developing the most appropriate interventions. It is not necessary for the client and nurse’s values to coincide; in fact, it is an unrealistic expectation. The client’s value system is important to consider throughout the nursing process. Values are influenced by culture and religious beliefs.

DIF: Cognitive Level: Comprehension REF: p. 51 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 14. Values clarification can be incorporated within the intervention phase of the nursing process

by a. b. c. d.

identifying ineffective family coping. identifying care guidelines. identifying client’s values. identifying specific nursing diagnoses.

ANS: B

Plans of care that support rather than discount the client’s health care beliefs are more likely to be received favorably. Your interventions include values clarification as a guideline for care.

Ineffective family coping is a nursing diagnosis, not an intervention. Values are identified and then used as care guidelines. Nursing diagnosis does not occur during the intervention phase of the nursing process.

DIF: Cognitive Level: Comprehension REF: p. 51 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care 15. During the third step in the critical thinking process a. new data are obtained. b. values are clarified. c. existing information is compared with past knowledge. d. the problem is identified.

ANS: C

During step 3, existing information is compared with past knowledge. New data are obtained in step 4. Values are clarified in step 2. The problem is identified in step 5.

DIF: Cognitive Level: Comprehension REF: p. 51 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 16. The student nurse can best learn the steps in critical thinking through a. reading journals. b. classroom instruction. c. repeated practice. d. developing a mnemonic.

ANS: C

The most effective method of learning the steps in critical thinking is by repeatedly applying them to clinical situations. Reading journals, classroom instruction, and developing a mnemonic are not the most effective ways of learning the steps in critical thinking.

DIF: Cognitive Level: Application REF: p. 54 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 17. The bioethical principle of autonomy refers to a. the client’s right to self-determination. b. avoiding actions that bring harm to another person. c. a decision resulting in the greatest good or least harm. d. being fair or impartial.

ANS: A

Autonomy is the client’s right to self-determination. Avoiding actions that bring harm to another person refers to the principle of nonmaleficence. A decision resulting in the greatest good or least harm refers to the principle of beneficence. Being fair or impartial refers to the principle of justice.

DIF: Cognitive Level: Knowledge REF: p. 42 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. Which of the following is true about critical thinkers? (Select all that apply.)

Critical thinkers a. are open minded. b. are able to consider alternatives. c. use a purposeful reasoning process. d. use a linear thinking process. e. are able to recognize information gaps.

ANS: A, B, C, E

Critical thinkers use specific thinking skills that are not rigid, and these allow the consideration of alternatives and recognition of gaps and available information. Critical thinkers do not use a linear process but constantly add new input.

DIF: Cognitive Level: Knowledge REF: p. 45 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 4: Clarity and Safety in Communication Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. A nurse manager is teaching a group of nurses about client safety. The nurse manager teaches

the nurses that safety is defined as “avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the process of health care itself.” What is the source of this definition? a. Hippocratic oath b. National Patient Safety Foundation c. American Association of Colleges of Nursing d. American Nurses Association’s Code of Ethics ANS: B

The National Patient Safety Foundation defines safety as “avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the process of healthcare itself.”

DIF: Cognitive Level: Application REF: p. 58 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. When conducting an in-service on serious medical errors, the nurse teaches that nearly 70% of

sentinel events are related to a. lack of education. b. inadequate resources. c. minimal rest periods. d. miscommunication.

ANS: D

Multiple studies have pinpointed miscommunication as a major causative agent in sentinel events, that is, errors resulting in unnecessary death and serious injury. Miscommunication is the root cause in nearly 70% of sentinel events.

DIF: Cognitive Level: Application REF: p. 58 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. When working on a nursing unit, the nurse recognizes that incomplete communication errors

most often occur during a. staff meetings. b. the night shift. c. a handoff procedure. d. medication administration.

ANS: C

It is estimated that 70% of reported errors are preventable. "Preventable" means the error occurs through a medical intervention, not because of the client's illness. Fatigue is repeatedly cited as a factor contributing to errors. The most common cause of error is incomplete communication during the very many ‘handoffs’ transferring responsibility for client care to another care provider, another unit, or agency. It is estimated that in 1 day a client may experience up to 8 handoffs.

DIF: Cognitive Level: Application REF: p. 58 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. A student nurse is learning about how to reduce errors and increase safety. The nursing

instructor recognizes that further teaching is warranted when the student nurse states which of the following? a. “When communicating with clients, I will be clear.” b. “I will be timely in my communication with clients.” c. “I will promote communication with clients that is ambiguous.” d. “When communicating with clients, I will ensure the client understood.”

ANS: C

Standardization of communication is an effective tool to avoid incomplete or misleading messages. Standardization needs to be institutionalized at the system level and implemented consistently at the staff level. Safe communication about client care matters needs to be clear, unambiguous, timely, accurate, complete, open, and understood by the recipient to reduce errors.

DIF: Cognitive Level: Application REF: p. 62 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. The nurse manager sets a goal to establish a new safety culture on a hospital unit. The nurse

manager recognizes that basic components in establishing a new safety culture include a. support of effective health care teamwork. b. encouragement of individualism. c. discouragement of new concepts. d. promotion of a hierarchical system.

ANS: A

A major international effort is underway to prioritize safety goals by improving communication about clients among his or her various providers. The aim is to reduce client mortality, decrease medical errors, and promote effective health care teamwork.

DIF: Cognitive Level: Application REF: p. 61 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. A nurse attends an in-service aimed to educate staff about reporting hospital errors. The nurse

demonstrates understanding when listing which of the following as consistent with error reporting within the United States? a. Error reporting is transparent b. Errors are overreported

c. Errors are underreported d. Providers are not concerned about consequences of reporting errors ANS: C

Providers are concerned about negative consequences of disclosing errors, such as malpractice litigation, reputation damage, job security, and personal feelings such as loss of self-esteem, among others. This has led to serious underreporting. In the United States, according to IOM, only a tiny fraction of unsafe care incidents are reported. Some estimate that more than 90% of errors go unreported.

DIF: Cognitive Level: Application REF: p. 59 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. When educating a newly diagnosed client about management of diabetes mellitus, the nurse

recognizes that health care–related communication a. does not lead to errors within the hospital. b. is generally well understood by most clients. c. is not an important component of client care. d. can cause clients to misunderstand information.

ANS: D

It is important to make verbal and written information as simple as possible. Nurses need to assess the health literacy level of each client. Nurses should provide privacy to avoid embarrassment and obtain feedback or “teach-backs” to determine the client's understanding of teaching: Simplify, Clarify, Verify!

DIF: Cognitive Level: Application REF: p. 72 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 8. A nurse manager encourages staff to improve error and near miss event reporting. The nurse

manager recognizes that as error reporting improves, a. the severity of errors increases. b. better, safer systems can be developed. c. the likelihood of other errors increases. d. error detection rates and severity remain unchanged.

ANS: B

Adequate error and near miss event reporting are necessary to designing better, safer systems.

Failure to report and track errors and near misses actually increases the likelihood of other errors.

DIF: Cognitive Level: Application REF: p. 59 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. When educating a student nurse about safety communication improvement solutions, the

nursing instructor recognizes that additional teaching is warranted when the student nurse lists which of the following as a safety communication improvement solution? a. Adopting technology-oriented tools b. Using standardized verbal and electronic communication tools

c. Disempowering clients to be partners in safer care d. Participating in team training communication seminars ANS: C

While a nurse’s clinical judgment remains a valid, essential aspect of communication, other safety communication improvement solutions include using standardized verbal and electronic communications tools, participating in team-training communication seminars, adopting technology-oriented tools, and empowering clients to be partners in safer care.

Communication that promotes client safety needs to include both communication of concise critical information and active listening.

DIF: Cognitive Level: Application REF: p. 65 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. The nurse is teaching the student nurse about how to use SBAR when calling a physician. The

student nurse verbalizes understanding of SBAR when stating that SBAR is a. used as a situational briefing. b. utilized strictly within the hospital setting. c. not used in e-mails due to HIPAA rules. d. never recorded within the client’s chart.

ANS: A

SBAR is used as a situational briefing, so the team is "on the same page." It is used across all types of agencies, groups, and even in e-mails. SBAR simplifies verbal communication between nurses and physicians because content is presented in an expected format. Some hospitals use laminated SBAR guidelines at the telephones for nurses to use when calling physicians about changes in client status and requests for new orders. Documenting the new order is the only part of SBAR that gets recorded.

DIF: Cognitive Level: Application REF: p. 66 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. A nurse recognizes that strategies for clear, accurate communication to promote client safety

include which of the following? a. Establishing a safe environment b. Maintaining a climate of closed communication c. Using unique interdisciplinary communication tools d. Using communication tools that promote vague communication ANS: A

Clear, accurate communication is the bedrock of safe care. Accurate, clear communication and best practice are indicators of quality of care and serve to maintain a safe environment.

DIF: Cognitive Level: Application REF: p. 57 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 12. When calling a physician, the nurse tells the physician her name, what unit and what hospital

she is calling from, the client’s name, and that the client is having trouble breathing. The nurse is demonstrating which step in the SBAR format for communicating with a client’s physician?

a. b. c. d.

Situation Assessment Background Recommendation

ANS: A

An example of the situation component of SBAR reporting is: “Dr. Preston, this is Wendy Obi, evening nurse on 4G at St. Simeon Hospital, calling about Mr. Lakewood, who’s having trouble breathing.” An example of the assessment component of SBAR reporting is: “I don’t hear any breath sounds in his right chest. I think he has a pneumothorax.” An example of the background component of SBAR reporting is: “Kyle Lakewood, DOB 7/1/60, a 53-year-old man with chronic lung disease, admitted 12/25, who has been sliding downhill  2 hours.

Now he’s acutely worse: VS heart rate 92, respiratory rate 40 with gasping, B/P 138/94, oxygenation down to 72%.” An example of the recommendation component of SBAR reporting is: “I need you to see him right now. I think he needs a chest tube.”

DIF: Cognitive Level: Application REF: p. 66 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 13. The nurse is caring for a client who is becoming increasingly short of breath. The nurse

decides to call the physician. Which of the following should the nurse initially do when speaking with the physician? a. State the problem b. Tell what is needed c. State the client’s allergies d. Relate the client’s background ANS: A

During the situation component of SBAR, the nurse identifies herself, the client, and the problem. During the recommendation component of SBAR, the nurse tells what is needed.

During the background component of SBAR, the nurse relates the client’s background.

DIF: Cognitive Level: Application REF: p. 66 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 14. When communicating with a client’s physician, the nurse suggests ordering a STAT chest x- ray for a client who is experiencing dyspnea. This is an example of which component of the

SBAR format for communicating with the client’s physician? a. Situation b. Assessment c. Background d. Recommendation ANS: D

During the recommendation component of SBAR, the nurse states an informed suggestion for the continued care of the client by proposing an action and stating what is needed and in what time frame it needs to be completed. During the situation component of SBAR, the nurse identifies herself, the client, and the problem. During the assessment component of SBAR, the nurse states a conclusion that is based on what she thinks is wrong. During the background component of SBAR, the nurse relates the client’s background.

DIF: Cognitive Level: Application REF: p. 66 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 15. When a night shift nurse completes a shift, she gives a report about her clients to the

oncoming day shift nurse. When beginning the report, the night shift nurse introduces herself and states her role, states the client’s name, identifiers, age, sex, and location. Which of the following should the nurse do next? a. State critical lab reports, allergies, and alerts b. List current medications and client’s family history c. Talk about any anticipated changes in the plan of care d. Relate client’s chief complaint, vital signs, symptoms, and diagnosis ANS: D

When using the acronym “I PASS the BATON,” the nurse should first introduce herself and state her role; then state the client’s name, identifiers, age, sex, and location; and then go over the client’s assessment, including the chief complaint, vital signs, symptoms, and diagnosis.

The fifth step in “I PASS the BATON” is safety concerns, which include critical lab reports, allergies, and alerts. The sixth step in “I PASS the BATON” is background, which includes comorbidities, previous episodes, current medications, and family history. The final step in “I PASS the BATON” is next, in which the plan is stated, including what will happen next, and includes any anticipated changes.

DIF: Cognitive Level: Application REF: p. 69 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 16. When using the acronym “I PASS the BATON,” the nurse demonstrates understanding by

beginning with an introduction; then stating the client’s name, identifiers, age, sex, and location; then discussing the assessment of the client; and then talking about a. safety concerns related to the client. b. the situation, including current status. c. a summary of the client’s medications. d. a synopsis of the client’s psychosocial needs.

ANS: B

After assessment, the next step using the acronym “I PASS the BATON” is situation, which includes current status, level of certainty, recent changes, and response to treatment. When using the acronym “I PASS the BATON,” safety concerns comes immediately after situation.

A summary of the client’s current medications occurs during the background step when using the acronym “I PASS the BATON.” A synopsis of the client’s psychosocial needs is not part of the acronym “I PASS the BATON.” DIF:

Cognitive Level: Application

REF: p. 69

TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. When educating staff about how to reduce errors and increase safety, the nurse manager

emphasizes the importance of communication that is (Select all that apply.) a. clear. b. vague. c. timely. d. accurate. e. unambiguous.

ANS: A, C, D, E

Changes in communication to reduce errors and increase safety need to be institutionalized at the system level and implemented consistently at the staff level. Safe communication about client care matters needs to be clear, unambiguous, timely, accurate, complete, open, and understood by the recipient to reduce errors. Safe communication about client matters should be clear, not vague.

DIF: Cognitive Level: Application REF: p. 62 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. The nurse manager is educating the unit staff about ways to promote safer clinical practice.

The nurse manager emphasizes that this can be done through the incorporation of which of the following? (Select all that apply.) a. Correlation b. Cooperation c. Collaboration d. Cultural sensitivity e. Communication clarity ANS: B, C, E

Beyond individual changes to create safer climates for our clients, we need to advocate for organizational system changes. Leadership is needed to incorporate the “3 Cs,” which promote safer clinical practice: • Communication clarity • Collaboration • Cooperation DIF: Cognitive Level: Application REF: p. 60 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 5: Developing Therapeutic Communication Skills Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. When therapeutically communicating with a client who has just found out he is HIV- positive,

the nurse should focus on a. professional needs. b. an unlimited time frame for communication. c. verbal communication only between the client and the nurse. d. achieving identified health-related goals.

ANS: D

Therapeutic communication is defined as a dynamic interactive process consisting of words and actions and entered into by a clinician and client for the purpose of achieving identified health-related goals. Originally conceptualized by Jurgen Ruesch in 1961, communication skills are essential drivers for developing therapeutic relationships and facilitating interdisciplinary collaborative communication with clients and families. Fundamental forms of health communication include verbal and written words and nonverbal communicative behaviors.

DIF: Cognitive Level: Application REF: p. 75 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. The nurse demonstrates understanding of the concept of metacommunication through a. recognizing the impact of communication on others. b. actively listening with good eye contact. c. implementing barriers to effective communication. d. ensuring that verbal and nonverbal messages are incongruent.

ANS: B

Metacommunication refers to how nonverbal cues are used to enhance or negate the meaning of words. In addition to observable nonverbal behavior, client choices about clothing, personal and religious items, hairstyle and hygiene, and voluntary use of gestures inform, add to, and complete verbal messages. Behavioral communication is influenced by life circumstances, culture, and immediate context, so it is susceptible to misinterpretation and requires validation.

DIF: Cognitive Level: Application REF: p. 76 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. When communicating with a client, the nurse recognizes that a barrier to effective

communication is a. cultural sensitivity. b. thinking ahead to the next question. c. completion of physical care in a nonhurried manner. d. focusing on the current questions asked by the client.

ANS: B

Barriers to effective communication within the nurse occur when the nurse is not fully engaged with the client because of thinking ahead to the next question; when the nurse has cultural stereotypes and biases; and when the nurse is in a hurry to complete physical care.

DIF: Cognitive Level: Application REF: p. 79 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 4. When communicating with clients, the nurse actively uses listening responses. Which of the

following types of listening response should the nurse use? a. Moralizing b. Giving advice c. False reassurance d. Paraphrasing ANS: D

Paraphrasing is an example of a listening response that focuses on the client. Moralizing, giving advice, and false reassurances are all examples of negative listening responses.

DIF: Cognitive Level: Comprehension REF: p. 86| p. 88 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. The nurse enters a client’s room with the intent of allowing the client to express feelings in

relation to her new cancer diagnosis. The nurse notices that the client is crying and guarding her incision site. After validating physical discomfort, the nurse should a. administer an analgesic and postpone the interaction. b. sit with the client and hold her hand. c. explain that pain is expected following surgery but that it is important to increase activity to avoid complications. d. acknowledge the physical pain but state that it is a priority to immediately address the emotional pain.

ANS: A

Communication breaks down when the nurse and client do not share the same understanding of messages. Barriers to effective communication occur in clients when they are preoccupied with pain, physical discomfort, worry, or contradictory personal beliefs. The client’s pain must be a priority for the nurse before other needs are addressed.

DIF: Cognitive Level: Analysis REF: p. 78 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. A nurse is conducting a medication education group for mentally ill clients. One of the clients

states, “I don’t think everyone needs medications. What about psychotherapy? Can you tell me about that?” What is an appropriate response by the nurse? a. Talk to the group about the benefits of psychotherapy. b. Tell the group that psychotherapy is ineffective and they need medication. c. Acknowledge the question, but explain the time limitations and focus of that particular group.

d. Explain that it is the physician’s decision what type of treatment modality is for

each client ANS: C

In the past, nurses had more time with clients. Today nurses must make every second count.

Nurses and clients need to select the most pressing health care needs for attention. The nurse should focus on what is essential to know, rather than what might be nice to know. This requires planning and sensitivity to client needs and preferences. Client readiness and capabilities are other factors to take into consideration in selecting content. Unless it is an emergency situation, the nurse can guide but not insist on a particular point of discussion.

DIF: Cognitive Level: Application REF: p. 92 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 7. When teaching a client how to administer insulin, the nurse recognizes that the best method of

communicating therapeutically with the client is to a. talk to the client in the visitors’ lounge. b. talk to the client within his personal space. c. communicate with the client using touch. d. face the client while leaning slightly forward.

ANS: D

Privacy, space, and timing are other aspects to consider. Clients need privacy, to be free from interruption, and to have their space requirements respected to fully engage in meaningful conversations. Therapeutic conversations typically take place within a social distance (3-4 feet is optimal). Touch has contextual and cultural meanings. Women are more likely to welcome and use touch in communication. Touch is a valued form of communication in some cultures.

In others, touch is reserved for religious purposes or is seldom used as a form of communication, for example in Asia. Before touching a client, assess the client's receptiveness to touch. Observing the client will provide some indication, but you may need to ask for validation. If the client is paranoid, out of touch with reality, verbally inappropriate, or mistrustful, touch is contraindicated as a listening response. Minimal physical cues (e.g., leaning towards the client, nodding, smiling) are used to accentuate words and to connect with people nonverbally as well as verbally.

DIF: Cognitive Level: Application REF: p. 76 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 8. When conducting an assessment interview, which of the following is the best communication

technique for the nurse to use? a. Ask multiple questions at the same time b. Offer limited time for the client to respond to each question that is asked c. Use short, unambiguous listening responses focused on current health issues and client concerns d. Ensure that all questions are answered immediately in order to avoid the need for related follow-up questions to clarify ANS: C

A client-centered interview begins with encouraging clients to tell the story of their illness.

This format helps nurses integrate personal with medical perspectives. Using short, unambiguous listening responses focused on current health issues and client concerns is the best means of helping clients tell their story. With relevant queries you will get a better idea of how the client communicates and what clients consider most important about their clinical situation. In addition to using a “here and now” approach, avoid asking more than one question at a time, and allow enough time for the client to fully answer. Related follow-up questions to clarify or help clients expand on what has been introduced can be helpful.

DIF: Cognitive Level: Application REF: p. 82 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. The nurse asks a newly admitted client, “Can you tell me what brought you to the hospital

today?” The purpose of an open-ended question is to a. influence the direction of an acceptable response. b. encourage the client to answer the question with a one-word response. c. allow clients latitude in telling their story. d. allow the client to engage in a passive relationship with the nurse.

ANS: C

Open-ended questions permit clients to express health problems and needs in their own words.

They are especially helpful at the start of a relationship, when the nurse’s objective is to gather information and to get to know the client as a person. You are more likely to elicit a client’s values, preferences, and ways of thinking about their illness if you allow them latitude in telling their story through open-ended questions. Sharing the personal meanings of an illness rather than identifying a diagnosis or listing discrete symptoms helps the client and nurse link the context of a health disruption with symptoms and provides more complete information. An open-ended question is similar to an essay question on a test. It is open to interpretation and cannot be answered by “yes,” “no,” or a one-word response. Open-ended questions ask clients to think and reflect on their situation. They help connect relevant elements of the client's experience without influencing the direction of the response. (e.g., relationships, impact of the illness on self or others, environmental barriers, potential resources). Open-ended questions are used to elicit the client's thoughts and perspectives without influencing the direction of an acceptable response.

DIF: Cognitive Level: Application REF: p. 82 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 10. Which of the following is the best questioning sequence during a client interview in which the

client is communicative and not in an emergency situation? a. Begin with focused questions and proceed to open-ended questions. b. Begin with open-ended questions and proceed to focused questions. c. Begin with closed questions and proceed to open-ended questions. d. Begin with open-ended questions and proceed to closed questions.

ANS: B

Start with open-ended questions to allow the client to tell his or her story in his or her own way to obtain general information. Use focused questions to obtain more specific information Start with open-ended, not focused or closed, questions. Proceed to focused questions, not closed questions.

DIF: Cognitive Level: Application REF: pp. 82-83 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 11. A client is admitted to the hospital for unsteady gait resulting in frequent falls. Which of the

following is a circular question that the nurse could ask this client? a. “Tell me more about your falls at home.” b. “How will this hospitalization affect your family?” c. “Have you experienced dizziness and imbalance before?” d. “Can you tell me what brought you here?”

ANS: B

Circular questions are a form of focused questions, which give attention to the interpersonal context in which an illness occurs. These are used to explore the impact of a health disruption on family functioning and relationships with significant others. “Tell me more about your falls at home” is a focused question. “Have you experienced dizziness and imbalance before?” is a closed-ended question. “Can you tell me what brought you here?” is an open-ended question.

DIF: Cognitive Level: Application REF: p. 83 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. A client states, “I can’t sleep all night because the nurses are noisy.” Which of the following

responses by the nurse best represents the nurse’s recognition of the client’s theme? a. “I will speak to the supervisor about your complaint.” b. “You cannot sleep because of the noise level at night?” c. “You need to understand that nurses communicate with other clients during the night.” d. “I will tell the night nurses that you complained.”

ANS: B

Listening for themes requires observing and understanding what the client is not saying, as well as what the person actually reveals. Identifying the underlying themes presented in a therapeutic conversation can relieve anxiety and provide direction for individualized nursing interventions. Speaking to a supervisor, explaining that nurses communicate with other clients during the night, and telling the night nurse of the complaint are actions by the nurse, not identification of themes.

DIF: Cognitive Level: Application REF: pp. 83-84 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 13. A client states, “I don’t know about taking this medicine the doctor is putting me on. I’ve

never had to take medication before, and now I have to take it twice a day.” The nurse’s response is, “It sounds like you don’t know what to expect from taking the medication.” The nurse’s response is an example of which of the following?

a. b. c. d.

Clarification Paraphrasing Restatement Validation

ANS: B

Paraphrasing is a listening response, which focuses on the cognitive component of a message.

It is used to check whether the nurse's translation of the client's words represents an accurate interpretation of the message. The strategy takes the essential information expressed in the client's original message and presents it in a shorter, more specific form, without losing its meaning. The focus is on the core elements of the original statement: “In other words, what I think I hear you saying is,” or “let me understand, are you saying that….?” Clarification is a listening response, used to ask clients for more information or for elaboration on a point. The strategy is useful when parts of a client's communication are ambiguous or not easily understood. Failure to ask for clarification when part of the communication is poorly understood means that the nurse will act on incomplete or inaccurate information. For example, you could say, “May I tell you what I have understood so far, and see if you think I understand your situation? Restatement is an active listening strategy used to broaden a client's perspective or provide a sharper focus on a specific part of the communication.

Restating a self-critical or irrational part of the message in a questioning manner focuses the client's attention on the possibility of an inaccurate or global assertion. Restatement is particularly effective when the client overgeneralizes or seems stuck in a repetitive line of thinking. To challenge the validity of the client's statement directly could be counterproductive, whereas repeating parts of the message in the form of a query serves a similar purpose without raising defenses; for example, “Let me see if I have this right…”

Validation is a special form of feedback, used to ensure that both participants have the same basic understanding of messages. Simply asking clients whether they understand what was said is not an adequate method of validating message content. Validation can provide new information that helps the nurse frame comments that match the client's need.

DIF: Cognitive Level: Application REF: pp. 87-88 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 14. The student nurse is working on an assignment in which she has to interview a fellow student

nurse for 30 minutes. The fellow student nurse talks about career plans, possible jobs after graduation, and her part-time work. After 10 minutes, she has stopped talking and both student nurses sit in silence. Which of the following is the best response by the interviewing student nurse? a. “Tell me more about how you selected your career goals.” b. “Who is the most significant person in your life?” c. “What impact will these plans have on your life?” d. Remain silent until the fellow student nurse breaks the silence.

ANS: C

An open-ended question is usually just the introduction, requiring further dialogue about relevant topics. Ending the dialogue with a general open-ended question such as, “Is there anything else that is concerning you right now?” can provide relevant information that might otherwise be overlooked. Asking a focused question allows the interviewer to obtain more specific information. “Who is the most significant person in your life” is a closed-ended question that is limiting. A silent pause can be helpful, but long silences can become uncomfortable.

DIF: Cognitive Level: Application REF: pp. 82-83 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 15. As the nurse communicates with a client, the feedback provided by the nurse should be a. descriptive, general, and content focused. b. client focused and evaluative. c. well-timed and general. d. specific and focused on observed behavior.

ANS: D

Feedback is a response message related to specific client behaviors and words. Nurses give and ask for client feedback to ensure mutual understanding. Feedback can focus on the content, the relationship between people and events, the feelings generated by the message, or parts of the communication that are not clear. Feedback should be specific and focused on observed behavior. Analyzing a client's motivations make clients defensive. Feedback should be a two-way process. Feedback responses reassure the client that the nurse is fully attentive to what the client is communicating. When it offers a neutral mirror, clients are able to view a problem or behavior from a different perspective. Feedback is most relevant when it only addresses the topics under discussion and doesn’t go beyond the data presented by the client.

Feedback provided to nurses about their health teaching helps them to individualize teaching content and methodology to better facilitate the learning process.

DIF: Cognitive Level: Knowledge REF: p. 92 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 16. A client tells the nurse, “I am having a tough time and I am scared about the future.” Which of

the following responses by the nurse is the best feedback? a. “I know what you mean.” b. “You should do something about it.” c. “I really don’t think you are having a tough time.” d. “You are having a tough time and you are scared.”

ANS: D

Feedback is a response message related to specific client behaviors and words. Nurses give and ask for client feedback to ensure mutual understanding. Feedback can focus on the content, the relationship between people and events, the feelings generated by the message, or parts of the communication that are not clear. Feedback should be specific and focused on observed behavior. Analyzing a client's motivations make clients defensive. Feedback should be a two-way process. Feedback responses reassure the client that the nurse is fully attentive to what the client is communicating. When it offers a neutral mirror, clients are able to view a problem or behavior from a different perspective. Feedback is most relevant when it only addresses the topics under discussion, and doesn’t go beyond the data presented by the client.

Feedback provided to nurses about their health teaching helps them to individualize teaching content and methodology to better facilitate the learning process. “I know what you mean” is disconfirming. “You should do something about it” and “I really don’t think you are having a tough time” are examples of responses that are judging or evaluating.

DIF: Cognitive Level: Application REF: p. 92 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 17. When caring for a hospitalized client, the nurse demonstrates effective communication when a. presenting several ideas at a time. b. using vocabulary that is unfamiliar to the client. c. stating key ideas only once. d. putting ideas in a logical sequence of related material.

ANS: D

Guidelines to effective verbal communication in the nurse-client relationship include putting ideas in a logical sequence of related material, focusing only on essential elements and presenting one idea at a time, keeping language as simple as possible through using vocabulary familiar to the client, and repeating key ideas.

DIF: Cognitive Level: Application REF: p. 92 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 18. Which of the following is true in relation to the use of humor? a. Humor is most effective when building rapport. b. Humor should focus on the client’s personal characteristics. c. Humor and laughter have healing purposes. d. Humor should dominate the situation.

ANS: C

Humor and laughter have healing purposes. Laughter generates energy, and activates b-endorphins, a neurotransmitter that creates natural highs and reduces stress hormones.

Humor is most effective when rapport is well established and a level of trust exists between the nurse and client. When humor is used, it should focus on the idea, event, or situation, or something other than the client’s personal characteristics. Humor should fit the situation, not dominate it.

DIF: Cognitive Level: Knowledge REF: pp. 94-95 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

Chapter 6: Variation in Communication Styles Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following is a description of metacommunication? a. Communication style b. Nonverbal communication c. Verbal communication d. Nonverbal and verbal communication ANS: D

Metacommunication is a broad term used to describe all of the factors that influence how the message is perceived. It is a message about how to interpret what is going on.

Metacommunicated messages may be hidden within verbalizations or be conveyed as nonverbal gestures and expressions. Communication style refers to the manner in which one communicates. Nonverbal style includes facial expression, gestures, body posture, etc. Verbal style includes pitch, tone, and frequency.

DIF: Cognitive Level: Comprehension REF: p. 100 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. The nurse puts his arm around an older adult client when assisting her to transfer to a chair.

The client could interpret the nurse’s touch as a. a positive gesture only. b. a threat. c. denotation. d. paralanguage.

ANS: A

Touching a client is one of the most powerful ways a nurse has to communicate nonverbally.

Within a professional relationship, affective touch can convey caring and reassurance. In studies, nurses’ touching clients has been reported to be perceived both positively as an expression of caring and negatively as a threat. Denotation refers to the generalized meaning of a word. Paralanguage is the way a verbal message is expressed.

DIF: Cognitive Level: Application REF: p. 103 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 3. A description of denotation is a. a personalized meaning of a word or phrase. b. a generalized meaning assigned to a word. c. a meaning shared by families. d. a meaning generally shared within a specific culture.

ANS: B

Denotation refers to the generalized meaning assigned to a word. Connotation refers to a personalized meaning of a word. Jargon or slang is referred to a meaning generally shared within a specific culture.

DIF: Cognitive Level: Knowledge REF: p. 101 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 4. When communicating about a client with a health care provider from another culture, the

nurse states, “The client stopped taking his medications last week when he fell off the wagon.” The health care provider looks at the nurse blankly. This is an example of a. connotation. b. information processing. c. time span between messages. d. nonverbal cultural variations.

ANS: A

Connotation refers to the use of words in a personalized way that is culturally specific.

Processing is not the problem; the health care provider requires an explanation of the meaning. The health care provider does not need more time to translate the message. This is an example of connotation, not nonverbal communication.

DIF: Cognitive Level: Application REF: p. 101 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. The nurse is assigned to care for a client who has been diagnosed with multiple sclerosis.

Which communication behavior will have the most impact on the client? a. What is said b. Tone of voice c. Sense of confidence d. Verbal message ANS: B

The oral delivery of a verbal message, expressed through tone of voice, inflection, sighing, and so on, is referred to as paralanguage. It is important to understand this component of communication because it affects how the verbal message is likely to be interpreted. When the tone of voice does not fit the words, the message is less easily understood and is less likely to be believed. Pitch and tone can either support or contradict the content of the verbal message.

Sense of confidence will be reflected in tone of voice. Verbal message is affected by voice inflection.

DIF: Cognitive Level: Application REF: p. 101 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 6. Communication is a combination of a. verbal and nonverbal behaviors. b. pitch, tone, and paralanguage. c. proxemics, touch, and kinesics. d. eye contact, facial expressions, and nonverbal messages.

ANS: A

Communication is a combination of verbal and nonverbal behaviors integrated for the purpose of sharing information. Pitch, tone, and paralanguage are all components of vocalization.

Proxemics, touch, and kinesics are all nonverbal components. Eye contact and facial expressions are nonverbal communication.

DIF: Cognitive Level: Knowledge REF: p. 100 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 7. The majority of person-to-person communication is a. verbal. b. process. c. nonverbal. d. content.

ANS: C

The majority of person-to-person communication is nonverbal. Actions speak louder than words. Process refers to interpersonal sensitivity. Content refers to giving information.

DIF: Cognitive Level: Knowledge REF: p. 102 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 8. When the nurse asks a client, “How are you?” the client states, “I am fine.” As the client turns

away, she is crying. This is an example of a. nonverbal communication. b. incongruence. c. proxemics. d. congruence.

ANS: B

When nonverbal and verbal cues do not match, it is known as incongruence. This situation includes both verbal and nonverbal content. Proxemics refers to personal space. Congruence occurs when verbal and nonverbal messages match.

DIF: Cognitive Level: Application REF: p. 107 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 9. An adult client responds to questions inappropriately. The nurse should do which of the

following? a. Assume that the client is depressed and seek further information. b. Ask other staff members whether the client is sick. c. Leave the client alone for now and return to reassess. d. Observe the client’s nonverbal behavior.

ANS: D

When nonverbal cues are incongruent with the verbal information, messages are likely to be misinterpreted. When the verbal message is inconsistent with the nonverbal expression of the message, the nonverbal expressions assume prominence and are generally perceived as more trustworthy than the verbal content.

DIF: Cognitive Level: Application REF: p. 102 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 10. The nurse is assessing a newly admitted Native American client. When assessing the client’s

perception of touch, the nurse should a. casually touch the client. b. use timing with touch. c. ask the client for permission to touch. d. shake the client’s hand.

ANS: C

Care must be taken to abide by the client’s cultural proscriptions about the use of touch. This varies across cultures. Some Native Americans use touch in healing, so that casual touching may be taboo. The nurse should ask for permission before the use of touch.

DIF: Cognitive Level: Application REF: p. 103 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 11. When communicating with a client, which of the following best demonstrates the use of

nonverbal communication? a. Ignoring nonverbal cues b. Holding the client’s hand c. Conversing with the client d. Using incongruent nonverbal behaviors ANS: B

Skilled use of nonverbal communication through [therapeutic] silences, use of congruent nonverbal behaviors, body language, touch, proximics, and attention to client nonverbal cues such as facial expression can improve the relationship and build rapport with a client.

Conversing with the client is an example of verbal communication.

DIF: Cognitive Level: Application REF: p. 103 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 12. A client states he is feeling fine, but the nurse observes that he has a tense body posture and a

frown on his face. The nurse suspects that he is experiencing pain based on knowledge of a. confirming responses. b. denotation. c. proxemics. d. kinesics.

ANS: D

Kinesics is an important component of nonverbal communication. Commonly referred to as body language, it is defined as involving the conscious or unconscious body positioning or actions of the communicator. Words direct the content of a message, whereas emotions accentuate and clarify the meaning of the words. Confirming responses are responses used by the nurse. Denotation refers to generalized meaning of words. Proxemics refers to personal space.

DIF: Cognitive Level: Application REF: p. 103 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 13. In relation to gender differences in communication, which of the following is true? a. Men use more verbal communication in interpersonal relationships. b. Women smile more often. c. Men require less personal space than women. d. Men have a greater range of vocal pitch.

ANS: B

Studies show that women tend to use more facial expressiveness, smile more often, maintain eye contact, touch more often, and nod more often. Men use less verbal communication than women in interpersonal relationships. Studies show that men prefer a greater interpersonal distance between themselves and others and that they use gestures more often. Women have a greater range of vocal pitch and also tend to use different informal patterns of vocalization than men. They use more tones signifying surprise, cheerfulness, and unexpectedness.

DIF: Cognitive Level: Comprehension REF: p. 106 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 14. Social cognitive competency refers to a. the ability to use verbal and nonverbal interventions. b. understanding the relationships between the roles of the sender and receiver. c. the ability to interpret message content within interactions from the point of view

of each participant. d. interpreting emotional content by observing body language.

ANS: C

Social cognitive competency is the ability to interpret message content within interactions from the point of view of each of the participants. The ability to use verbal and nonverbal interventions refers to message competency. Understanding relationships of the sender and receiver refers to role relationship. Interpreting emotional content by observing body language refers to body cues.

DIF: Cognitive Level: Knowledge REF: p. 109 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 15. Which of the following messages would validate the worth of the individual? a. The nurse says, “Take that tray to room 6 bed 2.” b. “I want to know about your physical symptoms following the chemotherapy.” c. “Now dear, we are going to have a nice bath.” d. “I would like to meet your family and we could talk to them about your aftercare.”

ANS: D

Styles that convey “caring” send a message of individual worth that sustains the relationship with the client. For example, clients prefer that providers use a “warm” communication style to show caring, give information, and to allow them time to talk about their own feelings.

Confirming responses validate the intrinsic worth of the person. These are responses that affirm the right of the individual to be treated with respect. They also affirm the client’s autonomy (i.e., his or her right, ultimately, to make his or her own decisions). Giving directives is a disconfirming message. Discussing physical symptoms is a behavior that decreases involvement with client’s emotional self. “Now dear, we are going to have a nice bath” depersonalizes the client.

DIF: Cognitive Level: Application REF: p. 102 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 16. A communication style the nurse can use to ensure that the message sent is the same as the

one received is to a. refer to the client by diagnosis. b. establish a common vocabulary. c. have interactions that focus on physical care. d. refer to the client by bed number.

ANS: B

For successful communication, words used should have a similar meaning to both individuals in the interaction. An important part of the communication process is the search for a common vocabulary so that the message sent is the same as the one received. Referring to the client by diagnosis, having interactions focus on physical care, and referring to the client by bed number are communication styles that do not ensure that the message sent is the same as the one received.

DIF: Cognitive Level: Knowledge REF: p. 109 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 17. Message competency refers to which phase of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation ANS: C

Message competency refers to the ability to use language and nonverbal behaviors strategically in the intervention phase of the nursing process to achieve the goals of the interaction. The assessment, planning, and evaluation phases of the nursing process are incorrect answers.

DIF: Cognitive Level: Knowledge REF: p. 109 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE

1. Which of the following is true in relation to the context of the message? (Select all that

apply.) a. It is shaped by the situation in which the interaction occurs. b. Taking time to evaluate the time and space in which the contact takes place allows for flexibility in choosing the appropriate context. c. Communication is shaped by the environment in which it takes place. d. Evaluating the physical setting in which the contact takes place allows for flexibility in choosing the appropriate context. e. The environment has little effect on communication.

ANS: A, B, C, D

Communication is always influenced by the environment in which it takes place. It does not occur in a vacuum but is shaped by the situation in which the interaction occurs. Taking time to evaluate the physical setting and the time and space in which the contact takes place, as well as the psychological, social, and cultural characteristics of each individual involved, gives the nurse flexibility in choosing the most appropriate context. The environment always influences communication.

DIF: Cognitive Level: Knowledge REF: p. 110 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Chapter 7: Cultural Contexts and Communication Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Cultural competence a. involves a lack of acceptance of cultural differences in others. b. requires self-awareness of one’s own cultural values. c. is a nonessential skill set required for health care providers. d. begins with developing knowledge and acceptance of cultural differences in others.

ANS: B

Cultural competence is defined as “a set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals that enables them to work effectively in cross-cultural situations.” Cultural competence is an essential skill set required for health care providers. Self-awareness of unintentional bias in health care is essential.

Value judgments are hard to eliminate, particularly those outside of awareness. Developing competence begins with self-awareness of one’s own cultural values, attitudes, and perspectives, followed by developing knowledge and acceptance of cultural differences in others.

DIF: Cognitive Level: Knowledge REF: p. 117 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. Which of the following best describes cultural diversity? a. Encompasses variations between cultural groups b. A smaller group of people living within the dominant culture who have adopted a

cultural lifestyle distinct from that of the mainstream population c. Groups in which members share a cultural heritage from one generation to another d. Heterogeneous society in which diverse cultural worldviews can coexist ANS: A

Cultural diversity refers to variations among cultural groups. People notice differences related to language, mannerisms, and behaviors in people of different cultures, in ways that don’t happen with people from their own culture. Subculture refers to a smaller group of people living within the dominant culture, who have adopted a cultural lifestyle distinct from that of the mainstream population. Ethnicity is used to describe “groups in which members share a cultural heritage from one generation to another.” Personal awareness of a common racial, geographic, religious, or history binds people together, with a strong commitment to ethnic values and practices. Multiculturalism describes a heterogeneous society in which diverse cultural worldviews can coexist with some general characteristics shared by all cultural groups and some perspectives that are unique to a particular population.

DIF: Cognitive Level: Knowledge REF: p. 114 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. When communicating with a client from Thailand who speaks limited English, the nurse

should

a. b. c. d.

use technical jargon and complex sentences. recognize nodding as an indicator the client agrees with what the nurse is saying. speak quickly and concisely, using complex words. provide advice in a matter-of-fact, concise manner.

ANS: D

People tend to think and process information in their native language, translating back and forth from English. This results in delayed responses that need to be taken into account, particularly in health teaching. Sometimes the nurse is aware only that the client seems to be taking more time than usual. All written information should be provided in the person’s native language whenever possible to avoid misinterpretation. It is important that the translator of information be as well-versed in medical interpretations as in relevant terms used in both languages. With clients demonstrating limited English proficiency, the nurse should speak slowly and clearly; use simple words; and avoid slang, technical jargon, and complex sentences. Asian clients prefer a polite, friendly, but formal approach in communication. They appreciate clinicians willing to provide advice in a matter-of-fact, concise manner.

Confrontation is avoided; clients will nod and smile in agreement, even when they strongly disagree.

DIF: Cognitive Level: Application REF: p. 130 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. When practicing cultural awareness, the nurse recognizes that cultural patterns a. are socially transmitted through ethnic groups. b. are nonessential parts of personal identity. c. are minor determinants of health-related attitudes. d. are important determinants of health-related beliefs.

ANS: D

Cultural patterns are socially transmitted through family and other social institutions. They are an essential part of personal identity. Cultural patterns are important determinants of health-related beliefs, attitudes, values, and behaviors.

DIF: Cognitive Level: Analysis REF: p. 113 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Management of Care 5. The nurse is performing an admission assessment on an Asian client. The intake includes a

cultural assessment. The nurse should ask the client, a. “Does a minister, priest, or rabbi visit you?” b. “Do you feel understood and loved?” c. “What language do you prefer to speak?” d. “Does life have meaning and value for you?”

ANS: C

A cultural assessment is defined as a systematic appraisal of beliefs, values, and practices conducted to determine the context of client needs and to tailor nursing interventions. It is composed of three progressive, interconnecting elements: (1) a general assessment; (2) a problem-specific assessment; and (3) the cultural details needed for successful implementation. Asking about visits from a spiritual leader would be part of the spiritual assessment. Feelings and value of life do not assess cultural issues.

DIF: Cognitive Level: Application REF: p. 122 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Management of Care 6. The nurse is caring for a Hispanic client. When communicating with the client’s family about

the client’s illness, which family member should the nurse contact? a. Oldest female family member b. Oldest male family member c. Oldest daughter of client d. Oldest son of client ANS: B

Hispanics are an extroverted people who value interpersonal relationships. Hispanic clients trust feelings more than facts. Strict rules govern social relationships (respecto), with higher status being given to older individuals, and to male over female individuals. Nurses are viewed as authority figures, to be treated with respect. Clients hesitate to ask questions, so it is important to ask enough questions to ensure that clients understand their diagnosis and treatment plan.

DIF: Cognitive Level: Application REF: p. 125 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. A nursing instructor is teaching a group of student nurses about culture. When teaching the

students nurses about the concept of ethnocentrism, the student nurses demonstrate cultural sensitivity when they state that their culture a. is superior to others. b. has the right to impose its standards of “correct” behavior and values on another. c. is a culture that warrants a sense of pride. d. should be the norm because it is considered better or more enlightened than others.

ANS: C

Ethnocentrism refers to a belief that one's own culture should be the norm because it is considered better or more enlightened than others. Other cultures are judged as inferior.

Taking pride in one's culture is appropriate, but when a person fails to respect the value of other cultures, it is easy to develop stereotypes and prejudice. Ethnocentrism fosters the belief that one culture has the right to impose its standards of “correct” behavior and values on another. Prejudice can be felt or expressed, and directed to either a group as a whole or toward an individual associated with the group.

DIF: Cognitive Level: Analysis REF: p. 116 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Management of Care

8. When caring for a client from a different culture, which of the following is the best

assessment approach by the nurse? a. “Are there any special cultural beliefs about your illness that might help me give you better care?” b. “Describe to me your position of greatest relief from pain and discomfort.” c. “I will return shortly to give you a pain medication. Is there anything else that you need?” d. “I will roll your bed down and place a pillow between your legs.”

ANS: A

When assessing client preferences in a client from a different culture, an assessment approach can include asking about special cultural beliefs related to the illness that might help the nurse to provide better care. Questions regarding a client’s level of physical comfort do not address the client’s culture.

DIF: Cognitive Level: Application REF: p. 121 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. The nurse is assigned to provide a bed bath to a client who cannot speak English. Which of

the following communication tools or strategies should the nurse use? a. Nonverbal communication b. Trained interpreter c. Family member as interpreter d. Other staff member who speaks the same language ANS: B

Federal law (Title VI of the Civil Rights Act) mandates the use of a trained interpreter for any client experiencing communication difficulties in health care settings because of language.

Interpreters should have a thorough knowledge of the culture, as well as the language.

Interpreters should be carefully chosen, keeping in mind variations in dialects as well as differences in the sex and social status of the interpreter and the client if these factors are likely to be an issue. There are quality assurance and ethical issues associated with the use of untrained interpreters such as family, friends, or ancillary staff. They may not be familiar with medical terminology or may unintentionally misrepresent the meaning of a message. The client may or may not want a relative, friend, or nonprofessional staff to “know their business” or have access to subjective information.

DIF: Cognitive Level: Application REF: p. 122 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care 10. The nurse is caring for a postpartum client who is African American. The nurse recognizes

that an essential component for successful communication when interacting with this client is the use of a. clergy in treatment plans. b. only simple language strategies. c. folk-healing strategies. d. trust development.

ANS: D

Although African Americans are represented in every socioeconomic group, approximately one third of them live in poverty. For many, their cultural heritage traces back to slavery and deprivation. This unfortunate legacy colors the expectations of African Americans with health care issues and explains the distrust many African Americans have about the American health care system. African Americans need to experience feeling respected by their caregivers to counteract the sense of powerlessness they feel in health care settings. Establishing trust is essential for successful communication with African American clients. They are more willing to participate in treatment when they feel respected and are treated as treatment partners in their health care. Trust must be established before any interventions, such as consultation with a folk healer or clergy. There is no language barrier mentioned in the question.

DIF: Cognitive Level: Application REF: p. 126 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 11. Which of the following statements is true? a. A Muslim client may refuse to take insulin if it contains beef. b. African American males have a lower chance of developing cancer. c. Hispanic clients make small talk before discussing their health problems. d. Asian clients frequently challenge health care workers.

ANS: C

Hispanic clients need to develop trust (confianza) in the health care provider. They do this by making small talk before getting down to the business of discussing their health problems.

Muslim clients are expected to follow the Hallal (lawful) diet, which calls for dietary restrictions on eating pork or pork products, and drinking alcohol. African American males have a significantly greater chance of developing cancer and of dying from it. Communication behaviors in the Asian culture are characterized by mutuality, respect, and honesty. Health care providers are considered health experts, so they are expected to provide specific advice and recommendations. Asian clients prefer a polite, friendly, but formal approach in communication. They appreciate clinicians willing to provide advice in a matter-of-fact, concise manner.

DIF: Cognitive Level: Comprehension REF: p. 126 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 12. When assessing a 5-year-old Asian client in the emergency department, the nurse observes

welts on the client’s body. The nurse’s first course of action should be to a. report child abuse to the authorities. b. consult a traditional healer. c. question the family about cultural practices. d. ignore it because it is an imbalance between “yin and yang.”

ANS: C

In some Asian countries, healers use a process of “coining,” in which a coin is heated and vigorously rubbed on the body to draw illness out of the body. The resulting welts can mistakenly be attributed to child abuse if this practice is not understood. A cultural assessment needs to be done first. The first course of action is to do a cultural assessment by questioning the family. The welts should not be ignored because they could indicate child abuse.

DIF: Cognitive Level: Analysis REF: p. 129 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Management of Care 13. When performing a newborn bath demonstration for the mother of a Native American infant,

the nurse should a. maintain constant eye contact with the mother. b. anticipate answering many of the mother’s questions. c. ask the mother to stand next to the nurse. d. deliver verbal instructions in a story-telling format.

ANS: D

When the nurse is performing a newborn bath demonstration, the Native American mother is likely to watch from a distance, avoid eye contact with the demonstrator, ask few or no questions, and decline a return demonstration. This learning style should not be seen as indifference or lack of understanding. Being an experiential learner, the Native American woman is likely to assimilate the information provided and simply give the newborn a bath when it is needed. Their learning style is observational and oral, so the use of charts, written instructions, and pamphlets is usually not well received. Verbal instruction delivered in a story-telling format is more familiar to Native Americans.

DIF: Cognitive Level: Application REF: p. 131 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Management of Care 14. Which of the following is a true statement in relation to the concept of poverty? a. Poverty affects only a small segment of the population. b. Poor people expect others to work with them in making things better. c. Communication strategies that empower the poor to take small steps toward

dependence are most effective. d. Lack of essential resources is associated with political and personal powerlessness.

ANS: D

Poverty is a difficult but important sociocultural concept because it has an adverse effect on a large segment of the population, limiting their options in health care. Lack of essential resources is associated with political and personal powerlessness. The idea that the poor can exercise choice or make a difference in their lives is not part of their worldview. People living in poverty may overlook opportunities simply because life experience tells them that they cannot trust their own efforts to produce change. Poor people often look to others, but do not expect others to work with them in making things better. Communication strategies that acknowledge, support, and empower the poor to take small steps to independence are most effective.

DIF: Cognitive Level: Knowledge REF: p. 131 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 15. When caring for the poor client, a major component of care is a. ignoring personal biases. b. allowing stereotypes to distort nursing interventions.

c. maintaining respect for human dignity. d. treating all clients exactly the same.

ANS: C

Respect for the human dignity of the poor client is a major component of proactive care. This means that the nurse pays strict attention to personal biases and stereotypes so as not to distort assessment or implementation of nursing interventions. It means treating each client as “culturally unique,” with a set of assumptions and values regarding the disease process and its treatment, and acting in a nonjudgmental manner that respects the client’s cultural integrity.

DIF: Cognitive Level: Knowledge REF: p. 132 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 08: Engaging With Humility: Authentic Interpersonal Communication in Partnership: With Indigenous Peoples Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. The nursing profession’s first nurse researcher, who served as an early advocate for

high-quality care and used statistical data to document the need for hand washing in preventing infection, was a. Abraham Maslow. b. Martha Rogers. c. Hildegard Peplau. d. Florence Nightingale.

ANS: D

An early advocate for high-quality care, Florence Nightingale’s use of statistical data to document the need for hand washing in preventing infection marks her as the profession’s first nurse researcher.

DIF: Cognitive Level: Knowledge TOP: Step of the Nursing Process: All Phases MSC: Client Needs: Management of Care 2. Today, professional nursing education begins at the a. undergraduate level. b. graduate level. c. advanced practice level. d. administrative level.

ANS: A

Today, professional nursing education begins at the undergraduate level, with a growing number of nurses choosing graduate studies to support differentiated practice roles and/or research opportunities. Nurses are prepared to function as advanced practice nurse practitioners, administrators, and educators.

DIF: Cognitive Level: Comprehension TOP: Step of the Nursing Process: All Phases MSC: Client Needs: Management of Care 3. Nursing’s metaparadigm, or worldview, distinguishes the nursing profession from other

disciplines and emphasizes its unique functional characteristics. The four key concepts that form the foundation for all nursing theories are a. caring, compassion, health promotion, and education. b. respect, integrity, honesty, and advocacy. c. person, environment, health, and nursing. d. nursing, teaching, caring, and health promotion.

ANS: C

Individual nursing theories represent different interpretations of the phenomenon of nursing, but central constructs—person, environment, health, and nursing—are found in all theories and models. They are referred to as nursing’s metaparadigm.

DIF: Cognitive Level: Knowledge TOP: Step of the Nursing Process: All Phases MSC: Client Needs: Management of Care 4. When admitting a patient to the medical-surgical unit, the nurse asks the patient about cultural

issues. The nurse is demonstrating use of the concept of a. person. b. environment. c. health. d. nursing.

ANS: B

The concept of environment includes all cultural, developmental, and social determinants that influence a patient’s health perceptions and behavior. A person is defined as the recipient of nursing care, having unique bio-psycho-social and spiritual dimensions. The word health derives from the word whole. Health is a multidimensional concept, having physical, psychological, sociocultural, developmental, and spiritual characteristics. The World Health Organization (WHO, 1946) defines health as “a state of complete physical, mental, social well-being, not merely the absence of disease or infirmity.” Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people.

DIF: Cognitive Level: Application TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. A young mother tells the nurse, “I’m worried because my son needs a blood transfusion. I

don’t know what to do, because blood transfusions cause AIDS.” Which central nursing construct is represented in this situation? a. Environment b. Caring c. Health d. Person ANS: D

The concept of environment includes all cultural, developmental, and social determinants that influence a patient’s health perceptions and behavior. Caring is not one of the four central nursing constructs. The word health derives from the word whole. Health is a multidimensional concept, having physical, psychological, sociocultural, developmental, and spiritual characteristics. The World Health Organization (WHO, 1946) defines health as “a state of complete physical, mental, social well-being, not merely the absence of disease or infirmity.” Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Person is defined as the recipient of nursing care, having unique bio-psycho-social and spiritual dimensions.

DIF: Cognitive Level: Application TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 6. The nurse performs a dressing change using sterile technique. This is an example of which

pattern of knowledge? a. Empirical b. Personal c. Aesthetic

d. Ethical ANS: A

Empirical knowledge is the scientific rationale for skilled nursing interventions. Personal ways of knowing allow the nurse to understand and treat each individual as a unique person.

Aesthetic ways of knowing allow the nurse to connect in different and more meaningful ways.

Ethical ways of knowing refer to the moral aspects of nursing.

DIF: Cognitive Level: Comprehension TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care 7. The nurse-patient relationship as described by Hildegard Peplau a. would not be useful in a short-stay unit. b. allows personal and social growth to occur only for the patient. c. facilitates the identification and accomplishment of therapeutic goals. d. focuses on maintaining a personal relationship between the nurse and the patient.

ANS: C

Hildegard Peplau offers the best-known nursing model for the study of interpersonal relationships in health care. Her model describes how the nurse-patient relationship can facilitate the identification and accomplishment of therapeutic goals to enhance patient and family well-being. In contemporary practice, Peplau’s framework is more applicable today in longer term relationships, and in settings such as rehabilitation centers, long-term care, and nursing homes. Despite the brevity of the alliances in acute care settings, basic principles of being a participant observer in the relationship, building rapport, developing a working partnership, and terminating a relationship remain relevant.

DIF: Cognitive Level: Knowledge TOP: Step of the Nursing Process: All Phases MSC: Client Needs: Psychosocial Integrity 8. The identification phase of the nurse-patient relationship a. sets the stage for the rest of the relationship. b. correlates with the assessment phase of the nursing process. c. focuses on therapeutic goals to enhance patient and family well-being. d. uses community resources to help resolve health care issues.

ANS: C

Hildegard Peplau offers the best-known nursing model for the study of interpersonal relationships in health care. Her model describes how the nurse-patient relationship can facilitate the identification and accomplishment of therapeutic goals to enhance patient and family well-being.

DIF: Cognitive Level: Knowledge TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care 9. Which of the following is NOT a specific way interpersonal health communication impacts

health care service quality? a. More effective diagnosis and earlier recognition of health changes. b. Better understanding of the patient’s condition. c. Development of a workable treatment partnership. d. Each communicator constructs a mental picture of the other during the conversation.

ANS: D

Communication between health care providers and patients impacts the way care is delivered; it is as important as the care itself. Outcomes of effective interpersonal communication in health care relate to higher patient satisfaction and productive health changes.

DIF: Cognitive Level: Applying TOP: Step of the Nursing Process: All Phases MSC: Client Needs: Management of Care 11. Which of the following statements about communication theory is true? a. Primates are able to learn new languages to share ideas and feelings. b. Concepts include only verbal communication. c. Perceptions are clarified through feedback. d. Past experience does not influence communication.

ANS: C

Feedback is the only way to know that one’s perceptions about meanings are valid. Human communication is unique. Only human beings have large vocabularies and are capable of learning new languages as a means of sharing their ideas and feelings. Communication includes language, gestures, and symbols to convey intended meaning, exchange ideas and feelings, and to share significant life experience. To encode a message appropriately requires a clear understanding of the receiver’s mental frame of reference (e.g., feelings, personal agendas, past experiences) and knowledge of its purpose or intent of the communication.

DIF: Cognitive Level: Knowledge TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. In the circular transactional model of communication, a. questions are framed in order to recognize the context of the message. b. people take only complementary roles in the communication. c. the context of the communication is unimportant. d. the purpose of communication is to influence the receiver.

ANS: A

A circular model expands linear models to include the context of the communication, feedback loops, and validation. With this model, the sender and receiver construct a mental picture of the other, which influences the message and includes perceptions of the other person’s attitude and potential reaction to the message.

DIF: Cognitive Level: Comprehension TOP: Step of the Nursing Process: All Phases MSC: Client Needs: Psychosocial Integrity 13. The nurse recognizes that feedback loops a. do not allow for correction of original information. b. are solely based on the General Systems Theory. c. do not allow for validation of information. d. allow the human system to correct its original information.

ANS: D

Feedback (from the receiver or the environment) allows the system to correct or maintain its original information. Feedback loops (from the receiver, or the environment) validate the information, or allow the human system to correct its original information. General Systems Theory, initially described by Ludwig von Bertalanffy (1968), focuses on process and interconnected relationships comprising the “whole.”

DIF: Cognitive Level: Knowledge TOP: Step of the Nursing Process: All Phases MSC: Client Needs: Psychosocial Integrity 14. Which of the following statements best represents therapeutic communication when a student

discovers a patient crying in bed? a. “I am the nurse who will be doing your treatments today.” b. “Will you listen to me so I can help you get better?” c. “This is what is going to happen during surgery.” d. “Can we talk about what seems to be bothering you?”

ANS: D

Asking about what is bothering the patient is goal directed. Its purpose is to promote patient well-being. “I am the nurse who will be doing your treatments today” is a statement of fact, and it ignores the patient’s emotional needs. “Will you listen to me so I can help you get better?” is not goal directed and does not involve mutuality. “This is what is going to happen during surgery” is simply one way. It does not engage the patient in a therapeutic manner.

DIF: Cognitive Level: Application TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 15. The central constructs of person, environment, health, and nursing are found in all nursing

theories and models and are referred to as a. telehealth. b. the medical model. c. nursing’s metaparadigm. d. five core areas of competency.

ANS: C

Individual nursing theories represent different interpretations of the phenomenon of nursing, but central constructs—person, environment, health, and nursing—are found in all theories and models. They are referred to as nursing’s metaparadigm. These constructs are the “metalanguage” of nursing, and together they act as basic building blocks for the discipline of professional nursing. Telehealth is fast becoming an integral part of the health care system, used both as a live interactive mechanism (particularly in remote areas, where there is a scarcity of health care providers) and as a way to track clinical data. Two important outcomes are reduced health costs and increased access to care. During the last century, the bulk of professional care was delivered in acute care settings, based on the disease-focused medical model. Switching to today’s community focus recognizes the fact that chronic medical conditions account for most of today’s care, with most being treated in the community. The IOM report Health professions education: A bridge to quality (2003) calls for the restructuring of clinical education responsive to the 21st century health system transformation goals of providing the highest quality and safest medical care possible. This report identified five core areas of competency required to cross the bridge to quality.

DIF: Cognitive Level: Comprehension

TOP: Step of the Nursing Process: All Phases

MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. The discipline of nursing has “a unique perspective, a distinct way of viewing all phenomena,

which ultimately defines and limits the nature of its inquiry,” related to (Select all that apply.) a. principles and laws that govern the life processes, well-being, and optimum functioning of human beings, sick or well. b. patterning of human behavior in interaction with the environment in critical life situations. c. processes by which positive changes in health status are affected. d. processes by which negative changes in health status are affected. e. patterning of human behavior in interaction with the environment in every life situation. f. principles and laws that govern the life processes, well-being, and optimum functioning of human beings, in relation to wellness only.

ANS: A, B, C

Donaldson and Crowley characterize the discipline of nursing as having “a unique perspective, a distinct way of viewing all phenomena, which ultimately defines and limits the nature of its inquiry,” related to “Principles and laws that govern the life processes, well-being, and optimum functioning of human beings, sick or well; patterning of human behavior in interaction with the environment in critical life situations; and processes by which positive changes in health status are affected.”

DIF: Cognitive Level: Application TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Chapter 9: Therapeutic Communication in Groups Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following is a characteristic of a secondary group? a. There is not a designated leader. b. They have a prescribed structure. c. They lack identified specific goals. d. The group remains together even when goals are achieved.

ANS: B

Secondary groups differ from primary groups in purpose and function because they have a prescribed structure; a designated leader; and specific goals. When the group completes its task or achieves its goals, the group disbands.

DIF: Cognitive Level: Knowledge REF: p. 136 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. The nurse is caring for a client who has a large extended family. The nurse recognizes the

client is part of a group known as a a. focus group. b. educational group. c. primary group. d. secondary group.

ANS: C

A group is a social unit that can satisfy a person’s need for belongingness. Groups are categorized as primary or secondary. Primary groups are formed early in life and are characterized by an informal structure and close personal relationships. Primary groups have a lifelong influence on self-identity and social behaviors. Group membership is automatic (e.g., in a family) or voluntarily chosen because of a common interest (e.g., long term friendship) and is open ended. Secondary groups are described as purposeful, planned, time-limited relationships with an established beginning and end. Secondary groups differ from primary groups in purpose and function because they have a prescribed structure; a designated leader; and specific goals. When the group completes its task or achieves its goals, the group disbands. People join secondary groups to meet personally established goals, to develop knowledge and skills, or because it is required by the larger community system to which the individual belongs. Work groups, social action, and health-related therapeutic or support groups are good examples.

DIF: Cognitive Level: Comprehension REF: p. 136 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. Which of the following describes group think? a. A member of a corporate executive committee states, “You could be making a big

mistake.” b. Members of a corporate executive committee fail to inform the chairperson that

some middle managers do not support the decision. c. A corporate executive committee cancels a press conference in light of poor

market survey results. d. Members demonstrate a willingness to take interpersonal risks ANS: B

Extreme cohesiveness can result in a negative group phenomenon referred to as group think.

Group think occurs when the approval of other group members becomes so important that group members support a decision they fundamentally don’t agree with, just for the sake of harmony. Individual members are afraid to express conflicting ideas and opinions for fear of being excluded from the group. The group exerts pressure on members to act as one voice in decision making. Realistic evaluation of issues doesn’t occur because group members minimize conflict in an effort to reach consensus.

DIF: Cognitive Level: Analysis REF: pp. 154-155 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 4. Which of the following statements is true in relation to task functions? a. When task functions predominate, member satisfaction increases. b. When maintenance functions predominate, goals are achieved. c. They are behaviors used to move toward goal achievement. d. They are behaviors designed to ensure personal satisfaction.

ANS: C

Functional roles differ from positional roles group members assume in that they are related to the type of member contributions needed to achieve group goals. Constructive role functions are the behaviors members use to move toward goal achievement (task functions) and behaviors designed to ensure personal satisfaction (maintenance functions). When task functions predominate, member satisfaction decreases. When maintenance functions override task functions, members have trouble reaching goals.

DIF: Cognitive Level: Knowledge REF: p. 142 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. When leading a group meeting, the nurse notices two group members talking. Which of the

following represents the best intervention by the nurse? a. Ask the group, “Have you noticed who is talking at this time?” b. Tell the two group members, “I would like you to stop talking.” c. Provide the two group members with a verbal summary of what the group has been discussing. d. Ask the two group members, “Would you share your comments with the group?”

ANS: D

Self-roles are roles a person uses to meet self-needs at the expense of other members’ needs, group values, and goal achievement. Self-roles detract from the group’s work and compromise goal achievement by taking time away from group issues and creating discomfort among group members. Challenging the talkers does not foster a safe environment in which to express feelings. With group communication strategies, the desired communication flow is from member to member, rather than from nurse leader to client.

DIF: Cognitive Level: Application REF: p. 142 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 6. The group leader states, “Today we discussed some of the issues about taking medications,

and each one of you developed a goal in relation to some of the problems you were experiencing. I think it was helpful that some of you were able to share your experiences with other group members.” The leader is using the technique of a. harmonizing. b. summarizing. c. encouraging. d. compromising.

ANS: B

Summarizing pulls related ideas together; restates key ideas; offers a group solution or suggestion for other members to accept or reject. Harmonizing attempts to reconcile disagreements; helps members reduce conflict and explore differences in a constructive manner. Encouraging indicates by words and body language unconditional acceptance of others; agrees with contributions of other group members; and is warm, friendly, and responsive to other group members. Compromising admits mistakes; offers a concession when appropriate; and modifies position in the interest of group cohesion.

DIF: Cognitive Level: Application REF: p. 142 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 7. The nurse notices that a group member is quiet during support group meetings. What is the

best intervention by the nurse for involving the quiet group member in the group process? a. Ask the group if they have noticed that a group member never talks. b. Ask the group what can be done to involve the quiet group member more. c. Set up a private meeting with the quiet group member to discuss group participation. d. Ask the quiet group member if he or she would like to comment on what another group member has just said.

ANS: D

Group participation on an equal basis should be a group expectation. Although the level of participation is never quite equal, discussion groups in which only a few members actively participate are disheartening to group members and limited in learning potential. Because the primary purpose of a discussion group is to promote the learning of all group members, other members are charged with the responsibility of encouraging the participation of more silent members. Sometimes, when more verbal participants keep quiet, the more reticent group member begins to speak.

DIF: Cognitive Level: Application REF: p. 151 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 8. A breast cancer support group is an example of a a. closed group.

b. private group. c. homogeneous group. d. heterogeneous group.

ANS: C

Homogeneous groups share common characteristics, for example, diagnosis (e.g., breast cancer support group) or a personal attribute (e.g., gender or age). Closed groups have a predefined selected membership with an expectation of regular attendance for an extended time period, usually at least 12 sessions. Group members may be added, but their inclusion depends on a match with group-defined criteria. Most psychotherapy groups fall into this category. A breast cancer support group is not an example of a private group but is an example of an open group in which individuals can come and go depending on their needs.

Heterogeneous groups represent a wider diversity of human experience and problems.

Members vary in age, gender, and psychodynamics. Most psychotherapy and insight-oriented personal growth groups have a heterogeneous membership. Educational groups held on inpatient units (e.g., medication groups) may have a homogeneous membership related to diagnosis or specific learning needs.

DIF: Cognitive Level: Knowledge REF: p. 143 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Management of Care 9. During the first session of an Alzheimer disease support group for family members, the nurse

recognizes the need to a. encourage member contributions and emphasize cooperation in recognizing each person’s talents related to group goals. b. accept differences in member perceptions as being normal and growth producing. c. encourage group members to introduce themselves and share a little of their background or their reason for coming to the group. d. link constructive themes while stating the nature of the disagreement.

ANS: C

The forming phase in therapeutic groups focuses on helping clients establish trust in the group and with each other. Communication is tentative. Members are asked to introduce themselves and share a little of their background or their reason for coming to the group. Once initial conflict is resolved in the storming phase, the group moves into the norming phase.

Group-specific norms have developed from discussions in the previous phase. The leader encourages member contributions and emphasizes cooperation in recognizing each person’s talents related to group goals. The storming phase helps group members move to a deeper level. In the storming phase, the gloves come off and communication can become controversial. The leader plays an important facilitative role in the storming phase by accepting differences in member perceptions as being normal and growth producing. By affirming genuine strengths in individual members, leaders model handling conflict with productive outcomes. Linking constructive themes while stating the nature of the disagreement is an effective modeling strategy.

DIF: Cognitive Level: Application REF: p. 145 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

10. When members of a group experience controversy, conflict, and disagreements, the nurse

leading the group recognizes the importance of a. encouraging member contributions and emphasizing cooperation in recognizing each person’s talents related to group goals. b. focusing on working together and participating in another person’s personal growth. c. having members introduce themselves and share a little of their background or their reason for coming to the group. d. accepting differences in member perceptions as being normal and growth producing.

ANS: D

The storming phase helps group members move to a deeper level. In the storming phase, the gloves come off and communication can become controversial. The leader plays an important facilitative role in the storming phase by accepting differences in member perceptions as being normal and growth producing. By affirming genuine strengths in individual members, leaders model handling conflict with productive outcomes. Linking constructive themes while stating the nature of the disagreement is an effective modeling strategy. Once initial conflict is resolved in the storming phase, the group moves into the norming phase. Group-specific norms have developed from discussions in the previous phase. The leader encourages member contributions and emphasizes cooperation in recognizing each person’s talents related to group goals. In the performing stage of group development, members focus on problem solving. Working together and participating in another person’s personal growth allows members to experience one another’s personal strengths and the collective caring of the group.

The forming stage is an orientation phase. Communication is tentative and structured to allow members to learn about each other and develop trust. The leader takes an active role in helping group members feel accepted during the forming stage. Members are asked to introduce themselves and share a little of their background or their reason for coming to the group.

DIF: Cognitive Level: Analysis REF: p. 146 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 11. A long-standing group therapy meeting has been in process for 1/2 hour when a member

arrives late. Another member says, “I thought we agreed as a group to come on time.” This statement represents which of the following? a. Regulation b. Law c. Role d. Norm ANS: D

Group norms refer to the unwritten behavioral rules of conduct expected of group members.

Norms provide needed predictability for effective group functioning and make the group safe for its members. There are two types of group norms: (1) universal and (2) group specific.

Universal norms are stated behavioral standards, which must be present in all groups for effective outcomes. Examples include confidentiality, regular attendance, and not socializing with members outside of the group. Unless group members can trust that personal information will not be shared outside the group setting (confidentiality), trust will not develop. Regular attendance at group meetings is critical to group stability and goal achievement. Personal relationships between group members outside of the group threaten the integrity of the group as the therapeutic arena for the group’s work. Group-specific norms evolve from the group itself in the storming phase. They represent the shared beliefs, values, and unspoken operational rules governing group function. Examples include tolerance for latecomers, use of humor or confrontation, and talking directly to other group members rather than about them.

Regulation, law, and role are not examples of behavioral standards set by the group.

DIF: Cognitive Level: Application REF: p. 154 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. During a support group meeting, a group member makes several sexually provocative remarks

toward the group leader. The best response by the group leader is, a. “What do you think your fellow group member is trying to tell us?” b. “I want to discuss your sexually provocative remarks privately after this meeting.” c. “Our group work is of the highest priority; please align your remarks with the group purpose.” d. “I don’t appreciate what you are saying, you are excused from the group.”

ANS: C

Members who test boundaries through sexually provocative, flattering, or insulting remarks should have limits set promptly. The group leader should refer to the work of the group as being of the highest priority and tactfully ask the person to align remarks with the group purpose. Limits need to be set promptly within the group. The group member should not be excused at this stage.

DIF: Cognitive Level: Application REF: p. 146 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 13. When a group leader encourages the group members to express their feelings about one

another with the stipulation that any concerns the group may have about an individual member or suggestions for future growth should be stated in a constructive way and the group leader summarizes goal achievement, the group has reached which phase of group development? a. Formative phase b. Engagement c. Active intervention d. Termination ANS: D

The final phase of group development, termination or adjournment, ideally occurs when the group members have achieved desired outcomes. This phase is about task completion and disengagement. The leader encourages the group members to express their feelings about one another with the stipulation that any concerns the group may have about an individual member or suggestions for future growth should be stated in a constructive way. The leader closes the group with a summary of goal achievement. By waiting until the group ends to share closing comments, the leader has an opportunity to soften or clarify previous comments and to connect cognitive and feeling elements that need to be addressed. Engagement occurs during the forming stage, and active interventions occur during the performing stage.

DIF: Cognitive Level: Knowledge REF: p. 147 TOP: Step of the Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 14. A staff nurse is assigned to lead a community group meeting comprised mostly of psychotic

clients. When setting up this type of group meeting, the nurse recognizes that a. refreshments should always be eliminated in order to keep the meeting room neat and orderly. b. acutely psychotic clients generally can participate in community group meetings prior to being stabilized. c. the group leader should take a passive role in order to avoid frightening the clients. d. choosing a fellow staff member to help co-lead the group is recommended.

ANS: D

Staff nurses are sometimes called upon to lead or co-lead unit-based group psychotherapy on inpatient units. Other times staff nurses participate in community group meetings comprised mostly of psychotic clients. Although acutely psychotic clients usually cannot participate until they are stabilized, community groups and small structured therapy groups can be useful. A directive but flexible leadership approach is needed. Because the demands of leadership are so intense with psychotic clients, co-leadership is recommended. Co-therapists can share the group process interventions, model healthy behaviors, offset negative transference from group members, and provide useful feedback to each other. An introductory format for support group leaders includes potentially allowing time for informal networking through providing a 10-minute break with or without refreshments in order to allow members to interact informally with each other. If a group topic is not forthcoming from members, the leader can introduce a relevant, concrete, problem-centered topic of potential interest to the group.

DIF: Cognitive Level: Application REF: p. 148 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 15. A member of a support group is concerned that the group has not been ending on time and

that some members have been pairing off to discuss group issues after the meetings. The concerned group member expresses these concerns during a group meeting. This is an example of which maintenance function? a. Setting standards b. Consensus taking c. Seeking information d. Initiating discussion ANS: A

Setting standards calls for the group to reassess or confirm implicit and explicit group norms when appropriate. Group norms refer to the behavioral rules of conduct expected of group members. Norms provide needed predictability for effective group functioning and make the group safe for its members. There are two types of group norms: (1) universal and (2) group specific. Universal norms are stated behavioral standards, which must be present in all groups for effective outcomes. Examples include confidentiality, regular attendance, and not socializing with members outside of the group. Unless group members can trust that personal information will not be shared outside the group setting (confidentiality), trust will not develop. Regular attendance at group meetings is critical to group stability and goal achievement. Personal relationships between group members outside of the group threaten the integrity of the group as the therapeutic arena for the group’s work. Group-specific norms evolve from the group itself in the storming phase. They represent the shared beliefs, values, and unspoken operational rules governing group function. Examples include tolerance for latecomers, use of humor or confrontation, and talking directly to other group members rather than about them. Maintenance functions are behaviors that help the group maintain harmonious working relationships. Consensus taking checks to see whether the group has reached a conclusion, and asks the group to test a possible decision. Consensus taking is an example of a task function. Seeking information or opinion involves requesting facts from other members, asking other members for opinions, and seeking suggestions or ideas for task accomplishment. Seeking information is an example of a task function. Initiating involves identifying tasks or goals, defining the group problem, and suggesting relevant strategies for solving the problem. Initiating is an example of a task function.

DIF: Cognitive Level: Application REF: p. 142 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 16. A member of a support group frequently whispers to other members of the group and appears

indifferent and passive during group meetings. Which of the following nonfunctional self-roles is represented in this situation? a. Aggressor b. Avoider c. Blocker d. Self-confessor ANS: B

An example of a nonfunctional self-role is the role of avoider, which is characterized by whispering to others, daydreaming, doodling, and acting indifferent and passive. Another example of a nonfunctional self-role is the role of aggressor, which is characterized by criticizing or blaming others, personally attacking other members, and using sarcasm and hostility in interactions. Another nonfunctional self-role is the role of blocker, which is characterized by instantly rejecting ideas or arguing an idea to death, citing tangential ideas and opinions, and obstructing decision making. A final example of a nonfunctional self-role is the role of self-confessor, which is characterized by using the group to express personal views and feelings unrelated to the group task.

DIF: Cognitive Level: Application REF: p. 142 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

17. The nurse recognizes an effective group includes which of the following characteristics? a. Power resides in the leader and is not shared. b. Communication is guarded and feelings are not always given attention. c. Goals are vague or imposed on the group without discussion. d. Goals are clearly identified and collaboratively developed.

ANS: D

Characteristics of effective groups include having goals that are clearly identified and collaboratively developed. Unshared leader power, guarded communication and feelings, and vague goals are examples of ineffective group characteristics.

DIF: Cognitive Level: Application REF: p. 152 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

Chapter 10: Self Concept in Professional Interpersonal Relationships Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following represents the role of the nurse in helping a client reframe a

potentially incapacitating sense of self into one with more hope and broader options when faced with a health-related difficulty? a. They can take a passive approach. b. They can negate potential possibilities. c. They can focus on personal weaknesses. d. They can reframe the client’s sense of self.

ANS: D

When life “throws a health-related curve ball,” nurses play a critical role in helping clients reframe a potentially incapacitating sense of self into one with more hope and broader options.

They can help clients revisit personal strengths, consider new possibilities, incorporate new information, and seek out appropriate resources as a basis for making good clinical decisions and taking constructive actions. Even a nurse’s “supportive presence” can give a client a reason to hope.

DIF: Cognitive Level: Comprehension REF: p. 161 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. An older adult client is admitted to the hospital with terminal cancer. The client expresses

acceptance of impending death and states, “I am very satisfied with the life I had.” The nurse recognizes the client is in Erikson’s stage of psychosocial development known as which of the following? a. Integrity vs. Despair b. Autonomy vs. Shame and Doubt c. Intimacy vs. Isolation d. Identity vs. Identity Diffusion ANS: A

In this stage, the focus is the meaning of life and worth. It includes acceptance of growing limitations while maintaining a maximum productivity. Expression of acceptance of certitude of death as well as satisfaction with one’s contributions to life are also characteristics of this stage. Autonomy versus Shame and Doubt occurs during the toddler stage of development.

Intimacy versus Isolation occurs during the young adult stage. Identity versus Identity Diffusion occurs during adolescence.

DIF: Cognitive Level: Application REF: p. 164 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. The nurse is caring for an adolescent client who has had an amputation of his right leg. The

client states, “I’m really worried my girlfriend might not want to be with me anymore. I don’t look the same.” Which of the following concepts is represented in this situation? a. Role performance

b. Body image c. Self-esteem d. Personal identity ANS: B

This situation refers to an individual’s perception of the body. The situation is not about how the client performs but about how he perceives his body. Self-esteem refers to the significance placed on self-concept. Personal identity concept refers to perceptual, cognitive, emotional, and spiritual elements.

DIF: Cognitive Level: Application REF: pp. 166-167 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 4. Which of the following statements about perception is true? a. Perception is a function of the senses. b. Perception is an interpersonal process. c. Positive images are retained longer than negative ones. d. Personal identity is constructed through cognitive processes of perception.

ANS: D

Personal identity is constructed through cognitive processes of perception and cognition.

Perception is a function of the mind, not the senses. Perception is an intrapersonal process.

Negative images are retained longer than positive ones.

DIF: Cognitive Level: Comprehension REF: p. 178 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. Identify the type of perceptual alteration represented in the following example: Jim, a

12-year-old, states, “I am different from others in my physical education class because I am the class dunce.” a. Distorted reality b. Selective attention c. Self-fulfilling prophecy d. Cognitive distortion ANS: C

Negative concepts of possible selves can become a self-fulfilling prophecy. Distorted reality refers to a sense of self not based in reality. Selective attention occurs when a person hears only part of the message. Cognitive distortion refers to a distortion in thinking.

DIF: Cognitive Level: Application REF: p. 160 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 6. A client states, “I am an obese, compulsive person.” The nurse demonstrates how to conduct a

perceptual check when stating which of the following? a. “Can you tell me more about this?” b. “Is it difficult for you to be this way?” c. “I wouldn’t worry about being very neat.” d. “It is okay to be this way; you are not hurting anyone.”

ANS: A

Frequent perceptual checks and active listening are helpful interventions. When combined with well–thought-out inferences about the meaning of client behaviors, they enhance the quality of decision making in the nurse-client relationship. Checking in with clients allows the nurse to use perceptual data in a conscious, deliberate way to facilitate the relationship process. “Is it difficult for you to be this way?” allows for only a “yes” or “no” answer and does not actively engage the client in conversation. “I wouldn’t worry about being very neat” does not encourage an active conversation. “It is okay to be this way; you are not hurting anyone” does not encourage an active conversation.

DIF: Cognitive Level: Analysis REF: p. 169 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 7. When learning about the Johari Window, the student nurse recognizes that the model consists

of four areas, and that the hidden self can best be described as a. what is known to self and others. b. what is known by others, but not by self. c. what is known by self, but not by others. d. what is unknown to self and also unknown to others.

ANS: C

Although cognitive awareness of the self-concept is never fully complete, the Johari Window provides a disclosure/feedback model to help people learn more about their self-concept (Luft & Ingham). The model consists of four areas: • Open self (arena): what is known to self and others • Blind self: what is known by others, but not by self • Hidden self (façade): what is known by self, but not by others • Unknown self: what is unknown to self and also unknown to others DIF: Cognitive Level: Application REF: p. 162 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 8. When giving a class presentation on self-concept, a student nurse notices that a classmate has

fallen asleep. The student nurse immediately decides that the presentation must be boring and that she will fail this assignment and subsequently obtain a poor grade in the course. This is an example of a. selective attention. b. negative self-talk. c. self-fulfilling prophecy. d. negative feedback.

ANS: B

Self-talk is a cognitive process people can use to lessen cognitive distortions. When the thought carries a negative value, it can affect the individual as though the thought represented the whole truth about the person. Selective attention occurs when a person hears only parts of a message. In this situation, it could become a self-fulfilling prophecy if her performance does in fact suffer. Negative feedback could occur if the instructor told the student the presentation was boring.

DIF: Cognitive Level: Application REF: p. 170 TOP: Step of the Nursing Process: All Phases of the Nursing Process MSC: Client Needs: Psychosocial Integrity 9. Which of the following statements is true about self-esteem? a. It is an objective emotional process. b. Achievements lead to high self-esteem. c. It is the emotional value a person places on his or her self-concept. d. It is a concept that becomes fixed.

ANS: C

Self-esteem is defined as the emotional value a person places on his or her self-concept. It identifies the degree to which people approve of themselves.

DIF: Cognitive Level: Comprehension REF: p. 170 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 10. When directing the behavior of clients, it is important for the nurse to a. understand the dimensions of self-concept. b. become personally involved with each client. c. learn to control one’s feelings. d. offer limited guidance and support.

ANS: A

Understanding the dimensions of self-concept and the critical role it plays in directing behavior is key to working effectively with clients and families. It is always a core variable to consider in nurse-client relationships. Nurses play an important role in providing support and guidance for clients related to self-concept. The nurse engages with the client in a goal-directed professional relationship. The nurse connects emotionally with the client.

DIF: Cognitive Level: Knowledge REF: p. 178 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 11. To adequately meet the spiritual needs of clients, the nurse should first a. learn to be considerate and sensitive. b. distinguish between his or her own spiritual needs and those of the client. c. meet the client’s spiritual needs. d. offer to pray and read the bible with the client.

ANS: B

Nurses need to distinguish between their own spiritual orientation and needs and those of their clients. It is not appropriate to impose a spiritual ritual on a client that would be at odds with his or her spiritual beliefs. There should be some evidence from the client’s conversation that praying or reading the bible with a client would be an acceptable support.

DIF: Cognitive Level: Application REF: p. 177 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

12. A client has just had his status changed to “comfort care only.” The nurse recognizes that the

client is spiritually distressed. The nurse understands that spiritual pain a. cannot be inferred from the client’s behavior. b. is not as severe as physical pain. c. cannot be verbally shared. d. can be as severe as physical pain.

ANS: D

Spiritual pain can be as severe as physical pain and often is closely accompanied by emotional pain. Asking about the effect an illness or health problem has had on spiritual beliefs yields useful information. Being able to talk freely about spiritual distress helps put it into perspective. Identifying a client’s current religious affiliations and practices is important, and inquiring about religious rituals important to the client is essential. Spiritual pain can be inferred from behavior and if the client is willing to share verbally.

DIF: Cognitive Level: Application REF: pp. 175-176 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 13. The nurse is caring for a client who is anxious about a new diagnosis of cancer. When

discussing chemotherapy with the client, the nurse understands that a. the client will need to be given instructions only once. b. the client may only hear part of the instructions. c. emotions obey the rules of logic. d. a cognitive lack of understanding may occur.

ANS: B

The nurse should avoid sensory overload, and repeat instructions if the client appears anxious.

DIF: Cognitive Level: Application REF: p. 169 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 14. After receiving her morning assignment, the nurse realizes that she will be caring for a client

with Alzheimer disease. The nurse understands that when communicating with this client, it will be important to a. avoid touch because this may be misinterpreted by the client. b. shorten processing time before the client becomes distracted. c. break instructions down into small, sequential steps. d. present ideas all at once before the client’s attention wanders.

ANS: C

Keeping communication simple can help the client compensate for cognitive deficits. Use of touch to emphasize directions or guide the client can help compensate for cognitive deficits.

Clients with cognitive deficits need more time to process information. Present ideas one at a time.

DIF: Cognitive Level: Application REF: p. 173 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

Chapter 11: Developing Therapeutic Relationships Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following examples indicates adherence to client confidentiality? a. Talking about the client’s symptoms in front of family members b. Using the client’s name in a social conversation c. Sharing client information with other members of the health care team as needed d. Reading a friend’s chart on another hospital unit ANS: C

The nurse should assure the client that personal information will be treated as confidential and explain that data will be shared with other members of the health care team as needed for making relevant clinical decisions and informing the client about the general composition of the health care team.

DIF: Cognitive Level: Comprehension REF: p. 183 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. When your are administering medications to a client with human immunodeficiency virus

(HIV), the client states, “I should just stop taking them and get it over with.” A therapeutic response by the nurse would be a. “You have to take these! If you stop you will get very sick.” b. “You’re just feeling depressed right now. You’ll feel better later.” c. “ Tell me more about what you’re feeling.” d. “You have the right to refuse treatment.”

ANS: C

Therapeutic relationships should directly revolve around the client’s needs and each person’s individualized expression of them. Using questions that follow a logical sequence and asking only one question at a time are practices that help clients feel more comfortable and are likely to elicit more complete data. Dealing with the client’s feelings with a statement such as, “Tell me more about…” keeps the conversation flowing. The client has the right to choose a course of action, even when it is at odds with the nurse’s ideas. The nurse stating how the client is feeling is an assumption by the nurse about what the client is feeling. Although the client has the right to refuse treatment, he is not really saying that he will refuse. The nurse needs to obtain more information.

DIF: Cognitive Level: Application REF: p. 190 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. A client has been informed by her physician that she requires emergency surgery. The client

tells the nurse, “I will have the surgery after I attend my family vacation.” Which of the following is the most appropriate mutual goal for the client? a. The client will accept the recommended medical regimen. b. The client will alternate activity with rest throughout the day. c. The client will take a leave of absence from her work schedule.

d. The client will check her blood pressure four times a day.

ANS: B

Nurse-client relationships are designed to empower clients and families to assume as much responsibility as possible in self-management of chronic illness. Both nurse and client have responsibilities and work toward agreed-upon goals. Shared knowledge, mutual decision-making power, and respect for the capacities of client to actively contribute to his or her health care to whatever extent is possible are active components. The client always has the right to choose the course of action, even if it does not coincide with medical advice. If the client takes a leave of absence from her work schedule, it is not a mutual goal. Setting the goal of having the client check her blood pressure four times a day does not address the issue from the client perspective.

DIF: Cognitive Level: Application REF: p. 183 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 4. A nurse whose father was an alcoholic is assigned to care for a client who is in alcohol

withdrawal. The nurse’s best therapeutic action would be to a. request another assignment. b. deliver care in short intervals to avoid projecting negativity. c. examine personal vulnerabilities, strengths, and limitations. d. monitor the client’s physical status closely.

ANS: C

Authenticity is a precondition for the therapeutic use of self in the nurse-client relationship.

Authenticity requires recognizing personal vulnerabilities, strengths, and limitations; working within this knowledge in the service of the client; and seeking help when needed to further relationship goals. Self-awareness allows the nurse to fully engage with a client, knowing that parts of the relationship may be painful, distasteful, or uncomfortable. Eventually the nurse will have to deal with the issue. Shortening care time would not be therapeutic. The nurse needs to be emotionally available to the client to be therapeutic.

DIF: Cognitive Level: Application REF: p. 186 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. A nurse returns to work to find that a substitute nurse has changed the treatment plan of her

favorite client. In the presence of the client, the nurse becomes angry and critical of the other nurse. This is an example of a. overinvolvement. b. client-centered approach. c. professional focus. d. disengagement.

ANS: A

Boundaries represent a continuum, with issues related to boundaries ranging from a lack of involvement to overinvolvement. The nurse has lost her focus on what is important for the client. The nurse has lost her objectivity. Disengagement is the opposite of overinvolvement.

DIF: Cognitive Level: Application REF: p. 185 TOP: Step of the Nursing Process: All phases

MSC: Client Needs: Psychosocial Integrity 6. The professional relationship goes through a developmental process characterized by

overlapping yet distinct stages, which are a. confidentiality, trust, and empathy. b. listening, hearing, and feeling. c. preinteraction, orientation, working phase, and termination phase. d. getting details, thoughts, and answers.

ANS: C

The professional relationship goes through a developmental process characterized by four overlapping yet distinct stages: (1) preinteraction, (2) orientation, (3) working phase, and (4) termination phase. The preinteraction phase is the only phase of the relationship the client is not part of. During the preinteraction phase, the nurse develops the appropriate physical and interpersonal environment for an optimal relationship, in collaboration with other health professionals and significant others in the client's life. Confidentiality, trust, and empathy are guiding principles, not phases. Listening, hearing, and feeling are communication skills.

Getting details, thoughts, and answers occurs during the orientation phase.

DIF: Cognitive Level: Comprehension REF: p. 181 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 7. Which of the following personality characteristics can affect the nurse’s ability to function in

a therapeutic manner, if disclosed to the client? a. The nurse is shy. b. The nurse becomes angry when criticized. c. The nurse has difficulty handling conflict. d. The nurse struggles with getting up in the morning.

ANS: B

It is up to the nurse, not the client, to resolve interpersonal issues that get in the way of the relationship. Nurses need to acknowledge overinvolvement, avoidance, anger, frustration, or detachment from a client when it occurs. By disclosing that she is shy, the nurse may assist the client to avoid misinterpreting cues. Disclosing that the nurse has difficulty handling conflict may open the way for the client to reveal problems and coping skills. The self-disclosure that the nurse struggles with getting up in the morning demonstrates humanness to the client.

DIF: Cognitive Level: Application REF: p. 186 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 8. In the preinteraction phase of the nurse-client relationship a. professional goals are communicated directly to the client. b. the content of the interaction is vital; the environment has little importance. c. the nurse develops the appropriate physical and interpersonal environment for an

optimal relationship. d. it is the nurse’s knowledge of principles and responsibilities that guarantees a

successful relationship.

ANS: C

The professional relationship goes through a developmental process characterized by four overlapping yet distinct stages: (1) preinteraction, (2) orientation, (3) working phase, and (4) termination phase. The preinteraction phase is the only phase of the relationship the client is not part of. During the preinteraction phase, the nurse develops the appropriate physical and interpersonal environment for an optimal relationship, in collaboration with other health professionals and significant others in the client's life.

DIF: Cognitive Level: Comprehension REF: pp. 187-188 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. Which of the following is a nontherapeutic statement during the orientation phase of a

relationship? a. “I am the nurse who will be caring for you today.” b. “My job is to make you better.” c. “I will be talking with you while I provide care.” d. “You will be receiving care from an assistant and myself.”

ANS: B

The orientation phase ends with a therapeutic contract mutually defined by nurse and client.

The nurse enters the relationship in the “stranger” role and begins the process of developing trust by providing the client with basic information about the nurse (e.g., name and professional status) and essential information about the purpose, nature, and time available for the relationship. It is therapeutic to provide the client with basic and essential information.

Providing information helps develop trust.

DIF: Cognitive Level: Application REF: pp. 188-189 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 10. The nurse practices “here and now” focus on problem identification, with an emphasis on

quickly understanding the context in which the problem is embedded during which of the following phases of the nurse-client relationship? a. Orientation b. Preinteraction c. Termination d. Working ANS: A

Orientation phase: The therapeutic alliance begins with the same type of introduction and description of purpose identified for long-term relationships with a focus on the nurse and client working as partners to develop a shared understanding of the client's health problems.

Establishing a working alliance where time is an issue requires a “here and now” focus on problem identification, with an emphasis on quickly understanding the context in which the problem is embedded. Meaningful connections occur when nurses initially strive to view each client as a person to be engaged with rather than focusing on what needs to be done.

DIF: Cognitive Level: Knowledge REF: p. 197 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

11. Self-disclosure by the nurse refers to the intentional revealing of personal experiences or

feelings that are similar to or different from those of the client. The purpose of self-disclosure is to a. deepen trust, to be a role model of self-disclosure as a beneficial mode of communicating. b. to find out how the client would like to be. c. to determine how things would be if the problems were solved. d. to work toward resolution of the client’s self-care needs.

ANS: A

Self-disclosure by the nurse refers to the intentional revealing of personal experiences or feelings that are similar to or different from those of the client. The purpose of self-disclosure is to deepen trust and to be a role-model of self-disclosure as a beneficial mode of communicating for people who have trouble disclosing information about themselves.

Appropriate self-disclosure can facilitate the relationship, providing the client with information that is both immediate and personalized.

DIF: Cognitive Level: Application REF: p. 194 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 12. The client becomes more self-directed during which of the following phases of the

nurse-client relationship? a. Orientation b. Preinteraction c. Identification d. Working ANS: D

The working phase focuses on self-direction and self-management to whatever extent is possible in promoting the client’s health and well-being. Orientation is the assessment phase.

The client is not present during the preinteraction phase. Nurses help clients express feelings and clarify ideas and expectations during the identification phase.

DIF: Cognitive Level: Application REF: p. 198 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 13. Which stage of the nursing process corresponds to the exploitation part of the working phase

of the therapeutic relationship? a. Diagnosis b. Assessment c. Implementation d. Planning ANS: C

The exploitation phase corresponds to the implementation phase of the nursing process, where the purpose is to work toward resolution of the client’s self-care needs. Nursing diagnoses are established during the orientation phase. Assessment corresponds to the orientation phase.

Planning corresponds to the working phase.

DIF: Cognitive Level: Comprehension

REF: p. 192

TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 14. When should the nurse first start planning for termination of the nurse-client relationship? a. From the initial encounter b. After goals have been achieved c. When the client requests it d. During the working phase of the relationship ANS: A

It is important to be clear from the beginning about how long a therapeutic relationship will last. During the course of the relationship, termination can be mentioned and clients should be told well in advance of an impending termination date. It is inappropriate to plan for termination after the goals have been achieved, when the client requests termination, or during the working phase of the relationship.

DIF: Cognitive Level: Knowledge REF: p. 195 TOP: Step of the Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 15. A primary difference between a therapeutic helping relationship and a social relationship is a. enjoyment. b. amount of listening. c. worth to participants. d. the focus.

ANS: D

Therapeutic helping relationships have a specific purpose and health-related goal. Enjoyment, amount of listening, and worth to participants can occur in both types of relationships.

DIF: Cognitive Level: Comprehension REF: p. 188 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 16. Which of the following is true about the helping relationship? a. The health care provider takes responsibility for maintaining appropriate

boundaries. b. Both the health care provider and the client have equal responsibility for the relationship. c. Self-disclosure for both the health care provider and the client is expected. d. Understanding does not always have to be put into words.

ANS: A

In a helping relationship, the health care provider takes responsibility for the conduct of the relationship and for maintaining appropriate boundaries.

DIF: Cognitive Level: Knowledge REF: p. 188 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 17. An appreciative client offers the nurse a box of chocolates. The nurse should a. accept all gifts offered by the client.

b. refuse to accept the chocolates in a gentle, tactful manner. c. accept or refuse based on the uniqueness of the relationship. d. accept the gift but also remind the client of intangible gifts.

ANS: C

In general, nurses should not accept money, or gifts of significant material value. There is no one answer about whether gifts should or should not be exchanged. In fact, if the nurse handled every situation in the same fashion, the nurse would be denying the uniqueness of each nurse-client relationship. Each relationship has its own character and its own strengths and limitations, so what might be appropriate in one situation would be totally inappropriate in another. Token gifts such as chocolates or flowers may be acceptable. In general, nurses should not accept money or gifts of significant material value. Some agencies have policies regarding accepting gifts; others do not. Accept or refuse based on the uniqueness of the situation.

DIF: Cognitive Level: Application REF: p. 196 TOP: Step of the Nursing Process: Evaluation MSC: Client Needs: Management of Care 18. The nurse has been working in a long-term care facility for several years. The nurse has

decided to leave the facility to work elsewhere. When terminating her relationship with clients, the nurse should a. prepare clients for termination. b. inform clients that she will “keep in touch.” c. inform clients that they have benefited from the relationship. d. discuss feelings with clients during the last encounter.

ANS: A

Termination of a meaningful nurse-client relationship in long-term settings should be final. To provide the client with even a hint that the relationship will continue is unfair. It keeps the client emotionally involved in a relationship that no longer has a health-related goal. There needs to be a mutual evaluation of benefits from the relationship. Feelings need to be expressed and discussed well before the last encounter.

DIF: Cognitive Level: Application REF: pp. 198-199 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 19. The student nurse has finished her rotation on the outpatient psychiatric unit. Her client, who

was diagnosed with borderline personality disorder, suddenly displays superficial scratches to both forearms. Which of the following is a nursing diagnosis for the client related to losses and endings in the nurse-client relationship? a. Noncompliance about impending termination of nurse-client relationship b. Knowledge deficit about impending termination of nurse-client relationship c. Self-care deficit related to impending termination of nurse-client relationship d. Anxiety related to impending termination of nurse-client relationship ANS: D

The client’s anxiety has led to the regression in her behavior. Noncompliance, knowledge deficit, and self-care deficit are not diagnoses dealing with losses and endings.

DIF:

Cognitive Level: Analysis

REF: p. 195

TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

Chapter 12: Bridges and Barriers in Therapeutic Relationships Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following describes caring? a. It is difficult to demonstrate professionally. b. It is an ethical responsibility. c. It is an intuitive process. d. It is not influenced by past experience.

ANS: B

Caring is an ethical responsibility that guides a health care provider to advocate for the client.

Caring is demonstrated professionally in the therapeutic relationship. It is an intentional action that is learned. A person who has received caring is more likely to be able to offer it to others.

DIF: Cognitive Level: Comprehension REF: p. 202 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. Which of the following should be achieved first in establishing the nurse-client relationship? a. Trust b. Empathy c. Mutuality d. Empowerment ANS: A

Establishing trust is the foundation in all relationships. The development of a sense of interpersonal trust, a sense of feeling safe, is the keystone in the nurse-client relationship.

Empathy is used by the nurse after trust is established. Mutuality is important in establishing client goals. Empowerment occurs when the client actively participates in his or her care plan.

DIF: Cognitive Level: Comprehension REF: p. 205 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. Which of the following describes mutual goals? a. Mutuality is based on client goals. b. Mutuality is based on interdisciplinary health team goals. c. Mutuality is based on the nurse’s goals. d. Mutuality is based on the physician’s goals.

ANS: A

Evidence of mutuality is seen in the development of individualized client goals and nursing actions that meet a client’s unique health needs—not on the goals of the health team, the nurse, or the physician.

DIF: Cognitive Level: Comprehension REF: p. 206 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Management of Care

4. Which of the following is a violation of client confidentiality? a. Sharing of information about a communicable disease b. Stating client’s diagnosis during change of shift report c. Photographing a client’s wound to monitor the healing process d. Discussing private information about the client casually with others ANS: D

Discussing private information casually with others is an abuse of confidentiality. It is legal to share information about public health issues such as a communicable disease. Information can be shared with the health care team. Photographing a client’s wound is not a breach of confidentiality; the pictures stay with the client’s record and are used for the benefit of the client.

DIF: Cognitive Level: Analysis REF: p. 215 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. Stereotypes are learned during a. exposure to early education. b. childhood and reinforced by life experiences. c. limited contact with other cultures. d. uncomfortable experiences with culturally diverse clients.

ANS: B

Stereotypes are learned during childhood and reinforced by life experiences.

DIF: Cognitive Level: Knowledge REF: p. 209 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. Which of the following describes proxemics? a. Study of relationship between message and topic at hand b. Study of implied meanings within individuals c. Study of an individual’s use of space d. Study of the emotional personal space boundary ANS: C

Proxemics is the study of an individual’s use of space. The study of relationships between messages and topics at hand and the study of implied meanings within individuals do not involve the use of space. An individual can use space as an invisible boundary.

DIF: Cognitive Level: Knowledge REF: p. 210 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. Which of the following is a barrier to communication? a. Intrusion into personal space b. Unconditional acceptance c. Self-awareness d. Gender differences ANS: A

Understanding communication barriers in a relationship (e.g., anxiety, stereotyping, or violations of personal space or confidentiality) affects the quality of the relationship.

Unconditional acceptance is an essential element in the helping relationship. Self-awareness enhances communication. No evidence exists showing that gender differences obstruct the therapeutic relationship.

DIF: Cognitive Level: Comprehension REF: p. 210 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 8. Which of the following is true about trust? a. The sender feels it. b. It is difficult to demonstrate professionally. c. It is an intuitive process. d. The trusting client feels comfortable revealing needs.

ANS: D

The development of a sense of interpersonal trust, a sense of feeling safe, is the keystone in the nurse-client relationship. Trust provides a nonthreatening interpersonal climate in which the client feels comfortable revealing his needs. The sender promotes a trusting relationship.

Trust is demonstrated professionally in the nurse-client relationship. The development of trust is based on past experiences, not intuition.

DIF: Cognitive Level: Comprehension REF: p. 205 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 9. The nurse demonstrates an understanding of mutuality when stating to the client, a. “Mr. Jones, I think you should go to bed now.” b. “Mr. Jones, I would like you to go to bed now.” c. “Mr. Jones, I don’t think you should sit in the chair.” d. “Mr. Jones, I thought we agreed that you would return to bed at this time.”

ANS: D

Mutuality basically means that the nurse and the client agree on the client’s health problems and the means for resolving them and that both parties are committed to enhancing the client’s well-being. When the nurse instructs the client what to do, it represents the nurse’s goals for the client and does not demonstrate mutuality.

DIF: Cognitive Level: Application REF: p. 206 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 10. When entering a client’s room, the nurse notices the client standing while wringing her hands

and wearing street clothes over pajamas. On further examination, it is noted that the client is hyperventilating with elevated vital signs. Which level of anxiety is the client experiencing? a. Mild b. Moderate c. Severe d. Panic ANS: C

Signs of severe anxiety include elevated vital signs, impaired problem-solving, and a confused mental state. Signs of mild anxiety are enhanced problem-solving and increased alertness. Signs of moderate anxiety do not include high blood pressure. During panic, the client is immobilized with no cognitive or coping abilities.

DIF: Cognitive Level: Analysis REF: pp. 208-209 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Physiological Adaptation 11. Which of the following situations is an example of the nurse using empathy? a. Setting up a rehabilitation placement for a client addicted to heroin b. Sitting quietly and holding a client’s hand while she cries following the news that

she has inoperable cancer c. Giving a bed bath to a client who suffers from a cerebral vascular accident (CVA) d. Telling a client all about the fun night at one of the local clubs ANS: B

Empathy is the ability to be sensitive to and communicate understanding of the client’s feelings. The client should be encouraged to be involved in his or her own care and to assume responsibility. The nurse should not tell a client about extracurricular activities because this is an example of nontherapeutic self-disclosure by the nurse.

DIF: Cognitive Level: Application REF: pp. 205-206 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 12. The nurse knocks on the client’s door and waits for the client to answer before entering the

room. The nurse is demonstrating a. nonverbal communication skills. b. respect for the client’s personal space. c. respect for the client’s confidentiality. d. respect for the client’s gender difference.

ANS: B

Giving warning before entering a client’s room demonstrates respect for personal space.

Knocking is not a demonstration of nonverbal communication. Knocking at a door before entering the room does not relate to respect for a client’s confidentiality. Respect for a client’s personal space should be demonstrated regardless of gender.

DIF: Cognitive Level: Application REF: p. 214 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 13. Which of the following is true regarding personal space? a. Individuals living in a Western culture need 40 square feet of personal space. b. Direct eye contact causes a need for less space. c. People need less space when they are anxious. d. The elderly need more control over their personal space.

ANS: D

The elderly need control over personal space because they can become profoundly disoriented in unfamiliar environments. Individuals living in a Western culture need 86-108 square feet of personal space. Direct eye contact causes a need for more space. People need more space when they are anxious.

DIF: Cognitive Level: Knowledge REF: p. 210 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 14. Which of the following demonstrates the use of the caring process? a. Respecting the uniqueness of every client b. Problem solving for the client c. Performing tasks for the client d. Communicating expectations of the health care team ANS: A

Caring is described as a commitment by the nurse that involves profound respect and concern for the unique humanity of every client and a willingness to confirm the client’s personhood.

Caring is demonstrated by problem-solving with the client, not for the client. Encouraging self-care empowers the client. The nurse needs to respond to the client’s expectations for health care.

DIF: Cognitive Level: Application REF: p. 205 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 15. In order to reduce clinical bias in nursing practice, the nurse should a. memorize beliefs held by different cultures. b. generalize beliefs based on ethnic membership. c. develop a nonjudgmental, neutral attitude. d. recognize that individuals of the same religion share the same characteristics.

ANS: C

Developing a nonjudgmental, neutral attitude toward a client helps the nurse reduce clinical bias in nursing practice. The nurse does not have to memorize beliefs to become culturally sensitive. Stereotypes are generalized beliefs based on ethnic membership. All individuals of a particular social group, race, or religion do not share the same characteristics.

DIF: Cognitive Level: Knowledge REF: p. 215 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. Which of the following nursing behaviors are included in the levels of nursing actions within

Level 1? (Select all that apply.) a. Confronts conflict b. Uses client’s correct name c. Maintains eye contact d. Adopts open posture e. Responds to cues

ANS: B, C, D, E

Using a client’s correct name, maintaining eye contact, adopting open posture, and responding to cues are responses that are demonstrated by the accepting category within Level 1 of levels of nursing action. Confronting conflict is an example of a nursing behavior at the analyzing category of Levels 4-5.

DIF: Cognitive Level: Knowledge REF: p. 213 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

Chapter 13: Communicating with Families Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Regardless of how uniquely they are defined, strong emotional ties and durability of

membership characterize a. family function. b. family process. c. family relationships. d. family ecomap.

ANS: C

A family is who they say they are. Identified family members may or may not be blood related. Strong emotional ties and durability of membership characterize family relationships regardless of how uniquely they are defined. Even when family members are alienated, or distanced geographically, they can never truly relinquish family membership. Family function refers to the roles people take in their families. Family process describes the communication that takes place within the family. An ecomap is essentially a sociogram, illustrating the shared relationships between family members and the external environment. Beginning with an individual family unit or client, the diagram extends to include significant social and community-based systems with which they have a relationship. These data identify at a glance the family’s interaction with environmental supports and its use of resources available through friends and community systems.

DIF: Cognitive Level: Comprehension REF: p. 217 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. When focusing on family interrelationships and the impact a serious health alteration has on

individual family members and the equilibrium of the family system, the nurse should use a. equifinality. b. diffuse boundaries. c. circular questions. d. morphostasis.

ANS: C

Interventive questioning is a nursing intervention that nurses can use with their client families to identify family strengths; help family members sort out their personal fears, concerns, and challenges in health care situations; and provide a vehicle for exploring alternative options.

Questionins can be either linear or circular. Circular questions focus on family interrelationships and the impact a serious health alteration has on individual family members and the equilibrium of the family system. The systems principle of equifinality describes how the same outcome, or end state, can be reached through different pathways. This principle helps explain why some individuals at high risk for poor outcomes do not develop maladaptive behaviors. Boundaries, defined as invisible limits surrounding the family unit, protect the integrity of the family system. Boundaries draw a line in the sand by identifying what belongs within the family system and what is external to it. They define the level of participation between family members. Clear generational boundaries provide security for family members by, for example, setting legitimate limits with children and balancing individual needs with the demands of caring for the needs of chronically ill family members.

Boundaries regulate the flow of information into and out of the family. Permeable boundaries welcome interactions with others and allow information to flow freely. Families with clear, permeable boundaries are better able to balance the demands of the illness with other family needs and can communicate more effectively with care providers. Diffuse boundaries lead to family overinvolvement, while rigid boundaries are operative in families with little interaction between members and family secrets. Rigid boundaries restrict flow of information.

Interaction with outsiders is discouraged, or heavily regulated. Diffuse boundaries are found in enmeshed families. Morphostasis refers to how the family is able to change and grow over time in response to challenges.

DIF: Cognitive Level: Knowledge REF: p. 230 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. A family systems theory that conceptualizes the family as an interactive emotional unit in

which family members assume reciprocal family roles, develop automatic communication patterns, and react to each other in predictable, connected ways, particularly when family anxiety is high, was created by a. Evelyn Duvall. b. Murray Bowen. c. McCubbin & McCubbin. d. Salvador Minuchin.

ANS: B

Murray Bowen’s family systems theory conceptualizes the family as an interactive emotional unit. Bowen believed that family members assume reciprocal family roles, develop automatic communication patterns, and react to each other in predictable, connected ways, particularly when family anxiety is high. Evelyn Duvall proposed a family life stage framework for understanding issues that normal families experience based on expected family development through the life span, each with its own set of tasks. Duvall’s model describes the life cycle of a family, using the age of the oldest child in the family as the benchmark for determining the family’s developmental stage. Developmental tasks represent the challenges and growth responsibilities each family experiences at different life stages. McCubbin & McCubbin’s Resiliency Model of Family Stress, Adjustment, and Adaptation is considered the most extensively studied model of family coping with traumatic and chronic illness. In this model, A (an event) interacts with B (resources) and with C (family’s perception of the event) to produce X (the crisis). Family structure models, pioneered by Salvador Minuchin, emphasize the structure (subsystems, hierarchies, and boundaries) of the family unit as the basis for understanding family function. Family structure refers to how the family is constructed legally and emotionally. The concept of hierarchy describes how families organize themselves into various smaller units, referred to as subsystems, that compose the larger family system.

DIF: Cognitive Level: Knowledge REF: p. 220 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. The nurse is caring for a client who is extremely dependent on the approval of others, causing

them to discount their own needs. The nurse recognizes that the client is demonstrating a. self-differentiation. b. emotional cutoff. c. poor self-differentiation. d. rigid boundaries.

ANS: C

Self-differentiation refers to a person’s capacity to define himself or herself within the family system as an individual having legitimate needs and wants. It requires making “I” statements based on rational thinking rather than emotional reactivity. Self-differentiation takes into consideration the views of others but is not dominated by them. Poorly differentiated people are so dependent on the approval of others that they discount their own needs. Emotional cutoff refers to a person’s withdrawal from other family members as a means of avoiding family issues that create anxiety. Emotional cutoffs range from total avoidance to remaining in physical contact, but in a superficial manner. Emotional cutoffs contain a negative anxiety that drains personal energy. The problems creating the emotional cutoff persist. Rigid boundaries are operative in families with little interaction between members and family secrets. Rigid boundaries restrict flow of information. Interaction with outsiders is discouraged, or heavily regulated.

DIF: Cognitive Level: Application REF: p. 220 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. The nurse is caring for a client who reports having marital difficulties. When experiencing

heightened anxiety related to his health issues, the client chooses to discuss his feelings with a female friend rather than with his spouse. The nurse recognizes the client’s actions as a defensive way of reducing, neutralizing, or defusing heightened anxiety known as a. systems’ thinking. b. triangles. c. feedback loops. d. multigenerational transmission.

ANS: B

Triangles refer to a defensive way of reducing, neutralizing, or defusing heightened anxiety between two family members by drawing a third person, or object into the relationship. If the original triangle fails to contain or stabilize the anxiety, it can expand into a series of “interlocking” triangles, for example into school issues or an affair. Systems’ thinking maintains that the whole is greater than the sum of its parts, with each part reciprocally influencing its function. If one part of the system changes or fails, it affects the functioning of the whole. Feedback loops describe the patterns of interaction that facilitate movement toward morphogenesis, or morphostasis; they impact goal setting in behavior systems.

Multigenerational transmission refers to the emotional transmission of behavioral patterns, roles, and communication response styles from generation to generation. It explains why family patterns tend to repeat behaviors in marriages, child rearing, choice of occupation, and emotional responses across generations, without understanding why it happens.

DIF: Cognitive Level: Application REF: p. 220 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 6. When performing an admission assessment on a client, the nurse asks about sibling position

based on the knowledge that sibling position can shape relationships and influence a person's expression of behavioral characteristics. The concept that each sibling position has its own strengths and weaknesses is based on the work of: a. Murray Bowen. b. Walter Toman. c. Medalie & Cole-Kelly. d. McCubbin & McCubbin.

ANS: B

Sibling position, a concept originally developed by Walter Toman (1992), refers to a belief that sibling positions shape relationships and influence a person's expression of behavioral characteristics. Each sibling position has its own strengths and weaknesses. This concept helps explain why siblings in the same family can exhibit very different characteristics.

Murray Bowen’s family systems theory conceptualizes the family as an interactive emotional unit. Bowen believed that family members assume reciprocal family roles, develop automatic communication patterns, and react to each other in predictable, connected ways, particularly when family anxiety is high. Medalie and Cole-Kelly describe the course of chronic illness as being a series of crises with relatively stable times in between McCubbin & McCubbin’s Resiliency Model of Family Stress, Adjustment, and Adaptation is considered the most extensively studied model of family coping with traumatic and chronic illness. In this model, A (an event) interacts with B (resources) and with C (family’s perception of the event) to produce X (the crisis).

DIF: Cognitive Level: Application REF: pp. 220-221 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 7. When performing an assessment that focuses on a set of standardized connections to

graphically record basic information about family members and their relationships over three generations, the nurse uses a. an ecomap. b. a gendergram. c. family time lines. d. a genogram.

ANS: D

A genogram uses a standardized set of connections to graphically record basic information about family members and their relationships over three generations. Genograms are updated and/or revised as new information emerges. An ecomap is essentially a sociogram, illustrating the shared relationships between family members and the external environment. Beginning with an individual family unit or client, the diagram extends to include significant social and community-based systems with whom they have a relationship. These data identify at a glance the family’s interaction with environmental supports and its use of resources available through friends and community systems. Adding the ecomap is an important dimension of family assessment, providing awareness of community supports that are, or are not, being used to assist families. A gendergram is used to understand gender role development in families and its influences on current role enactments. Family time lines offer a visual diagram that captures significant family stressors, life events, health, and developmental patterns through the life cycle. Family history and patterns developed through multigenerational transmission are represented as vertical lines. Horizontal lines indicate timing of life events occurring over the current life span. These include such milestones as marriages, graduations, and unexpected life events such as disasters, war, illness, death of person or pet, moves, or births. Timelines are useful in looking at how the family history, developmental stage, and concurrent life events might interact with the current health concern.

DIF: Cognitive Level: Application REF: p. 223 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 8. When interviewing the family of a client newly diagnosed with Alzheimer disease, the nurse’s

primary goal is to help the family members sort out their personal fears and identify family strengths through the use of a. interventive questioning. b. genogram. c. ecomap. d. offering commendations.

ANS: A

Interventive questioning is an intervention that nurses can use with their client families to identify family strengths; help family members sort out their personal fears, concerns, and challenges in health care situations; and provide a vehicle for exploring alternative options. A genogram uses a standardized set of connections to graphically record basic information about family members and their relationships over three generations. Genograms are updated and/or revised as new information emerges. An ecomap is essentially a sociogram illustrating the shared relationships between family members and the external environment. Beginning with an individual family unit or client, the diagram extends to include significant social and community-based systems with whom they have a relationship. These data identify at a glance the family’s interaction with environmental supports and its use of resources available through friends and community systems. Adding the ecomap is an important dimension of family assessment, providing awareness of community supports that are, or are not, being used to assist families. Offering commendations is the practice of noticing, drawing forth, and highlighting previously unobserved, forgotten, or unspoken family strengths, competencies, or resources.

DIF: Cognitive Level: Application REF: p. 230 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 9. When interviewing the family of a client who is suffering from alcoholism, the

communication technique used by the nurse is called circular questioning. The advantage of this technique is that it a. examines relationships. b. aids the nurse in establishing a diagnosis. c. focuses on the equilibrium of the family system. d. helps the nurse gain specific information.

ANS: C

Circular questions focus on family interrelationships and the impact of a serious health alteration on individual family members and the equilibrium of the family system. The nurse uses information the family provides as the basis for additional questions. A technique used to examine relationships is called ecomap. Circular questioning assists the nurse in developing interventions, not diagnoses. Circular questioning helps the nurse gain multidimensional, not specific, information.

DIF: Cognitive Level: Application REF: p. 230 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 10. Which of the following describes the dyad family unit? a. A father and mother with one or more children living together b. Second- and third-generation members related by blood or marriage but not living

together c. Divorced, never married, separated, or widowed male or female and at least one

child d. Husband and wife or other couple living alone without children ANS: D

A dyad family is a husband and wife or other couple living alone without children. A nuclear family is a father and mother with one or more children living together. An extended family is second- and third-generation members related by blood or marriage but not living together. A single-parent family is a divorced, never married, separated, or widowed male or female and at least one child.

DIF: Cognitive Level: Knowledge REF: p. 218 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Management of Care 11. Which of the following is a true statement when comparing biological and blended families? a. In biological families, rules are varied and complicated. b. A blended family is born of loss. c. In biological families, there are multiple sets of rules. d. In blended families, traditions are shared.

ANS: B

In blended families, family is born of loss and rules are varied and complicated. In biological families, one set of family rules evolves. There are two sets of family traditions in blended families.

DIF: Cognitive Level: Knowledge REF: p. 219 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Management of Care 12. When the nurse cares for a client with a terminal illness, a question that the nurse can ask the

client’s family to elicit information about family strengths is a. “Who best understands what the doctors have told you?” b. “What has the family been doing so far that is helpful?” c. “Who is most uncomfortable at the bedside?” d. “Who is now taking care of the house?”

ANS: B

Questions nurses can use specifically to elicit family strengths include, “What has the family been doing so far that has been helpful?” Questions regarding level of understanding, comfort, and who is taking care of the house are not the best questions that the nurse can ask the client’s family to elicit information about family strengths.

DIF: Cognitive Level: Application REF: p. 230 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 13. The nurse-family relationship in client care depends on what type of relationship between the

nurse and the family? a. A dependent relationship b. A relationship that begins informally c. A reciprocal relationship d. A relationship that promotes inequality between the nurse and family ANS: C

The nurse-family relationship in client care depends on a reciprocal relationship between the nurses and family in which both are equal partners and sources of information. The initial encounter sets the tone for the relationship. How nurses interact with each family member may be as important as what they choose to say. The nurse should begin with formal introductions and explain the purpose of gathering assessment data.

DIF: Cognitive Level: Application REF: p. 228 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 14. When caring for clients, it is important for the nurse to understand that a. treatment plans should be tailored around personal family goals. b. meaningful involvement in the client’s care will be consistent among family

members. c. the nurse should listen to only immediate family members when considering

implications for family involvement. d. individual family members have different perspectives.

ANS: D

Meaningful involvement in the client’s care not only differs from family to family, it also differs among individual family members. Individual family members have different perspectives. Hearing each family member’s perspective helps the family and nurse develop a unified understanding of significant treatment goals and implications for family involvement.

Although treatment plans should be tailored around personal client goals, acknowledging family needs, values, and priorities enhances compliance, especially if they are different.

DIF: Cognitive Level: Application REF: p. 231 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. The home health nurse is visiting a family who is having difficulty coping. The family has a

2-month-old malnourished child whom they are feeding diluted formula along with rice cereal. The parents of the child are unemployed and are unable to pay their monthly expenses.

The father of the child complains of not being able to find a job, while the mother of the child accuses him of not even trying to find employment. Which of the following techniques would be most helpful for the nurse to use in this situation? (Select all that apply.) a. Linear questioning b. Interventive questioning c. Circular questioning d. Encouraging their coping style e. Identifying family strengths ANS: A, B, C, E

Interventive questioning is a nursing intervention that nurses can use with their client families to identify family strengths; help family members sort out their personal fears, concerns, and challenges in health care situations; and provide a vehicle for exploring alternative options.

Interventive questioning can be either linear or circular. Encouraging the family’s current coping style is not useful because it clearly has detrimental effects, including a malnourished child.

DIF: Cognitive Level: Application REF: p. 230 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 2. The nurse is designing therapeutic interventions for a family whose child is hospitalized with

a terminal condition. The nurse recognizes that nursing actions that can be offered to the family that can promote positive change in family functioning include which of the following?

(Select all that apply.) a. Encouraging the telling of illness narratives b. Commending family on individual strengths c. Offering information and opinions d. Discouraging the use of respite care ANS: A, B, C

Suggested nursing actions to promote positive change in family functioning include • encouraging the telling of illness narratives.

• commending family and individual strengths.

• offering information and opinions.

• validating or normalizing emotional responses.

• encouraging family support.

• supporting family members as caregivers.

• encouraging respite.

DIF: Cognitive Level: Application REF: p. 231 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

Chapter 14: Resolving Conflicts between Nurse and Client Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for an intoxicated client who has been admitted to the emergency

department. The client appears very angry and frequently shouts at the nurse and demands to see the physician. The best response by the nurse is to use a. blaming. b. empathy. c. competition. d. “I” statements.

ANS: B

Effective nurse-client communication is critical to efficient care provision and to providing quality care. Knowing how to respond in emotional situations allows the nurse to use feelings as a positive force. Nurses often find themselves in dramatic situations in which a calm response is required. Some clients approach their initial encounter with a nurse with hostility or embarrassment, such as the intoxicated client admitted to an emergency department. To listen and to respond creatively to intense emotion when the nurse’s first impulse is to withdraw or to retaliate demands a high level of skill. It requires self-control and empathy for what the client may be experiencing. The nurse should avoid blaming, which will only make the client feel defensive or angry. Competition is a response style characterized by domination. In this contradictory style, one party exercises power to gain his own goals at the expense of the other person. It is characterized by aggression and lack of compromise.

Authority may be used to suppress the conflict in a dictatorial manner. This leads to increased stress. It is an effective style when there is a need for a quick decision, but it leads to problems in the long term, making it a lose-lose situation. Timing is also important if an individual is very angry. The key to assertive behavior is choice. Sometimes it is better to allow the client to let off some “emotional steam” before engaging in conversation.

DIF: Cognitive Level: Application REF: p. 258 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 2. When working in situations that involve conflict, the nurse recognizes that which of the

following is true in relation to conflict? a. Conflict always leads to impaired relationships. b. Conflict arises from compatible goals and needs. c. Most people experience conflict as a lack of discomfort. d. Conflict serves as a warning that something in the relationship needs closer attention.

ANS: D

Conflict has been defined as tension arising from incompatible goals or needs, in which the actions of one frustrate the ability of the other to achieve a goal, resulting in stress or tension.

Conflicts in any relationship are inevitable: they serve as warning that something in the relationship needs closer attention. Conflict can lead to improved relationships. Conflict has been defined as tension arising from incompatible goals or needs. Most people experience conflict as discomfort.

DIF: Cognitive Level: Knowledge REF: p. 241 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. A nurse manager is educating nurses about the risk of violence experienced by nurses and

social workers in their workplace when compared to other professionals. The nurse manager states that nurses and social workers are at a. three times greater risk to experience violence in their workplace than are other professionals. b. four times greater risk to experience violence in their workplace than are other professionals. c. no greater risk to experience violence in their workplace than are other professionals. d. two times greater risk to experience violence in their workplace than are other professionals.

ANS: A

Violence against health care workers is increasing. Nurses are at greater risk because of their close contact with clients. In fact, nurses and social workers are at three times greater risk to experience violence in their workplace than are other professionals.

DIF: Cognitive Level: Knowledge REF: p. 242 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. The most effective problem-solving style for genuine resolution that creates a win-win

situation is a. accommodation. b. avoidance. c. competition. d. collaboration.

ANS: D

Collaboration is a solution-oriented response in which individuals work together cooperatively to problem solve. To manage a conflict, those involved commit to finding a mutually satisfying solution. This involves directly confronting the issue, acknowledging feelings, and using open communication to solve the problem. Steps for productive confrontation include: identifying concerns of each party; clarifying assumptions; communicating honestly to identify the real issue; and working collaboratively to find a solution that satisfies everyone. This is considered to be the most effective style for genuine resolution. This is a win-win situation. Accommodation is a lose-win situation. Avoidance can turn into a lose-lose situation. Competition can lead to a lose-lose situation.

DIF: Cognitive Level: Knowledge REF: p. 245 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 5. When a physician writes an order for the nurse to withhold life-saving treatment from a

terminally ill client, the nurse is faced with two different choices, each supported by a different ethical principle. This type of conflict is known as

a. b. c. d.

covert conflict. overt conflict. interpersonal conflict. intrapersonal conflict.

ANS: D

A conflict can be internal (intrapersonal); that is, it can represent opposing feelings within an individual. Intrapersonal conflict arises when nurses are faced with two different choices, each supported by a different ethical principle. More often, conflict is covert and not so clear-cut.

The conflict issues are hidden. The client talks about one issue, but talking does not seem to help and the issue does not get resolved. Overt conflict refers to conflict that is observable in the client's behavior and expressed verbally. Interpersonal conflict occurs between two or more people.

DIF: Cognitive Level: Application REF: p. 251 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 6. Which of the following best describes the goal of assertiveness? a. Offering responses that contain “you” statements b. Indirect communication c. Standing up for one’s personal rights d. Ignoring the rights of others ANS: C

Assertive behavior is defined as setting goals; acting on those goals in a clear, consistent manner; and taking responsibility for the consequences of those actions. Assertive communication is conveying this objective in a direct manner, without anger or frustration.

The assertive nurse is able to stand up for personal rights and the rights of others.

DIF: Cognitive Level: Knowledge REF: p. 247 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 7. Which of the following is true about assertion communication? a. Components include the ability to say no and to ask for what you want. b. It includes a demonstration of deference to the demands of others. c. It consistently violates the needs of others. d. It includes the expression of only positive thoughts and feelings.

ANS: A

Components of assertion communication include the following four abilities to: (1) say no, (2) ask for what you want, (3) appropriately express both positive and negative thoughts and feelings, and (4) initiate, continue, and terminate the interaction.

DIF: Cognitive Level: Knowledge REF: p. 247 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 8. A client yells at the nurse frequently and uses profane language. Which of the following is the

most appropriate response by the nurse? a. Remain silent and do not respond

b. Use an “I” statement when speaking to the client c. Tell the client, “You make me angry.” d. Ignore the behavior and walk away ANS: B

Assertive responses contain “I” statements that take responsibility. This behavior is in contrast to aggressive behavior, which has a goal of dominating while suppressing the other person’s rights. The goal of assertiveness is to communicate directly, standing up for one’s personal rights while respecting the rights of others. Conflict creates anxiety, which may prevent one from behaving assertively. Aggressive behavior has a goal of dominating while suppressing the other person’s rights. Aggressive responses often consist of “you” statements that fix blame on the other person. Assertive behaviors range from making a direct, honest statement about one’s beliefs to taking a very strong, confrontational stand about what will and will not be tolerated in the relationship.

DIF: Cognitive Level: Application REF: p. 247 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 9. A client states to the nurse in a hostile voice, “I am sick of being poked at and stuck with

needles. Go away and leave me alone.” Which of the following is the best statement by the nurse? a. “I am not surprised that you wish to be left alone.” b. “I’m so sorry you are feeling so upset.” c. “You feel vulnerable and depressed as a result of all these treatments.” d. “Okay, I will go away.”

ANS: B

Validating the anger and reframing are useful. Comments such as, “I’m sorry you are feeling so upset,” recognize the significance of the emotion being expressed without getting into the cause. “I am not surprised that you wish to be left alone” validates the client’s anger, but does not reframe the situation. The nurse should not make inferences about what the client is feeling without first validating. “Okay, I will go away” is avoidant behavior by the nurse.

DIF: Cognitive Level: Application REF: p. 251 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 10. A client on a psychiatric unit is found pacing the halls and angrily punching at the wall. The

nurse’s primary goal should be to a. assertively tell the client to stop the behavior. b. suggest that the client write in a journal to help relieve anxiety. c. speak in a loud voice in order to alert other staff members. d. maintain safety while helping the client.

ANS: D

The nurse should help the client own the angry feelings by getting the client to verbalize things that make him or her angry. Acknowledging a client’s anger may prevent an expression of abusive ranting. It is essential that the nurse use empathetic statements or active listening to acknowledge the client’s anger and maintain a nonthreatening demeanor before moving on to try to discuss the issue. The goal is to maintain safety while helping the client. Psychiatric clients can be unpredictable and at this point would not be likely to respond positively to a suggestion such as writing in a journal. Speaking assertively or in a loud voice may escalate the situation, and the client is already out of control.

DIF: Cognitive Level: Application REF: p. 257 TOP: Step of the Nursing Process: Intervention MSC: Client Needs: Safety and Infection Control 11. After fasting from 10 p.m. the previous evening, a client learns that the procedure has been

cancelled. The client curses at the nurse and accuses the nurse of being incompetent. The nurse’s best response would be a. “You have no right to say that to me. You are nasty.” b. “I can understand that you’re upset, but I feel uncomfortable when I am cursed at.” c. “Perhaps we shouldn’t get so angry when things don’t work out the way we think they should.” d. to leave the room and refuse to return to answer the call light when the client calls.

ANS: B

Assertive behaviors range from making a direct, honest statement about one’s beliefs to taking a very strong, confrontational stand about what will and will not be tolerated in the relationship. Assertive responses contain “I” statements that take responsibility. This behavior is in contrast to aggressive behavior, which has a goal of dominating while suppressing the other person’s rights. Aggressive responses often consist of “you” statements that fix blame on the other person. “We” statements should be used only when the nurse actually means to look at an issue collaboratively. Thus, the statement, “Perhaps we both need to look at this issue a little closer.” may be appropriate in certain situations. However, the statement, “Perhaps we shouldn’t get so angry when things don’t work out the way we think they should.” is a condescending statement thinly disguised as a collaborative statement. What is actually being expressed is the expectation that both parties should handle the conflict in one way—the nurse’s way. Some nurses were socialized to act passively. Passive behavior is defined as a response that denies our own rights in order to avoid conflict.

DIF: Cognitive Level: Application REF: p. 246 TOP: Step of the Nursing Process: Intervention MSC: Client Needs: Psychosocial Integrity 12. When providing home health care to a client suffering from Alzheimer disease who fell and

broke his hip 3 weeks ago, the nurse teaches the client’s family correct use of the walker. This represents which stage of the nurse-caregiver relationship? a. Worker-helper b. Worker-worker c. Nurse as manager; family as worker d. Nurse as nurse for family caregiver ANS: B

A Canadian study of home health nurses and family caregivers of elderly relatives identified four evolving stages in the nurse-caregiver relationship. The initial stage is “worker-helper,” with the nurse providing care to the ill client with the family helping. Next comes “worker-worker,” when the nurse begins teaching the needed care skills to family members.

Third is “nurse as manager; family as worker,” as the family members learn needed care skills. The final stage, “nurse as nurse for family caregiver,” occurs as the family member becomes exhausted. In the worker-helper stage, the nurse provides care to the ill client with the family helping. In the nurse as manager; family as worker stage, the nurse acts as manager with the family learning care skills. In the nurses as nurse for family caregiver stage, the family member is exhausted and the nurse cares for him or her as well as the client.

DIF: Cognitive Level: Application, Knowledge TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Management of Care

REF: p. 259

13. A client yells, “Take this mess away from here. How could anyone eat this food? What kind

of place are you running here?” The nurse uses skills of assertiveness to promote change that is focused on a. feelings. b. attitudes. c. behaviors. d. motivations.

ANS: C

Undesired behaviors, not feelings, attitudes, and motivations, are the focus for change.

Feelings, attitudes, and motivations are not the focus for change.

DIF: Cognitive Level: Application REF: p. 247 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care 14. The nurse is teaching an unlicensed assistive personnel (UAP) on potential approaches for

dealing with difficult clients. The nurse recognizes that additional teaching is required when the UAP states a. “I will be assertive by conveying my irritation toward the client’s behavior.” b. “I will collaborate with staff so we all use the same uniform approach when responding to the client’s demands.” c. “I will promote trust in the client by providing immediate feedback.” d. “I will explain to the client the limits of my role as an UAP.” ANS: A

Potential approaches for dealing with difficult clients include using a calm tone and avoiding conveying irritation. Potential approaches for dealing with difficult clients also include: working with staff so all use the same uniform approach to the client’s demands; promoting trust by providing immediate feedback; and explaining the limits of one’s role.

DIF: Cognitive Level: Application REF: p. 252 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

15. When interacting with the nurse, a client makes several condescending remarks directed

toward the nurse. The nurse recognizes this behavior as an example of a. the use of humor. b. active listening. c. a verbal clue to anger. d. assertiveness.

ANS: C

Nonverbal clues to anger include grimacing, clenching jaws or fists, turning away, and refusing to maintain eye contact. Verbal clues by a client may, of course, include use of an angry tone of voice, but they may also be disguised as witty sarcasm or as condescending or insulting remarks. The client’s remarks are condescending, not humorous. The client’s remarks are verbal, not nonverbal. Use of condescending remarks is an example of passive-aggressive communication.

DIF: Cognitive Level: Application REF: p. 257 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 16. The nurse’s first response in dealing with a conflict situation that involves a client is to a. understand the context of the situation. b. impose more controls on the client. c. gain a clear understanding of one’s own personal response. d. encourage the client to discount statements made by the nurse.

ANS: C

Conflicts between nurse and client are not uncommon. The first step for the nurse is to gain a clear understanding of one’s own personal response. No one is equally effective in all situations. The second step is to understand the context of the situation. Most interpersonal conflicts involve some threat to one’s sense of control or self-esteem. Nurses have been shown to respond to the stress of not having enough time to complete their work by imposing more controls on the client, who then often reacts by becoming more difficult. Other situations, which may lead to conflict between the nurse and the client, include having statements discounted.

DIF: Cognitive Level: Knowledge REF: p. 243 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 17. The initial interpersonal strategy to help the client reduce strong emotion to a workable level

involves a. talking the emotion through with someone. b. providing a neutral, accepting, interpersonal environment. c. taking action that might help the client come to terms with the emotional consequences. d. obtaining more information.

ANS: B

The initial interpersonal strategy used to help clients reduce strong emotion to a workable level is to provide a neutral, accepting, interpersonal environment. The second step in defusing the strength of an emotion is to talk the emotion through with someone. The third phase is to take action. The specific needs expressed by the emotion suggest actions that might help the client come to terms with the consequences of the emotion. This responsibility might take the form of obtaining more information or of taking some concrete risks to change behaviors that sabotage the goals of the relationship.

DIF: Cognitive Level: Knowledge REF: p. 253 TOP: Step of the Nursing Process: Intervention MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 1. Which of the following are strategies the nurse should use when dealing with an angry client?

(Select all that apply.) a. Defuse hostility b. Avoid responding to a client’s anger by getting angry c. Speak quickly and use a higher tone of voice d. Use empathy when communicating with the client e. Remain with the client ANS: A, B, D

The nurse should defuse hostility by avoiding responding to a client’s anger by becoming angry also. The nurse should use empathy in his or her communication. An angry client needs to have the nurse acknowledge both the issue and his or her feelings about that issue. Only then can the client begin to interact in a meaningful way. Empathy by the nurse may help defuse the situation. The nurse should deliberately begin to lower his or her voice and speak more slowly. When we get upset, we tend to speak quickly and use a higher tone of voice. If the nurse does the opposite, the client may begin to mimic him or her and thus calm down.

The goal is to maintain safety while helping the client. Therefore, it may not always be appropriate to remain with the client because this may place the nurse in danger of physical harm. If the nurse feels in danger of physical harm, he or she should always maintain a space for safety and plan an exit.

DIF: Cognitive Level: Knowledge REF: p. 255 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Safety and Infection Control

Chapter 15: Communication Strategies for Health Promotion and Disease Prevention Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. When conducting an initial assessment, a client informs the nurse about difficulty getting to

doctors’ appointments due to lack of transportation. When considering examples of PRECEDE Diagnostic Behavioral Factors, the nurse recognizes this as what type of factor? a. Reinforcing factor b. Epidemiologic factor c. Enabling factor d. Predisposing factor ANS: C

Enabling factor involves environmental factors that facilitate or present obstacles to change (e.g., transportation, scheduling, and availability of follow-up).

DIF: Cognitive Level: Comprehension REF: pp. 274-275 TOP: Step of the Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 2. The concept of well-being consists entirely of the ability to a. work at producing an income. b. perform activities of daily living. c. define one’s subjective experience of life satisfaction. d. partner with a health professional.

ANS: C

Well-being is defined as a person’s subjective experience of satisfaction about his or her life related to six personal dimensions: (1) intellectual, (2) physical, (3) emotional, (4) social, (5) occupational, and (6) spiritual. The concept of well-being is a personal experience.

DIF: Cognitive Level: Knowledge REF: p. 263 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Health Promotion and Maintenance 3. Which of the following is an example of tertiary prevention? a. Mammogram b. Smoking cessation c. Safe sex counseling d. Diabetic meal planning class ANS: D

Tertiary prevention strategies focus on minimizing the damaging effects of a disease or injury once it occurs. Preventing complications and helping people achieve their highest quality of life regardless of their health circumstances is the goal of tertiary health promotion strategies.

Primary prevention strategies emphasize taking proactive actions that can prevent targeted conditions. They target modifiable risk factors with health education to promote a healthy lifestyle; for instance, promoting exercise and diet as ways to prevent obesity and diabetes.

Other examples include immunizations, low-cost flu shots, safe sex counseling, smoking cessation, use of car seats and seat belts, motorcycle helmets, and bans on texting while driving. Advocacy for these health protections is easily incorporated into ordinary nursing care. Secondary prevention strategies focus on early disease detection through regular health screenings for prostate cancer, osteoporosis, and diabetes; regular mammograms and pap smears for women; periodic colonoscopies; and blood pressure screenings. Individuals with known risk factors such as family history, high cholesterol, elevated blood sugar, high blood pressure, and age should be screened periodically. Screening for mental health problems during the course of primary care visits can detect undiagnosed depression, anxiety, and substance abuse. Early diagnosis has a direct impact on the course and treatment of acute and chronic illness. With early case finding, the emergence or course of a chronic disease can be modified to allow a stronger quality of life.

DIF: Cognitive Level: Comprehension REF: p. 268 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. A client who is recovering from her second myocardial infarction refuses to give up smoking.

She states, “I’ve smoked so long now there’s no point quitting as the damage is done.” This statement is best understood in the context of which of the following? a. Social learning theory b. Pender’s health promotion model c. The transtheoretical model of change d. Healthy People 2010 ANS: B

Pender’s health promotion model serves as a guide for planning successful education with individuals and targeted high risk groups. A person’s capacity to absorb and use health promotion information depends to a large degree on what the person believes about his or her health and the extent to which personal actions will influence their health. In social learning theory, motivation is a fundamental component of learning readiness. Motivation to change is a state of readiness that fluctuates. Healthy People 2010 represents the health promotion agenda for the nation.

DIF: Cognitive Level: Application REF: pp. 264-265 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Health Promotion and Maintenance 5. A client who has an elevation in serum cholesterol continues to eat red meat and fried foods.

Which stage of change is this client experiencing? a. Determination b. Action c. Precontemplation d. Contemplation

ANS: C

In the precontemplation stage, a person either doesn’t see a health problem, even though it may be obvious to others, or doesn't have any intention of modifying it in the foreseeable future.

DIF: Cognitive Level: Application REF: p. 266 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. A client who overeats and is overweight is admitted to the hospital for shortness of breath.

Which of the following statements by the nurse reflects Bandura’s social theory? a. “Your cardiac studies reveal an enlarged heart. This is a sign of cardiac problems.” b. “I know you love to eat, but your current lifestyle is not conducive to good health.” c. “Can you remember what it was like to get up and go to work every day? Your buddies miss you.” d. “If you were to lose weight, you would no longer experience shortness of breath.

Just think about how much better you would feel to breathe normally.”

ANS: D

Bandura considers learning to be a social process. He identified three sets of motivating factors that promote the learning necessary to achieve a predetermined goal: (1) physical motivators, (2) social incentives, and (3) cognitive motivators. “Your cardiac studies reveal an enlarged heart. This is a sign of cardiac problems.”; “I know you love to eat, but your current lifestyle is not conducive to good health.”; and “Can you remember what it was like to get up and go to work every day? Your buddies miss you.” are interventions used with the transtheoretical model of change.

DIF: Cognitive Level: Application REF: pp. 266, 268 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 7. When caring for a client who is a newly diagnosed diabetic and who requires teaching about

self-administration of insulin, the nurse recognizes that teaching will be most effective when a. passive involvement of the learner is encouraged. b. there is little focus on practicing essential skills. c. optimizing engagement in only one sense in the learning process is encouraged. d. encouraging teach-back feedback when demonstrating new skills.

ANS: D

A highly participatory learning format, one that encourages different ways of thinking and opportunities to try out new behaviors, is far more effective than giving simple instructions to a client or family or demonstration without teach-back feedback. Active involvement of the learner enhances learning. Most people learn best when they engage more than one sense in the learning process and have an opportunity to practice essential skills.

DIF: Cognitive Level: Application REF: p. 273 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Health Promotion and Maintenance 8. Which of the following is the best intervention for a client who is illiterate? a. Speak loudly and clearly.

b. Use symbols and images. c. Personalize speech by using first name. d. Use touch with speech.

ANS: B

Using symbols and images with which the client is familiar helps overcome the barriers of low literacy. The client with low literacy is not necessarily hard of hearing. Personalizing speech by using first name and using touch with speech do not help with understanding.

DIF: Cognitive Level: Application REF: p. 279 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is caring for an older adult client who is newly diagnosed with diabetes and has a

low literacy level. Which of the following guidelines for teaching low-literacy clients should the nurse use when working with this client? a. Teach the largest amount possible in each teaching session. b. Sequence key behavior information last when teaching the client. c. Use symbols and images with which the client is familiar. d. Use words that are abstract and provide teaching in long sentences.

ANS: C

Educationally disadvantaged or functionally illiterate people are interested in learning, but nurses need to adapt teaching situations to accommodate literacy learning differences. Marks (2009) suggests having written materials modified to six- to eighth-grade reading levels and providing lists of key instructions for use after visits. Using symbols and images with which the client is familiar helps overcome the barriers of low literacy. Taking the time to understand the client's use of words and phrases provides the nurse with concrete words and ideas that can be used as building blocks in helping the client understand difficult health-related concepts.

Otherwise, the client may misunderstand what the nurse is saying. It is also important to check with the client about the environmental infrastructure needed to implement self-management strategies. Don’t assume that the client understands the implications of a clinical recommendation.

DIF: Cognitive Level: Application REF: p. 279 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. When caring for clients, the nurse recognizes that which of the following statements is true

related to developmental level? a. Developmental level affects only teaching strategies. b. All clients are at the beginning level of the learning spectrum. c. Developmental learning capacity is always age related. d. Social and emotional development does not always parallel cognitive maturity.

ANS: D

Social and emotional development does not always parallel cognitive maturity.

Developmental level affects both teaching strategies and subject content. Clients are at all levels of the learning spectrum with regard to their social, emotional, and cognitive development. Developmental learning capacity is not always age related.

DIF: Cognitive Level: Application

REF: pp. 280-281

TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 11. A client requires teaching about a newly prescribed medication. The nurse recognizes that in

order to support the learning process of the client, the teaching process should include a. all parties needing information. b. only immediate family members. c. the preferred communication style of the nurse. d. limited cultural recognition of learning needs.

ANS: A

In many cultures, the family assumes a primary role in care of the client even when the client is physically and emotionally capable of self-care. Including them, and especially those expected to support the learning process of the client from the outset, in all aspects of health teaching for health promotion is important. The culturally sensitive nurse develops knowledge of the preferred communication style of different cultural groups and uses this knowledge in choosing teaching strategies. Client motivation and participation increase with the use of indigenous teachers and cultural recognition of learning needs.

DIF: Cognitive Level: Application REF: p. 281 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. A client visits the wound clinic for treatment of an infected nonhealing leg ulcer. The nurse

recognizes the client is in the precontemplation stage of change. When interacting with this client, the nurse should a. provide the client with informational feedback to raise awareness of the health problem and health risks involved. b. allow open discussion related to the pros and cons of changing the client’s current behavior. c. assist the client in justifying a positive commitment toward making healthier lifestyle changes. d. assist the client in choosing the best course of action to take in resolving the current problem.

ANS: A

In the precontemplation stage of change, a suggested approach is to raise doubt by giving informational feedback to raise awareness of a problem and health risks.

DIF: Cognitive Level: Application REF: p. 266 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 13. A client has just completed an alcohol detoxification program. The client has recently

experienced the loss of his wife and has been having difficulties at work. The client has some serious health effects from long-term alcohol abuse, including elevated serum liver enzymes.

The client states, “Alcohol is ruining my life; I will do anything to quit drinking.” The nurse should a. ask the client what kinds of changes will be needed in order to stop drinking. b. discuss the client’s elevated serum liver enzymes and the predictive consequences of serious health problems, including premature death.

c. ask the client what life would be like without alcohol. d. remind the client that he or she has been abstinent from drinking, allowing liver

tests to significantly improve.

ANS: A

The client is in the preparation stage of change, in which characteristic behaviors include the client deciding there is a problem and the client’s willingness to make a change. A suggested approach in this stage is to help the client choose the best course of action to take in resolving the problem. A sample statement by the nurse includes, “What kinds of changes will you need to make to stop drinking? Most people find Alcoholics Anonymous (AA) helpful as a support.

Have you heard of them?” In the precontemplation stage of change, the client does not think there is a problem and is not considering the possibility of change. A suggested approach in this stage is to raise doubt by giving informational feedback to raise awareness of a health problem and health risks. A sample statement by the nurse includes, “Your lab tests show liver damage. These tests can be predictive of serious health problems and premature death.”

In the contemplation stage of change, the client thinks there may be a problem, is thinking about change, and is going back and forth between concern and unconcern. A suggested approach in this stage is to tip the balance; allow open discussion of pros and cons of changing behavior; build motivation for change; and help the client justify a positive commitment. A sample statement by the nurse includes, “It sounds as though you think you may have a drinking problem, but are not sure you are an alcoholic. What would your life be like without alcohol?” In the maintenance stage of change, the client perseveres with positive behavioral change. A suggested approach in this stage is to help the client identify and use strategies to sustain progress, to point out positive changes, and to accept temporary setbacks and use steps in the determination phase, if needed. A sample statement by the nurse includes, “It’s hard to let go of old habits, but you have been abstinent for 3 months now, and your liver tests are significantly improved.”

DIF: Cognitive Level: Application REF: p. 266 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 14. Which of the following strategies in health education does the U.S. Preventive Services Task

Force recommend? a. Using a standardized teaching format b. Eliminating established behaviors c. Offering limited information regarding the purpose of interventions d. Suggesting small changes rather than large ones ANS: D

Recommendations of the U.S. Preventive Services Task Force include suggesting small changes and baby steps rather than large ones. The task force also recommends framing the teaching to match the client’s perceptions, linking new behaviors to old behaviors, adding new behaviors rather than eliminating established behaviors whenever possible, and fully informing clients of the purposes and expected outcomes of interventions and when to expect these new effects.

DIF: Cognitive Level: Knowledge REF: p. 277 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

15. The personal values and beliefs in one’s ability to achieve health behavior changes is known

as a. b. c. d.

social incentive. self-efficacy. cognitive motivator. physical motivator.

ANS: B

Education and counseling for health promotion can include information on risk factors or behaviors impacting health and ways to address negative social, economic, and environmental determinants of health. A health promotion format considers a person’s personal values and beliefs about his or her ability to achieve health behavior changes (self-efficacy) as part of client assessment. Social incentive, cognitive motivator, and physical motivator are motivating factors.

DIF: Cognitive Level: Knowledge REF: p. 266 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. The client states, “I have emphysema, so I have enrolled in a smoking cessation program.”

According to Prochaska’s stages of change, the client is in which of the following stages? a. Action b. Determination c. Precontemplation d. Contemplation ANS: A

During the action stage of change, the client engages in concrete actions to effect needed change. In the determination stage, the client decides there is a problem and is willing to make a change. In the precontemplation stage, the client does not think there is a problem and is not considering the possibility of change. In the contemplation stage, the client thinks there may be a problem, is thinking about change, and goes back and forth between concern and unconcern.

DIF: Cognitive Level: Knowledge REF: pp. 266-267 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 17. A 3-year-old child is having surgery tomorrow. A preoperative teaching strategy the nurse

should use is to a. encourage self-directed learning. b. involve parents in teaching. c. allow child to touch and play with all equipment. d. incorporate previous life experience.

ANS: B

Parents can provide useful information about their child’s immediate life experiences and commonly used words to incorporate in health teaching. Encouraging self-directed learning and incorporating previous life experience are principles of adult learning. The child should touch and play with safe equipment.

DIF:

Cognitive Level: Application

REF: pp. 280-281

TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Precede components of the Precede/Proceed Model of Health Promotion include which of the

following? (Select all that apply.) a. Social diagnosis b. Epidemiological diagnosis c. Implementation d. Outcome evaluation e. Educational and organizational diagnosis ANS: A, B, E

Social, epidemiological, and educational and organizational diagnoses are components of the precede phase. Implementation and outcome evaluation are components of the proceed phase.

DIF: Cognitive Level: Knowledge REF: pp. 274-275 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

Chapter 16: Communication in Health Teaching and Coaching Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Educational standards requiring health care agencies to provide systematic health education

and training for clients were established by a. American Nurses Association. b. State Nurse Practice Acts. c. The Joint Commission. d. Medicare.

ANS: C

Health teaching is not an option. It is a legal and ethical responsibility. The Joint Commission has established educational standards requiring health care agencies to provide systematic health education and training for clients that is specific to the client’s needs; sufficient for clients to make informed decisions and to take responsibility for self-management activities related to their needs; provided to clients in an understandable manner and designed to accommodate various learning styles; and reflected in documented evidence of the client’s understanding and response to the medical information. Professional nursing standards, developed by the American Nurses Association (ANA), reinforce the importance of health teaching as an essential nursing intervention. State Nurse Practice Acts mandate health teaching as an independent professional nursing function. Medicare requirements portray health teaching as a skilled nursing intervention for reimbursement purposes.

DIF: Cognitive Level: Knowledge REF: p. 285 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Health Promotion and Maintenance 2. When initiating health teaching, the nurse recognizes that readiness to learn a. is the same as the cognitive ability to learn. b. involves a smooth and linear developmental process. c. requires the nurse to consistently challenge the client’s learning pattern. d. involves incorporation of the client’s learning pattern into new opportunities for

learning.

ANS: D

Rather than challenge the client’s learning pattern, the nurse needs to understand it and incorporate it into new opportunities for learning. Readiness to learn is not the same as the cognitive ability to learn. Nurses need to remember that learning is never smooth or linear in its development. Rather than challenge the client’s learning pattern, the nurse needs to understand it and incorporate it into new opportunities for learning.

DIF: Cognitive Level: Application REF: p. 293 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. When the nurse formulates a goal that “the client will be able to accurately draw up the

correct dose of insulin,” the nurse recognizes this goal as referring primarily to health teaching in which domain?

a. b. c. d.

Changing attitudes Psychomotor Understanding content Promoting acceptance

ANS: B

Health teaching is a dynamic process, which involves making relevant connections to meaning within three domains: (1) cognitive (understanding content); (2) affective (changing attitudes and promoting acceptance); and (3) psychomotor (hands-on skill development).

Changing attitudes and promoting acceptance are in the affective domain. Understanding content occurs in the cognitive domain.

DIF: Cognitive Level: Application REF: pp. 286-288 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. The nurse is caring for a client who has a history of alcohol abuse. When formulating a goal

that “the client will be able to identify three physical effects of alcohol abuse,” the nurse recognizes this goal as referring primarily to health teaching in which domain? a. Cognitive b. Affective c. Psychomotor d. Promoting acceptance ANS: A

Health teaching is a dynamic process, which involves making relevant connections to meaning within three domains: (1) cognitive (understanding content); (2) affective (changing attitudes and promoting acceptance); and (3) psychomotor (hands-on skill development).

Affective refers to changing attitudes and promoting acceptance. Psychomotor refers to hands-on skill development. Promoting acceptance refers to the affective domain of health teaching.

DIF: Cognitive Level: Application REF: pp. 286-288 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 5. A theoretical foundation for the use of teaching methodologies in which a learner-centered

approach engages clients as active partners in the learning process and helps them to take responsibility for their own learning to whatever extent possible is known as a. Skinner’s behavioral approach. b. Premack’s principle. c. modeling. d. client-centered health teaching.

ANS: D

Carl Rogers’ (1983) ideas provide a theoretical foundation for the use of teaching methodologies in client-centered health teaching. Rogers emphasizes the primacy of the teacher-learner relationship as the means through which learning occurs. He describes learner-centered teaching as an interactive process. Applied to health care, a learner-centered approach involves engaging clients as active partners in the learning process and helping them take responsibility for their own learning to whatever extent possible. Rogers insists that the teacher must start where the learner is, structuring the learning process to support the learner’s natural desire to learn and being mindful of learner characteristics that enable or impede the process.

DIF: Cognitive Level: Knowledge REF: p. 289 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. When planning an education class for clients suffering from addiction, the nurse recognizes

that a format that encourages empowerment is an important goal of health teaching. Which of the following is a strategy that could be viewed as disempowering? a. Providing the client with sufficient information b. Providing the client with emotional support c. Placing the learner in charge of his or her learning d. Having the nurse assume primary responsibility for the learning process ANS: D

A highly participative learning environment, in which the nurse provides the teaching while the learner assumes primary responsibility for the learning process, encourages empowerment.

Empowerment strategies include providing sufficient information, specific instructions, and emotional support—but no more than is required—to allow each client to take charge of his or her health care to whatever extent is possible. Client-centered strategies place the learner in charge of his or her learning and build on personal strengths to achieve learning objectives.

DIF: Cognitive Level: Application REF: p. 289 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 7. A nurse is working with a client in a drug rehabilitation center. The nurse provides positive

reinforcement each time the client demonstrates behavior that moves him closer to accomplishing the goal of remaining drug free. The nurse recognizes this type of reinforcement will motivate the client to engage in the desired behavior. This type of reinforcement is known as a. empowerment. b. chaining. c. modeling. d. shaping.

ANS: D

Shaping refers to the reinforcement of successive approximations of the target behavior. The long-term goal is broken down into smaller steps. The person is reinforced for any behavior that gets him or her closer to accomplishing the desired behavior. Rewarding specific behaviors that move the person in the direction of the desired behavior (successive approximations) motivates the person to engage in the desired behavior. Steps build one upon the other, moving learners from the familiar to the unfamiliar as they progress toward meeting treatment goals.

DIF: Cognitive Level: Knowledge REF: pp. 303-304 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. The concept that “the teacher must start where the learner is” was proposed by whom? a. Skinner b. Premack c. Rogers d. Taylor ANS: C

Rogers insists that the teacher must start where the learner is, structuring the learning process to support the learner’s natural desire to learn and being mindful of learner characteristics that enable or impede the process.

DIF: Cognitive Level: Knowledge REF: p. 285 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Health Promotion and Maintenance 9. The nurse is caring for a client who is suffering from schizophrenia and cocaine abuse. The

client remains isolated in his room, refusing to attend unit activities. When implementing a behavioral approach, what is the first step the nurse should take? a. Define specific consequences. b. Describe the behavior requiring change. c. Reframe the problem as a solution statement. d. Identify the tasks in sequential order.

ANS: B

A behavioral approach starts with a careful description and quantification of a concrete behavior requiring change. During the third step of implementing a behavioral approach, the nurse and client reframe the problem as a solution statement (e.g., “The client will attend all scheduled unit activities.”). If the problem and solution are complex, the nurse can break them down into simpler definitions, beginning with the simplest and most likely behavior to stimulate client interest. The nurse should identify the tasks in sequential order; define specific consequences, positive and negative, for behavioral responses; and solicit the client’s cooperation.

DIF: Cognitive Level: Application REF: p. 303 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 10. A client is newly diagnosed with diabetes mellitus. When planning a teaching session to

review insulin administration with this client, the nurse should

a. b. c. d.

pick times for teaching when energy levels are low. schedule teaching sessions during hospital visiting hours. reserve a block of time for health teaching. provide the client with extensive information during 30-minute intervals.

ANS: C

Teaching interventions should never be eliminated because the nurse lacks time, but they can be streamlined. Even in the most limited situation, the nurse should schedule a block of time for health teaching. The nurse should pick times for teaching when energy levels are high, the client is not distracted by other things, it is not visiting time, and the client is not in pain.

People have saturation points as to how much they can learn in one time period. Since even under the best of circumstances, people can absorb only so many details and fine points, the nurse should limit information to two or three points at a time. The nurse should keep the teaching session short, interesting, and to the point. Ideally, teaching sessions should last no longer than about 20 minutes, including time for questions. Otherwise the client may tire or lose interest. Scheduling shorter sessions with time in between to process information helps prevent sensory overload and reinforces teaching points.

DIF: Cognitive Level: Knowledge REF: p. 297 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 11. Accurate documentation of client health teaching is a critical component of quality care.

When documenting in the client’s chart about health teaching for a client admitted for alcoholism, the nurse should write a. “Client was educated on the physical complications of alcoholism.” b. “Client received written and verbal instructions on diet and vitamin therapy.” c. “Client was educated on the signs and symptoms of alcohol withdrawal and when to seek medical assistance.” d. “Client was able to identify five triggers for relapse and was assisted to develop a relapse prevention plan.”

ANS: D

The Joint Commission requires written documentation of all client health teaching. Notes about the initial assessment should be succinct, but comprehensive and objective. Teaching content should be linked to assessment data, including client preferences, previous knowledge, and values. Included in the documentation are the teaching actions, the client response, and any clinical issues or barriers to compliance. If family members are involved, you should identify their role, content provided, and teaching outcomes in your documentation. Accurate documentation helps ensure continuity and prevents duplication of teaching efforts. The client's record informs other health care providers of what has been taught and what areas need further work.

DIF: Cognitive Level: Application REF: p. 300 TOP: Step of the Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 12. The nurse is teaching a support group about schizophrenia. The format includes a 20-minute

video, a didactic portion, and a discussion period. The nurse recognizes that a. establishment of rapport with the audience is unnecessary. b. a humorous opening grabs the audience’s attention.

c. minimal preparation is needed for this format. d. it is important to refrain from making eye contact with the audience.

ANS: B

An initial quote at the beginning capturing the meaning of the presentation or a humorous opening grabs the audience’s attention. In a group presentation, the nurse will need to establish rapport with the audience. Preparation and practice can ensure that the presentation is clear, concise, and well spoken. The nurse should make eye contact immediately and continue to do so throughout the presentation. Extension of eye contact to all participants communicates acceptance and inclusion.

DIF: Cognitive Level: Application REF: p. 305 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 13. The nurse is preparing teaching material for a class of diabetic clients. The most important

aspect when preparing a presentation with slides for group teaching is a. the inclusion of greater than five items per slide. b. use of large font so all participants can see from a distance. c. use of slides as the primary content for the presentation. d. having the presenter face the slides, not the audience.

ANS: B

Use slides to identify key points. Slides help you stay on track and move through the agenda.

The font should be large enough to see from a distance (32 point is recommended). Include no more than four or five items per slide. Face the audience, not the slides. Practice your presentation to ensure that you keep within the time frame and allot time for short discussion points. It is up to you as the presenter to set the pace. No matter how interesting the presentation and dialogue that it stimulates, running out of time is frustrating for the audience.

DIF: Cognitive Level: Application REF: p. 305 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 14. Which of the following statements is true related to home care? a. The nurse should consider herself a member of the family when entering the

client’s home. b. The nurse should arrive at the client’s home unannounced to get an accurate

picture of the client’s situation. c. Part of the teaching assessment includes appraisal of the home environment. d. The nurse should wash her hands in the kitchen sink when visiting the client.

ANS: C

In home care the nurse is a guest in the client’s home. Part of the teaching assessment includes appraisal of the home environment, family supports, and resources, as well as client needs.

The nurse should always call before going to the client’s home. This is a common courtesy; it also protects the nurse’s time if the client is going to be out. When in the home, it is important to model appropriate behaviors (e.g., washing hands in the bathroom sink before touching the client). Simple strategies, like not washing one’s hands in the kitchen sink where food is prepared, encourage the client to do likewise.

DIF:

Cognitive Level: Knowledge

REF: p. 305

TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 15. An older adult client is hospitalized after a fall. The client states, “I want to return home

because I like to be independent.” The nurse notes that the client lives alone and will be required to attend physical therapy three times a week. Which of the following nursing diagnoses is appropriate for this client? a. Anxiety b. Ineffective coping c. Self-care deficit d. Impaired home maintenance ANS: C

The client lives alone and requires physical therapy related to a fall. The client will require assistance with care. There is insufficient evidence to diagnose anxiety. The client states that he is independent, which indicates coping skills, and there is no evidence of impairment in home maintenance.

DIF: Cognitive Level: Application REF: p. 306 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 16. Which of the following is an effective teaching objective? The client will be able to a. ambulate short distances around the nursing unit. b. learn subcutaneous self-administration of insulin. c. understand diabetes and its lifestyle implications. d. perform foot care correctly after three teaching sessions.

ANS: D

Objectives are powerful guides to organizing content and suggesting appropriate planning activities. Each objective should describe an immediate action step that the client should take to accomplish relevant treatment outcomes. Teaching objectives should be modest and achievable in the time frame allotted. They should be logically organized and build on one another for maximum effectiveness. To determine whether an objective is achievable, the nurse should consider the client’s level of experience, educational level, resources, and motivation; then the nurse should define each learning objective needed to achieve the health goal in specific, measurable behavioral terms. Ambulating short distances is not specific enough or measurable. Learning subcutaneous self-administration of insulin is not specific.

Understanding diabetes and its lifestyle implications is not measurable.

DIF: Cognitive Level: Comprehension REF: p. 290 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 17. A client requires health teaching for exercises related to an arthritic shoulder. During an

assessment, the client tells the nurse she is a kinetic learner. What teaching resource should the nurse recommend to this client? a. Reading a book about arthritis b. Watching an exercise video c. Performing water aerobics d. Listening to an exercise audiotape

ANS: C

The kinetic learner learns best with hands-on involvement. The visual learner would use books and videos. An exercise audiotape would benefit the auditory learner.

DIF: Cognitive Level: Application REF: p. 292 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. When assessing teaching and learning needs at discharge, the nurse should focus on which of

the following? (Select all that apply.) a. What potential problems are likely to prevent a safe discharge b. The client’s ability to pay for his or her hospitalization c. What potential problems are likely to cause complications or readmission d. What prior knowledge or experience the client and family has with the current problem e. What skills and equipment are needed to manage the problem at home f. Who or what agency will assume responsibility for continuing care ANS: A, C, D, E, F

Assessing teaching and learning needs at discharge includes asking the following questions: What potential problems are likely to prevent a safe discharge? What potential problems are likely to cause complications or readmission? What prior knowledge or experience does the client and family have with this problem? What skills and equipment are needed to manage the problem at home? Who (what agency) will assume responsibility for continuing care? The client’s ability to pay for hospitalization should not be a focus of teaching and learning needs at discharge. If the client has concerns about ability to pay for hospitalization, the nurse can ask a case manager to visit with the client.

DIF: Cognitive Level: Comprehension REF: pp. 291-295 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

Chapter 17: Communication in Stressful Situations Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Current research suggests that men and women respond to stress in which of the following

ways? a. Men use nurturing activities to reduce stress. b. Women use a “tend and befriend” approach to stress. c. Men and women respond to stress in a similar manner. d. Women respond to stress with patterns of “fight or flight.”

ANS: B

Current research suggests that men and women respond to stress differently. Men respond with patterns of “fight or flight” while women use a “tend and befriend” approach. Women use nurturing activities to reduce stress and promote safety for self and others. They seek social support from others, particularly from other women.

DIF: Cognitive Level: Knowledge REF: p. 311 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. Which of the following is true in relation to stress? a. Men and women respond to stress in the same fashion. b. Culture does not affect the stress experience. c. Stress is always a negative experience. d. Stress can have protective and adaptive functions.

ANS: D

Hans Selye used the term eustress to describe a short-term mild level of stress. It acts as a positive stress response with protective and adaptive functions and is perceived as being within the person’s ability to manage. Current research suggests that men and women respond to stress differently. The nurse should pay attention to cultural values. What is a small stressor in one culture can be huge in another, and normal coping strategies can be quite different.

Stress results from positive as well as negative forces, for example, a job promotion, impending wedding, or birth of a child.

DIF: Cognitive Level: Knowledge REF: p. 310 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. The nurse is conducting a family assessment in which alcoholism by the parents is suspected.

When assessing the children within this family for symptoms of stress, the nurse recognizes that a. the children will most likely verbalize their feelings about the stressor. b. the children will demonstrate the ability to sort out the meaning of the illness. c. signs of distress can include academic decline, gastric distress, and headaches. d. physical complaints by the children can only be related to a physiological etiology.

ANS: C

Signs of distress such as academic decline, gastric distress, and headaches can alert the nurse to unvoiced stress. Children express stress through behavior. Health disruptions create special problems for children because they lack the words and life experience to sort out the meaning of illness, either their own or that of a significant family member.

DIF: Cognitive Level: Application REF: p. 320 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. A short-term mild level of stress that acts as a positive stress response with protective and

adaptive functions and is perceived as being within the person’s ability to manage is known as a. stress. b. eustress. c. stressor. d. distress.

ANS: B

Hans Selye used the term eustress to describe a short-term mild level of stress. It acts as a positive stress response with protective and adaptive functions and is perceived as being within the person’s ability to manage. Stress represents a natural physiologic, psychological, and spiritual response to the presence of a stressor. A stressor is defined as a demand, situation, internal stimulus, or circumstance that threatens a person’s personal security or self-integrity. Distress is defined as a negative stress that causes a higher level of anxiety and is perceived as exceeding the person’s coping abilities. It is experienced as being unpleasant and diminishes performance.

DIF: Cognitive Level: Application REF: p. 310 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. A three-stage progressive pattern of nonspecific physiologic responses known as alarm,

resistance, and exhaustion is based on a. Cannon’s scientific physiologic response theory. b. Selye’s General Adaptation Syndrome. c. Holmes and Rahe’s stimuli stress model. d. Lazarus and Folkman’s transactional model of stress.

ANS: B

Hans Selye’s General Adaptation Syndrome describes responses to longer-term stress exposure. Selye described a three-stage progressive pattern of nonspecific physiologic responses, which he branded as alarm, resistance, and exhaustion. Walter Cannon was the first to describe a scientific physiological basis for an acute stress response. Cannon believed that when people feel physically well, emotionally centered, and personally secure, they are in a state of dynamic equilibrium or homeostasis. Stress disturbs homeostasis. Thomas Holmes and Richard Rahe developed a stress model that considered stressful life events such as marriage, divorce, death, and losing a job as stimuli that threaten or disrupt homeostasis.

Lazarus and Folkman’s transactional model of stress is one of the most widely used to explain stress responses. It is based on the premise of a dynamic relationship between a situation or circumstance in the environment (stressor) and the individual experiencing the stressor that accounts for its impact on a person.

DIF: Cognitive Level: Knowledge REF: p. 311 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 6. A client is experiencing anxiety related to hospitalization. When assessing this client, the

nurse anticipates which assessment finding? a. Increased socialization b. Improved sleep c. Greater recall ability d. Disengagement from the stressor ANS: D

Stress doesn’t always look like a “stressor response.” Some people internalize stress. They withdraw or seem disengaged from an obvious stressor, when stressed.

DIF: Cognitive Level: Analysis REF: p. 318 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 7. A client’s spouse becomes anxious and demonstrates hostility toward the nurse. The best

response by the nurse is to a. recognize the spouse feels a sense of control. b. view the hostility as a personal attack. c. become stoic and refrain from listening to the spouse. d. respond empathetically to contributory themes and feelings.

ANS: D

What a hostile anxious client or family needs most at that moment—despite their behavior—is understanding, comforting, and human caring. The nurse should listen, ask, and respond empathetically to contributory themes and feelings. Anger and hostility are the most common stress emotions associated with feeling helpless or psychologically threatened. Recognizing hostility as a cry for help in coping with escalating stress makes it easier to respond empathetically. Most outbursts have little to do with the nurse personally other than that the nurse is available, is the one most involved with the care of the loved one, and is least likely to retaliate.

DIF: Cognitive Level: Application REF: pp. 317-318 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 8. A client tells the nurse, “I think I’m losing my mind.” The best response by the nurse is a. “Tell me what you are experiencing right now.” b. “You should take a nap now; it will help you to feel better.” c. “If you say that you’re losing mind, you really will lose your mind.” d. “I don’t think you really feel that you are losing your mind.”

ANS: A

The nurse should listen carefully and ask gentle, probing questions. A helpful statement can include, “Can you tell me what you are experiencing right now?” This listening response allows the client to put concerns into words. The nurse should allow clients to be in charge of areas and issues that are not at odds with a treatment protocol, and helping clients discover the real causes of their frustration can reduce stress through direct action. Clients experiencing stress should be given the opportunity to express their feelings, thoughts, and worries. Crying, anger, and magical thinking are normal reactions to situations that one cannot control.

Acknowledging the legitimacy of feelings as a normal response to an abnormal situation reinforces the client’s self-integrity and helps the client put boundaries on their anxiety.

DIF: Cognitive Level: Application REF: p. 321 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 9. A client who has been diagnosed with cancer asks the nurse, “If I take the chemotherapy, will

I be cured, or am I going to die anyway?” The nurse’s best response is a. “Tell me what prompted your question.” b. “I don’t think you should have chemotherapy; it will harm you more than help you.” c. “Let’s not talk about dying; I’m sure you will be cured.” d. “I really don’t think you should worry about such things; it isn’t something you can control.”

ANS: A

It is difficult to directly answer stress-related questions about uncertainties, like, “If I take the chemotherapy, will I be cured, or am I going to die anyway?” The reality is that there may be no single answer. It helps to ask the client what prompted the question and to have a good idea of the client’s level of knowledge before answering. Allowing clients to be in charge of areas and issues that are not at odds with a treatment protocol and helping clients discover the real causes of their frustration can reduce stress through direct action. Clients experiencing stress should be given the opportunity to express their feelings, thoughts, and worries.

DIF: Cognitive Level: Analysis REF: p. 323 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 10. A nurse consistently works extra shifts in the hope of earning a promotion. The nurse is

becoming increasingly fatigued and frustrated because the promotion has not occurred. The nurse is experiencing a. distress. b. burnout. c. eustress. d. primary appraisal.

ANS: B

Burnout is defined as “a state of fatigue or frustration brought about by devotion to a cause, way of life, or relationship that failed to produce an expected reward.” It develops in individuals involved with “people work” and is characterized by emotional exhaustion, depersonalization, and a sense of diminished professional accomplishment. Distress is defined as a negative stress that causes a higher level of anxiety and is perceived as exceeding the person’s coping abilities. It is experienced as being unpleasant and diminishes performance.

Hans Selye used the term eustress to describe a short-term mild level of stress. It acts as a positive stress response with protective and adaptive functions and is perceived as being within the person’s ability to manage. Primary appraisal focuses on the stressor or stressful event itself—its content and strength as a personal threat.

DIF: Cognitive Level: Application REF: pp. 326-328 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 11. The nurse is caring for a client who works as a boxer. The client states, “I was picked on a lot

when I was little, so I got really angry and now I work through the anger by boxing.” The nurse recognizes the client is demonstrating which ego defense mechanism? a. Denial b. Intellectualization c. Sublimation d. Repression ANS: C

Sublimation is redirecting socially unacceptable unconscious thoughts and feelings into socially approved outlets. Sublimation is used to channel extreme anger impulses into acceptable behaviors—for example by becoming a butcher or boxer. Denial is the unconscious refusal to allow painful facts, feelings, or perceptions into awareness.

Intellectualization is the unconscious focusing on only the intellectual and not the emotional aspects of a situation or circumstance. Repression is unconscious forgetting of parts or all of an experience.

DIF: Cognitive Level: Application REF: p. 315 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. Which of the following interventions would be classified as secondary prevention for stress? a. Classify stressor b. Mobilize resources c. Educate client and family d. Coordinate resources ANS: B

Mobilizing resources is classified as a secondary prevention intervention. A primary intervention is to classify the stressor. Educating client and family is a primary intervention.

Coordinating resources is a tertiary intervention.

DIF: Cognitive Level: Knowledge REF: p. 318 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity

Chapter 18: Communicating With People With Communication Disorders Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following is true in relation to communication deficits? a. Communication deficits occur only as a result of physical disabilities. b. Communication deficits can arise from sensory deprivation. c. Individuals who are equally impaired are equally disabled. d. The primary nursing goal is to minimize the client’s independence.

ANS: B

Communication deficits can arise from the kind of sensory deprivation that occurs in some agencies and units such as intensive care units. A communication disability definition includes any client who has any impairment in body structure or function that interferes with communication. Specifically, the client has a communication difficulty due to impaired functioning of one or more of his five senses or he has impaired cognitive processing functioning. Communication deficits can arise from the kind of sensory deprivation that occurs in some agencies and units such as intensive care units. Two individuals can have the same sensory impairment but not be equally communication disabled. Each person compensates for their impairment in different ways. The primary nursing goal is to maximize the client’s ability to successfully interact with the health care system.

DIF: Cognitive Level: Knowledge REF: p. 334 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. The nurse is caring for an older adult client who has recently withdrawn from relationships,

appears depressed, and appears reluctant to seek information from the nurse. The nurse suspects the client is experiencing hearing loss. The nurse recognizes that a. the client will readily acknowledge that this is the problem if asked. b. the client may try to hide deficits and withdraw from relationships. c. decreased hearing ability is not related to conversational style. d. older adults, as a group, have better consonant discrimination.

ANS: B

Deprived of a primary means of receiving signals from the environment, clients with hearing loss may try to hide deficits, may withdraw from relationships, become depressed, or be less likely to seek information from health care providers.

DIF: Cognitive Level: Application REF: p. 335 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. The nurse is caring for a client who has experienced a stroke. The client has aphasia. The

nurse recognizes that aphasia is a a. neurological linguistic deficit. b. cognitive comprehension deficit. c. sensory deprivation deficit. d. mental disorder deficit.

ANS: A

Aphasia is defined as a neurological linguistic deficit. There may be no cognitive, sensory, or mental impairment. While there may be no cognitive impairment, the client may need more “think time” for cognitive processing during a conversation.

DIF: Cognitive Level: Application REF: p. 335 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 4. When communicating with a client diagnosed with a serious mental disorder, it is important

for the nurse to recognize which of the following? a. Clients with mental disorders never have intact sensory channels b. Clients with a ‘flat affect’ are easier to understand c. Clients with mental disorders are always very talkative d. Clients with mental disorders may suffer from social isolation and impaired coping ANS: D

Clients with serious mental disorders may have a different type of communication deficit resulting from a malfunctioning of the neurotransmitters that normally transmit and make sense out of messages in the brain. Social isolation and impaired coping may accompany the client’s inability to receive or express language signals. Other communication problems occur with different mental disorders. As an example, some clients with mental disorders can perhaps have intact sensory channels, but they cannot process and respond appropriately to what they hear, see, smell, or touch. The nurse may notice a lack of vocal inflection and an unchanging facial expression. A ‘flat affect’ makes it difficult to truly understand the client.

Some clients with mental disorders present with a poverty of speech and limited content.

Speech appears blocked; reflecting disturbed patterns of perception, thought, emotions, and motivation.

DIF: Cognitive Level: Application REF: p. 336 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. When caring for a hearing-impaired client, the nurse should a. face the interpreter when speaking to the client. b. use gestures that reinforce verbal content. c. speak distinctly while exaggerating words. d. communicate in a dimly-lit room.

ANS: B

For hearing-impaired clients, the nurse should use facial expressions and gestures that reinforce verbal content. The nurse should always face the client when communicating, so the client can see the nurse’s lips move. The nurse should speak distinctly without exaggerating words. Partially deaf clients respond best to well-articulated words spoken in a moderate, even tone. The nurse should stand or sit to face the client and allow the client to see facial expressions and mouthing of words. The nurse should also communicate in a well-lighted room.

DIF: Cognitive Level: Knowledge REF: p. 338 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

6. When caring for the client with macular degeneration, the nurse should a. face the client directly. b. stand to the client’s side. c. hold the client’s arm when walking. d. refrain from touching the client.

ANS: B

When caring for clients with macular degeneration, the nurse should remember to stand to their side, an exception to the “face them directly” rule applied with hearing loss clients.

Macular degeneration clients often still have some peripheral vision. For vision-impaired clients, the nurse should not lead or hold the client’s arm when walking; instead, the nurse should allow the person to take her arm. The nurse should use touch and close physical proximity while with the client, and the nurse should give the client something substantial to touch when leaving the client.

DIF: Cognitive Level: Application REF: p. 340 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 7. Which of the following clients with a communication deficit requires the use of touch during a

therapeutic encounter? a. Vision-impaired client b. Client with a hearing loss c. Mentally ill client d. Client with schizophrenia ANS: A

The social isolation experienced by blind clients can be profound, and the need for human contact is important. Touching the client lightly as the nurse speaks alerts the client to the nurse’s presence. For vision-impaired clients, the nurse should let the person know when approaching by a simple touch, and always indicate when leaving. The nurse should use touch and close physical proximity while with the client, and give the client something substantial to touch when leaving the client. The nurse should tap on the floor or table to get the client’s attention via vibration. Other communication problems occur with different mental disorders.

As an example, some clients with mental disorders can have intact sensory channels, but they cannot process and respond appropriately to what they hear, see, smell, or touch. In some forms of schizophrenia, there are alterations in the biochemical neurotransmitters in the brain that normally conduct messages between nerve cells and help orchestrate the person’s response to the external environment. Messages have distorted meanings.

DIF: Cognitive Level: Knowledge REF: p. 340 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 8. The nurse is caring for an older adult client who is recovering from a stroke. When the nurse

speaks to the client, the client nods her head and responds using incoherent words. Which type of aphasia does this client exhibit? a. Expressive b. Receptive c. Global

d. Cognitive ANS: A

The client with expressive aphasia can understand what is being said but cannot express thoughts or feelings in words. Receptive aphasia creates difficulties in receiving and processing written and oral messages. With global aphasia, the client has difficulty with both expressive language and reception of messages. A client may have feelings of loss and social isolation imposed by the communication impairment. While there may be no cognitive impairment, the client may need more “think time” for cognitive processing during a conversation.

DIF: Cognitive Level: Application REF: p. 341 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 9. The nurse is caring for a client who has experienced global aphasia secondary to a stroke.

Which of the following interventions is most appropriate for this client? a. Refrain from exploiting any language skills that are preserved b. Frequently remind the client they cannot be understood c. Encourage short, positive sessions to communicate d. Spend long periods of time talking with the client to provide stimulation ANS: C

Clients who lose both expressive and receptive communication abilities have global aphasia.

These clients can become frustrated when they are not understood. Struggling to speak causes fatigue. Short, positive sessions are used to communicate. Otherwise, the client may become nonverbal as a way of regaining energy and composure. Any language skills that are preserved should be exploited.

DIF: Cognitive Level: Analysis REF: p. 341 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 10. The nurse is caring for an unconscious client. The client’s family member reports that a nurse

at the client’s bedside stated, “I wouldn’t want to live in this condition.” What did this nurse not realize about the client’s capabilities? a. The client can read lips b. Hearing can remain acute in clients who are not fully alert c. The client can respond to statements through written communication d. The client can be sensitive to the nurse’s nonverbal behavior ANS: B

When a client is not fully alert, it is not uncommon for nurses to speak in their presence in ways they would not if they thought the client could fully understand what is being said, forgetting that hearing can remain acute. Good clinical practice suggests never saying anything the nurse would not want the client to hear. The ability to read lips, respond to written communication, or be sensitive to nonverbal behavior does not relate to the verbal statement made by the nurse.

DIF: Cognitive Level: Application REF: p. 342 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

11. The nurse is caring for a client who is nonverbal. When caring for this client, the nurse should a. insist the client communicate in a two-way mode. b. continue to initiate communication in a one-way mode. c. refrain from explaining procedures because the client will not understand. d. limit orienting cues in order to reduce environmental stimuli.

ANS: B

When clients are unable or unwilling to engage in a dialogue, the nurse should continue to initiate communication in a one-way mode. Giving orienting cues is recommended, such as labeling of meals as breakfast, lunch, or dinner; and linking events to routines (e.g., saying, “The x-ray technician will take your chest x-ray right after lunch”) helps secure the client in time and space.

DIF: Cognitive Level: Application REF: p. 343 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 12. When attempting to communicate a procedure to a Spanish-speaking client, a strategy that the

nurse could use to facilitate understanding would be a. speak distinctly while exaggerating words. b. attempt to use sign language. c. use pictographs. d. explain what is happening in complex terms.

ANS: C

Pictographs are one of many tools recommended for communicating within nursing. For hearing-impaired clients, the nurse should speak distinctly without exaggerating words. There is no mention in the question of this client being hearing-impaired. American Sign Language has been a standard communication tool for many years; however, few care providers were able to use it. Even when a client appears not to understand, the nurse should explain in very simple terms what is happening.

DIF: Cognitive Level: Application REF: p. 338 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 13. The nurse is caring for a client who is hearing-impaired and legally blind in his right eye. The

client has just returned from cataract surgery on his left eye. The nurse recognizes that a. the client’s arm should be held when walking. b. verbal speech is useless in this situation. c. signals should be developed to indicate changes in pace or direction while walking. d. the client should be discouraged from reading lips.

ANS: C

For vision-impaired clients, the nurse should develop and use signals to indicate changes in pace or direction while walking. The nurse should not lead or hold the client’s arm when walking, but instead allow the client to take the nurse’s arm. The nurse should speak distinctly without exaggerating words. Partially deaf clients respond best to well-articulated words spoken in a moderate, even tone. The client with hearing loss should be encouraged to verbalize speech, even if they only use a few words or the words are difficult to understand at first. The nurse should always face the client when communicating so the client can see the nurse’s lips move.

DIF: Cognitive Level: Application REF: p. 338 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 14. The nurse understands that as clients age, they are more likely to have vision problems that

may interfere with the communication process, including the lens of the eyes becoming less flexible, making it difficult to accommodate shifts from far to near vision. The nurse recognizes that this condition is known as a. receptive aphasia. b. autism. c. presbycusis. d. presbyopia.

ANS: D

As clients age, they are more likely to have vision problems that may interfere with the communication process because the lens of the eyes become less flexible, making it difficult to accommodate shifts from far to near vision. This is a condition known as presbyopia.

Receptive aphasia creates difficulties in receiving and processing written and oral messages.

Atypical communication is often the first behavioral clue to cognitive impairment in young children, associated with conditions such as mental retardation, autism, and affective disorders. Presbycusis, or degeneration of ear structures, is a sensorineural dysfunction that normally occurs as one ages.

DIF: Cognitive Level: Application REF: p. 335 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Chapter 19: Communicating With Children Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. In mastering QSEN competency of patient-centered care, effective tools need to be a. cognitive, developmentally appropriate, and educational. b. cultural, educational, interpersonal, and societal. c. attitudinal, cognitive, and developmentally appropriate. d. attitudinal, cultural, and developmentally appropriate.

ANS: C

In mastering QSEN competency of patient-centered care, effective tools need be attitudinal, cognitive, and developmentally appropriate.

DIF: Cognitive Level: Knowledge REF: p. 345 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. When caring for a preschooler, the nurse understands that this child tends to interpret

language in a literal way and that the child will not ask for clarification, leading to a misunderstanding of messages. The nurse recognizes a preschooler is in which of Piaget’s cognitive stages of development? a. Concrete operations b. Formal operations c. Preoperational d. Sensorimotor ANS: C

Throughout the preoperational period, young children tend to interpret language in a literal way. For example, the child who is told that he will be “put to sleep” during the operation tomorrow may think it means the same as the action recently taken for a pet dog who was too ill to live. Children do not ask for clarification, so messages can be misunderstood quite easily. The concrete operations stage occurs from approximately 7 to 11 years of age. The formal operations stage starts at about age 12+ years. The sensorimotor stage is from birth to about 2 years of age.

DIF: Cognitive Level: Application REF: p. 347|p. 353 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Health Promotion and Maintenance 3. When communicating with a preschooler who is admitted to the hospital for a fractured arm,

which is the best method for the nurse to describe the preschooler’s impending surgery? a. Encourage the preschooler to put a bandage on a teddy bear’s arm. b. Explain what surgery will be like, using abstract terminology. c. Explain to the preschooler how long the surgery will take and that it will be done by noon. d. Inform the preschooler that fixing the fractured arm will make it possible to play sports in the future.

ANS: A

Preschoolers tend to think of their illness, their separation from parents, and any painful treatments as punishment. Play can be used to help children express their feelings about an illness and to role play coping strategies. Allowing the young child to manipulate syringes and give “shots” to a doll or put a bandage or restraint on a teddy bear’s arm gives the child a chance to act out his feelings. The child becomes “the aggressor.” Play can be a major channel for communication in the nurse-client relationship involving a young child. Preschool children develop communication themes through their play and work through conflict situations in their own good time; the process cannot be rushed. When working with a school-age child, the nurse should search for concrete examples to which the child can relate rather than giving abstract examples. Abstract thinking occurs in the formal operations stage. Children who are 7-11 years of age are in Piaget’s concrete operations stage, in which they master the use of numbers and other concrete ideas such as classification and conservation. Children who are 12+ years of age are in Piaget’s formal operations stage, in which they tend to think about the future.

DIF: Cognitive Level: Analysis REF: p. 354 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 4. When assessing a child’s reaction to illness, it is important for the nurse to a. observe the interaction between parent and child. b. recognize that chronological age matches cognitive level. c. realize that children are more comfortable with female health care providers. d. recognize that the child’s behavior will be age appropriate.

ANS: A

Assessing a child’s reaction to illness requires knowing the child’s normal patterns of communication. Interactions are observed between parent and child. Variations occur across situations, so that the child under stress or in a different environment may process information at a lower level than he would under normal conditions. Because two children of the same chronological age may have quite different skills as information processors, the nurse needs to assess level of functioning. Some studies show school-age children are more satisfied if their health care provider is the same gender. A severe illness can cause a child to show behaviors that are reminiscent of an earlier stage of development. A certain amount of regression is normal.

DIF: Cognitive Level: Application REF: p. 348 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. The nurse is caring for a child with a severe illness who is demonstrating behaviors that are

reminiscent of an earlier stage of development. When the child has toileting accidents, the nurse should a. recommend a urology consult. b. obtain a urine sample and send it to the lab. c. reassure the child’s parents that this is common. d. eliminate all fluids after dinner.

ANS: C

A severe illness can cause a child to show behaviors that are reminiscent of an earlier stage of development. A certain amount of regression is normal. Common behaviors include whining, demanding undue attention, withdrawal, or having toileting “accidents.” These behaviors might stem from the powerlessness the child feels in attempting to cope with an overwhelming, frightening environment. Reassuring the parents that this is a common response to the stress of illness can be helpful and is the best approach.

DIF: Cognitive Level: Analysis REF: pp. 348-349 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 6. A pediatric nurse is educating parents about how children cope with hospitalization. Which of

the following statements by the nurse is correct? a. “The quiet, compliant child who never complains is comfortable on the nursing unit.” b. “The child who screams and cries is much more frightened of hospitalization than the quiet child.” c. “The 2-year-old child who asks for a bedtime bottle is showing signs of regression.” d. “The child who screams and cries may be less frightened than the quiet, overly compliant child who never complains.”

ANS: D

Because children have limited life experience to draw from, they exhibit a narrower range of behaviors in coping with threat. The quiet, overly compliant child who does not complain may be more frightened than the child who screams or cries. The nurse needs to obtain detailed information regarding the usual behavioral responses of the family and child. Some behaviors that look regressive may be a typical behavioral response for the child (e.g., the 2-year-old who wants a bedtime bottle).

DIF: Cognitive Level: Application REF: p. 348 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 7. When communicating with hospitalized infants and toddlers, the nurse knows a. she should use long sentences with soothing words. b. she cannot communicate with a preverbal infant. c. moving to the child’s eye level and maintaining eye contact are important. d. she should pick up an 18-month-old infant immediately.

ANS: C

Face-to-face position, bending or moving to the child’s eye level, maintaining eye contact, and making a reassuring facial expression help in interactions with infants. To help the child’s comprehension, the nurse should use phrases rather than long sentences and repeat words for emphasis. Cues to assessment of the preverbal infant include tone of the cry, facial appearance, and body movements. Because the infant uses the senses to receive information, nonverbal communication (e.g., touch) is an important tool for the pediatric nurse. Tone of voice, rocking motion, use of distraction, and a soothing touch can be used in addition to or in conjunction with verbal explanations. The nurse should anticipate developmental behaviors such as “stranger anxiety” in infants between 9 and 18 months of age. Rather than reaching to pick a child up immediately, the nurse might smile and extend a hand toward the child or stroke the child’s arm before attempting to hold the child. In this way, the nurse acknowledges the infant’s inability to generalize to unfamiliar caregivers.

DIF: Cognitive Level: Comprehension REF: p. 350 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 8. During the preoperational period the nurse recognizes that children a. ask numerous questions to clarify a message. b. can process auditory information quickly. c. can clearly distinguish between fantasy and reality. d. misunderstand messages quite easily.

ANS: D

Throughout the preoperational period, young children tend to interpret language in a literal way. For example, the child who is told that he will be “put to sleep” during the operation tomorrow may think it means the same as the action recently taken for a pet dog who was too ill to live. Children in the preoperational stage do not ask for clarification, so messages can be misunderstood quite easily. Preschool children have limited auditory recall and are unable to process auditory information quickly. Before the age of 7 years, most children cannot make a clear distinction between fantasy and reality. Everything is “real,” and anything strange is perceived as potentially harmful.

DIF: Cognitive Level: Comprehension REF: p. 353 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 9. The nurse is caring for a postoperative preschooler who is crying and has been refusing to eat.

The best communication strategy for the nurse to use is to a. avoid providing the child with simple explanations. b. assign the child to a different nurse in order to optimize socialization. c. give the child some clay, crayons, and paper. d. encourage the child to express complex thoughts and feelings.

ANS: C

Play materials vary with the age and developmental status of the child. Simple, large toys are used with young children; more intricate playthings are used with older preschoolers. Clay, crayons, and paper become modes of expression for important feelings and thoughts about problems. Play can be the nurse’s primary tool for assessing preschool children’s perceptions about their hospital experience, their anxieties, and their fears. Play can increase their coping ability. Simple explanations reduce the child’s anxiety. No child should ever be left to figure out what is happening without some type of simple explanation. Assigning the same caregiver reduces insecurity. The preschooler lacks a suitable vocabulary to express complex thoughts and feelings.

DIF: Cognitive Level: Application REF: p. 354 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 10. Which of the following is true in relation to the stress of having an ill child? a. Coping with uncertainty over the outcome is the most stressful factor for parents. b. Factors connected with the child’s illness causes more stress than alleviation of the

child’s pain. c. Uncertainty about a critically ill child’s current condition is considered to be a

minor source of stress. d. The parents’ inability to comfort the child is more stressful than factors connected with the illness.

ANS: D

Having an ill child is stressful for parents. Many research studies have shown that loss of the ability to act as the child’s parent, to alleviate the child’s pain, and to comfort the child is more stressful than factors connected with the illness, including coping with uncertainty over the outcome. Major sources of stress for parents of critically ill children include uncertainty about current condition or prognosis, lack of control, and lack of knowledge about how to best help their hospitalized child or how to deal with their child’s response.

DIF: Cognitive Level: Knowledge REF: p. 360 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 11. When admitting an adolescent to a hospital unit, the nurse knows she should keep in mind

which of the following? a. The nurse should use the “three wishes” question to assess cognitive level. b. When a teen asks a direct question, the teen does not really want the answer. c. Teens recognize that life is a roller-coaster ride with ups and downs. d. Teens are able to self-assess competency.

ANS: A

To assess a teen’s cognitive level and to find out about the ability to make long-term plans, an easy approach is to use the “three wishes” question. The nurse should ask the teen to name three things he would expect to have in 5 years. Answers can be analyzed for factors such as concreteness, realism, and goal-directness. When a teen asks a direct question, he is ready to hear the answer. The nurse should answer directly and honestly. Some teens lack sufficient experience to recognize that life has ups and downs and that things will eventually be better.

Adolescents still rely primarily on feedback from adults and from friends to judge their own competency.

DIF: Cognitive Level: Application REF: p. 357 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. The pediatric nurse is working on an oncology unit with a terminally ill child. The nurse

conveys respect to the child by a. interacting as a buddy to the child. b. protecting the child from the truth about the terminal illness. c. using the concept of mutuality. d. being emotionally unavailable.

ANS: C

When interacting with the older child, using the concept of mutuality will promote respect and should foster more positive and lasting health care outcomes. Being authentic does not mean being overly familiar. Trying to interact with older children and adolescents as though the nurse is a buddy is confusing to the client. What the child wants is an emotionally available, calm, caring, competent resource that can protect, care about, and above all, listen to him or her. Providing truthful answers is a hallmark of respect.

DIF: Cognitive Level: Application REF: p. 360 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 13. The nurse is caring for a 2-year-old child on a pediatric unit. The child’s parents have just left

the unit for the night. The child is standing at the edge of the crib and crying. Which of the following interventions is most appropriate for the nurse to use? a. Limit the use of kinesthetic approaches when caring for the child. b. Talk to the child about Mommy and Daddy and how much the child cares for them. c. Maintain a flat affect when interacting with the child. d. At first maintain a distance of 8 feet from the child.

ANS: B

Handling separation anxiety when the primary caregiver is absent includes establishing rapport with the caregiver (parent) and encouraging them to be with the child and reassuring the child that staff will be there if they are away. At first the nurse should keep at least 2 feet between herself and the infant. The nurse should talk to and touch the infant and initially smile often. The nurse should provide for kinesthetic approaches; offer self while infant is protesting (e.g., stay with the child; pick the child up and rock or walk; talk to the child about Mommy and Daddy and how much the child cares for them).

DIF: Cognitive Level: Analysis REF: p. 351 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 14. The nurse recognizes that guidelines for developing a workable limit-setting plan include

having consequences that are a. applied after a detailed verbal exchange with the client. b. person centered, not situation centered. c. applied in a matter-of-fact manner, without lengthy discussion.

d. applied at a time negotiated between the nurse and client.

ANS: C

Guidelines for developing a workable limit-setting plan include having consequences that are applied in a matter-of-fact manner, without lengthy discussion, are logical and fit the situation, and occur immediately following the transgression.

DIF: Cognitive Level: Knowledge REF: p. 359 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 15. A school-aged child is admitted to the hospital because of an accident during gymnastics. The

child complains of not feeling her legs. The child’s parents ask the nurse, “What is going to happen to our daughter? Will she walk again?” The best response by the nurse is a. “I’m sure everything will be okay. She is in good hands.” b. “The best thing you can do for your child is to act like everything is alright.” c. “You will have to ask the doctor; he is in surgery right now.” d. “You must have several fears and concerns. We will let you know the test results as soon as they are available.”

ANS: D

The nurse should reassure the parents when appropriate that their child’s hospitalization is indeed frightening and it is all right to be scared. The nurse should remember to demonstrate interest in the client as a person and to use listening responses to create an atmosphere of concern. The nurse should keep the parents continually informed regarding their child’s progress. The nurse should avoid communication blocks, such as giving false reassurance, telling the client what to do, or ignoring the concerns; such behavior effectively cuts off therapeutic communication.

DIF: Cognitive Level: Analysis REF: p. 361 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity

Chapter 20: Communicating With Older People Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. The nurse is caring for an older adult client. The nurse recognizes that the factor most closely

associated with the older adult’s inability to live independently is a. chronological age. b. functional status. c. relationship needs. d. social functioning.

ANS: B

More than any other factor, impaired functional status is a determinant of an older adult's inability to live independently. Stress, acute and chronic illness, and age-related physiologic changes will influence a person's functional status. Functional status, rather than chronologic age, should be the stronger indicator of disability-related needs in older adults because functional impairment is not associated solely with age.

DIF: Cognitive Level: Application REF: p. 367 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. An older adult client tells the nurse, “My life has been a waste.” The nurse recognizes this

statement as demonstrating which aspect of psychosocial development? a. Ego integrity b. Ego despair c. Lack of generativity d. Isolation ANS: B

Erikson’s (1982) model of psychosocial development is used to describe older adult psychosocial development. His is one of the only developmental models that specifically addresses later adulthood (> 60 years) as a stage of ego development. Erikson portrays the maturational crisis of old age as that of ego integrity versus ego despair. Awareness of one’s personal mortality leads to the psychosocial crisis identified with this last stage of ego development. Ego despair describes the failure of a person to accept one’s life as appropriate and meaningful. Left unresolved, despair leads to feelings of emotional desolation and bitterness. Ego integrity relates to the capacity of older adults to look back on their lives with satisfaction and few regrets, coupled with a willingness to let the next generation carry on their legacy. Lack of generativity and isolation are not stages found in the older adult client.

DIF: Cognitive Level: Application REF: p. 366 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. A client has an order for a new medication. When preparing to administer the medication to

the client for the first time, the nurse gets ready to educate the client and the client’s daughter about the medication. When educating the client and the daughter, the nurse should do all of the following except

a. observe the client before implementing teaching and gear teaching strategies to

meet the individual needs of the client. b. direct instructions to the client’s daughter. c. draw on the client's experiences and interests in planning teaching. d. make the teaching session short enough to avoid tiring the client.

ANS: B

Assuming that cognitive intact older adults lack the capacity to understand instructions is a common error. Health care providers often direct instruction to the older adult client's younger companion, even when the client has no cognitive impairment. This action invalidates the client and diminishes self-worth. Simple modifications to reduce age-related barriers to learning when teaching older adults include: • Explain why the information is important to the client.

• Use familiar words and examples in providing information.

• Draw on the client's experiences and interests in planning teaching.

• Make teaching sessions short enough to avoid tiring the client, and frequent enough for continuous learning support.

• Speak slowly, naturally, and clearly.

Health teaching for the elderly is critical if they are to master the tasks of old age and maintain their health. Healthy older adult learning capabilities remain intact, although older adults may need more time to think about how they want to handle a situation. The sensitive nurse observes the client before implementing teaching and gears teaching strategies to meet the individual learning needs of each client. Four aspects of successful aging—fall prevention, adequate nutrition, socialization, and medication management—lend themselves to health teaching formats.

DIF: Cognitive Level: Application REF: p. 377 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 4. The nurse is caring for an older adult client who has recently experienced losses associated

with deaths of important people in her life. The nurse recognizes that this type of problem challenges which of Maslow’s hierarchy of needs? a. Physiological integrity b. Love and belonging c. Self-actualization d. Safety and security ANS: B

Maslow’s hierarchy of needs helps nurses prioritize nursing actions, beginning with basic survival needs. Physiological integrity, followed by safety and security, emerge as the most basic critical issues for aging adults, and need to be addressed first. Love and belonging needs are challenged by increased losses associated with death of important people. Esteem needs, especially those associated with meaningful purpose, and independence remain important issues in later life. Abraham Maslow believed that self-actualization occurs more often in middle aged and older adults. Love and belonging needs are challenged by increased losses associated with death of important people. Esteem needs, especially those associated with meaningful purpose, and independence remain important issues in later life. Abraham Maslow believed that self-actualization occurs more often in middle-aged and older adults.

DIF: Cognitive Level: Application REF: p. 367 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. When communicating with older adult clients, the nurse recognizes that a. hearing problems can diminish an older person’s ability to interact with others. b. hearing loss associated with normal aging begins after age 40 years. c. older adults who experience hearing loss initially cannot hear lower-frequency

sounds of vowels. d. older adults distinguish sounds better against background noises.

ANS: A

Hearing problems can diminish an older person’s ability to interact with others, attend concerts and other social functions, and understand medical directions. Hearing loss associated with normal aging begins after age 50 due to loss of hair cells (which are not replaced) in the organ of Corti in the inner ear. This change leads initially to a loss in the ability to hear high-frequency sounds (e.g., f, s, th, sh, ch) and is called presbycusis.

Lower-frequency sounds of vowels are preserved longer. Older adults have special difficulty in distinguishing sounds against background noises and in understanding fast-paced speech.

DIF: Cognitive Level: Knowledge REF: p. 369 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 6. When assessing an older adult client, the nurse recognizes the client has a significant hearing

loss. The most appropriate intervention by the nurse is to a. introduce herself first. b. shout into the client’s good ear. c. repeat words the client doesn’t understand. d. check the hearing aid batteries.

ANS: D

Adaptive strategies for hearing loss include helping older adults adjust hearing aids. Older adults lack fine-motor dexterity and may not be able to insert aids correctly to amplify hearing. The nurse should make sure hearing aids are turned on. If difficulties persist, the nurse should check the batteries. Adaptive strategies for hearing loss also include addressing the person by name before beginning to speak (it focuses attention) and speaking slowly and distinctly. If the nurse’s voice is high pitched, the nurse should lower it and rephrase rather than repeat words if the older adult doesn’t understand certain words.

DIF: Cognitive Level: Application REF: p. 370 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 7. The nurse has just completed a care plan on a visually impaired client. Which of the following

interventions is most appropriate for this client? a. Stand away from the client when communicating to not obstruct the view of the immediate environment. b. Provide the client with reading material that has all capital letters. c. Verbally explain all written information while discouraging the client from asking questions. d. Ensure the client’s room has bright lighting with no glare.

ANS: D

Adaptive strategies for vision loss include providing bright lighting with no glare, having the nurse stand in front of the client, and considering the font and letter size for readability when using written materials. Upper and lower case letters rather than all capitals should be used.

Solid paper with sharp, contrasting writing and a lot of white space should also be used.

Adaptive strategies for vision loss also include verbally explaining all written information while allowing time for the client to ask questions.

DIF: Cognitive Level: Application REF: pp. 370-371 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 8. The nurse is caring for a frail older adult client who is admitted to the hospital after falling.

The client has been living alone independently and appears reluctant to accept assistance. The nurse recognizes that the client’s reluctance to accept assistance is most likely caused by fear of a. inability to pay for services. b. additional financial burden on the family. c. relinquishing independent living. d. loss of privacy.

ANS: C

The nurse may need to directly observe environmental supports, bearing in mind that a potential association exists in the older adult’s mind between accepting help and relinquishing independent living.

DIF: Cognitive Level: Application REF: p. 374 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. When visiting a client in his or her home, the home health nurse notes that the client

frequently shifts the conversation to reminisce. Which of the following communication techniques would be most effective for the nurse to use with this client? a. Restating b. Changing the subject c. Providing information d. Asking about the client’s life history ANS: D

Older adults appreciate having the nurse provide structure to the history-taking interview by explaining the reasons for it and what it will involve. Asking clients to share something about themselves and their life history, apart from the reasons for the health visit or admission, helps to establish rapport and increases the client’s comfort level. By relating their life stories and exploring options relevant to their current health situation, older adults are able to step back and look at their situation in the present from a broader perspective. Nurses get to know the client as a person rather than categorically as an “older adult.” Ego integrity relates to the capacity of older adults to look back on their lives with satisfaction and few regrets, coupled with a willingness to let the next generation carry on their legacy. Integrity involves acceptance of “one’s one and only life cycle” as something that had to be and that by necessity permitted of no substitution. Acceptance develops through self-reflection and dialogue with others about the meaning of one’s life. Nursing strategies encouraging life review and reminiscence groups facilitate the process. Old age “is shaped by a lifetime of experience.” Assessment of older adult clients begins with their story. As they relate their story, the nurse should look for value-laden psychosocial issues (e.g., independence, fears about being a burden, role changes, and vulnerability) and client preferences. These are significant issues for older adult clients that may not be directly expressed.

DIF: Cognitive Level: Application REF: p. 368 TOP: Step of the Nursing Process: Intervention MSC: Client Needs: Psychosocial Integrity 10. When assessing an older adult client, the nurse notes that the client demonstrates an inability

to take purposeful action even when the muscles, senses, and vocabulary appear to be intact.

The client appears to register on a command but acts in a way that suggests little understanding of what transpired verbally. The nurse recognizes these assessment findings as consistent with which of the following conditions? a. Presbycusis b. Somatization c. Apraxia d. Polypharmacy ANS: C

Apraxia, defined as the loss of the ability to take purposeful action even when the muscles, senses, and vocabulary seem intact, is a common feature of dementia. The person appears to register on a command but acts in ways that suggest he or she has little understanding of what transpired verbally. Hearing loss associated with normal aging begins after age 50 years and is due to loss of hair cells (which are not replaced) in the organ of Corti in the inner ear. This change leads initially to a loss in the ability to hear high-frequency sounds (e.g., f, s, th, sh, ch) and is called presbycusis. Although most people weather the necessary losses of life, late life depression is an often untreated problem in older adults. Unlike symptoms of depression in younger people, somatization with vague physical complaints may be its first presenting sign. Polypharmacy is a fact of life for older adults. As people age, many need multiple medications to maintain a healthy lifestyle. Polypharmacy places older adults at risk for side effects and drug interactions because of age-related changes in metabolism. Medications in general have a stronger effect on the older population and take longer to be eliminated from the body.

DIF: Cognitive Level: Knowledge REF: p. 379 TOP: Step of the Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity 11. The nurse is caring for an older adult client who has early moderate cognitive impairment and

has been diagnosed with dementia. When interacting with the client’s family, the nurse should teach family members that a. memory for recent events is retained longer than remote memory. b. it is important to focus on recent events when asking the client questions. c. reminiscing about the past can cause the client undue distress. d. reminiscing about the past can be a means of connecting.

ANS: D

Remote memory (recall of past events) is retained longer than memory for recent events.

Family members can be encouraged to reminisce with dementia clients. This can be a meaningful experience for the family member, even when the client cannot actively engage in the discussion, because it is a means of connecting. It is not uncommon for a dementia client to show through facial expression or garbled words that he/she too experiences the connection, even if only for a fleeting moment. Or it may come later. Asking mild to early moderate cognitively impaired older adults about their past life experiences serves as a way to connect verbally with those who might have difficulty telling you what they had for breakfast 2 hours ago.

DIF: Cognitive Level: Application REF: p. 380 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 12. The nurse is performing an admission assessment on a client with cognitive impairment.

When developing a plan of care for this client, the nurse should plan to a. provide instructions one step at a time. b. offer several instructions at a time when orienting the client to their room. c. teach the client new skills using complex instructions with multiple steps. d. refrain from mentioning the client’s past life experiences when asking questions.

ANS: A

Cognitively impaired clients have trouble following instructions consisting of multiple steps.

Breaking instructions into single steps helps these clients master tasks that otherwise are beyond their comprehension. Keep the conversation simple and focused on one step at a time.

Asking mild to early moderate cognitively impaired older adults about their past life experiences is a way to connect verbally with those who might have difficulty telling you what they had for breakfast 2 hours ago. Remote memory (recall of past events) is retained longer than memory for recent events. When cognitively impaired adults share memories, they are giving a gift to the nurse by sharing part of themselves when they may have very little else to give.

DIF: Cognitive Level: Knowledge REF: p. 380 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 13. A client diagnosed with dementia is becoming increasingly unable to express complete

thoughts and is having difficulty engaging in simple conversations. When communicating with this client, the nurse should a. use words directly applicable to the client’s daily routine.

b. restate ideas using different words in a different sequence. c. refrain from validating the meaning of the client’s responses. d. ask the client questions that require more than a yes or no answer.

ANS: A

Instead of using abstract prompts (like a specific time), the nurse should use words directly applicable to the client’s daily routine, like “before lunch,” to anchor the client’s recognition of time frames. The nurse should restate ideas using the same words and sequence and validate the meaning of a client’s response. As dementia progresses, clients become increasingly unable to express complete thoughts and eventually cannot carry on even simple conversations. The nurse should use questions that can be answered with a yes or no for clients with less verbal skill. The nurse should note whether the client’s behavior is consistent with the yes or no answer and follow up if the behavior is incongruent with the words.

DIF: Cognitive Level: Application REF: p. 380 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 14. The nurse is caring for an older adult client who has been diagnosed with dementia. The nurse

recognizes which of the following as true in relation to the use of touch with this client? a. Clients with dementia can ask for touch. b. Clients with dementia can create touch for themselves. c. Clients with dementia can become more anchored in the present time, space, and humanity when touched. d. Clients with dementia can tell the nurse about the meaning of touch.

ANS: C

Touch is something clients with dementia can no longer ask for, create for themselves, or tell another of its meaning. Touch is a form of communication, used to reinforce simple verbal instructions with cognitively impaired adults and as a primary form of communication. It is experienced "not only physically as sensation, but also affectively as emotion and behavior."

As dementia progresses, gentle touch can anchor an anxious or disoriented person in present time, space, and humanity. When used to gain a client's attention or to guide a person toward an activity, touch can acknowledge a client's stress, calm an agitated client, or provide a sense of security. In general, clients with dementia appreciate the use of touch.

DIF: Cognitive Level: Knowledge REF: p. 381 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 15. When caring for an older adult client who is experiencing memory loss, the nurse notes that

the client emotionally overreacts to situations, appearing as if having temper tantrums when responding to real or perceived frustration. The nurse recognizes the client is experiencing a catastrophic reaction. When caring for this client, the nurse should a. attempt to keep the client awake for extended periods of time. b. demand the client stop demonstrating inappropriate behavior. c. increase the client’s environmental stimuli. d. use distraction to move the client away from the offending environmental stimuli.

ANS: D

Instead of focusing on the behavior, the nurse should try to identify and eliminate the cause(s).

The nurse should use distraction to move older adults away from the offending stimuli in the environment or use postponement. Older adults with memory loss lack the cognitive ability to develop alternatives. They emotionally overreact to situations and can have what look like temper tantrums in response to real or perceived frustration. Older adult tantrums are called catastrophic reactions and represent a completely disorganized set of responses. Usually there is something in the immediate environment that precipitates the reaction. Fatigue, multiple demands, overstimulation, misinterpretations, or an inability to meet expectations are contributing factors.

DIF: Cognitive Level: Knowledge REF: p. 382 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 16. When performing a mental status examination on an older adult client, the nurse discovers

that the client is illiterate and only has a third-grade education. How should the nurse assess the client’s cognition? a. Have the client spell the word “world” backwards. b. Have the client spell the word “world” forwards. c. Ask the client to perform serial 7s. d. Instruct the client to state the days of the week backwards.

ANS: D

The nurse should determine the client’s level of formal education. If the client never learned to spell, it will be impossible to spell “world” backwards. Saying the days of the week backwards is a good alternative. Spelling and use of serial 7s would not be an appropriate alternative with this client’s level of formal education.

DIF: Cognitive Level: Application REF: p. 371 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Chapter 21: Communicating with People in Crisis Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. A client experiences an unusually stressful life event that exceeds their resources and coping

skills. The nurse recognizes the client is experiencing which type of crisis? a. Developmental b. Private c. Adventitious d. Situational ANS: D

A situational crisis is an unusually stressful life event that exceeds a person’s resources and coping skills. Examples include unexpected illness or injury, rape, car accident, loss of home, spouse, job, etc. Erik Erikson’s stage model of psychosocial development forms the basis for understanding developmental crises. Each stage is associated with a psychosocial crisis to be resolved. Successful resolution of each maturational stage leaves a person better able to meet the interpersonal challenges and stressors of the next. Examples of critical incidents associated with developmental crises include: marriage, pregnancy and birth of a child, midlife crisis, retirement, meaning in aging, etc. A private crisis affects individuals and families but not the community at large. Examples include suicide, terminal diagnosis, a car crash, rape, or the death of a family member. An adventitious crisis is not a part of everyday experience. It is unplanned, unusual, horrific, and beyond anyone’s control. Examples of adventitious crisis include natural disasters such as floods, earthquakes, fires, mud slides; national disasters such as terrorism, riots, wars; and crimes of violence such as rape, child abuse, assault, or murder.

DIF: Cognitive Level: Application REF: p. 388 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. A model of psychosocial development in which each stage is associated with a psychosocial

crisis to be resolved was developed by which theorist? a. Caplan b. Erikson c. Aguilera d. Roberts ANS: B

Erikson’s stage model of psychosocial development forms the basis for understanding developmental crises. Each stage is associated with a psychosocial crisis to be resolved.

Successful resolution of each maturational stage leaves a person better able to meet the interpersonal challenges and stressors of the next. Lindemann and Caplan are considered primary contributors to the development of crisis theory. Caplan broadened Lindemann’s model to include developmental crisis and personal crisis. Although the direct focus of crisis intervention is on secondary prevention because the crisis state is already in motion, Caplan applied concepts of primary, secondary, and tertiary prevention to crisis intervention. Aguilera developed a nursing model identifying how a crisis develops and corresponding factors needed for resolution. Roberts provides a seven-stage sequential blueprint for clinical intervention, which can be used to structure the crisis intervention process in nurse-client relationships. This model is compatible with the nursing process sequencing of assessment, planning, implementation, and evaluation.

DIF: Cognitive Level: Knowledge REF: p. 388 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. When educating a student nurse about the definition of a crisis state, the nurse recognizes that

additional instruction is needed when the student nurse states, a. “A crisis state is an acute normal human response.” b. “A crisis state is a mental illness.” c. “A crisis state represents a personal response.” d. “A crisis state creates a temporary disconnect from attachment to others.”

ANS: A

Everly defines a crisis state as an acute normal human response to severely abnormal circumstances; it is not a mental illness. Because a crisis state represents a personal response, two people experiencing the same crisis event will respond differently to it. A crisis state creates a temporary disconnect from attachment to others, loss of meaning, and a disruption of previous mastery skills.

DIF: Cognitive Level: Application REF: p. 387 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. The nurse is caring for a client who is experiencing a crisis situation. The nurse recognizes

that after feeling a sense of shock, the client will go through a period of recoil in which the client a. behaviors can appear normal to outsiders. b. takes constructive actions to face and resolve the reality issues present. c. achieves at least precrisis functioning. d. experiences variations in emotions.

ANS: A

Caplan described the initial response to a crisis situation as shock, with variations in emotions ranging from anger, laughing, hysterics, crying, and acute anxiety to social withdrawal. Then follows an extended period of adjustment, a period of recoil. This period can last from 2 to 3 weeks. Client behaviors can appear normal to outsiders, but the person often describes nightmares, phobic reactions, and flashbacks of the crisis event. Caplan uses the term restoration or reconstruction to describe the final phase of crisis intervention. This phase involves taking constructive actions to face and resolve the reality issues present in a crisis situation. If successfully negotiated, the person achieves precrisis functioning, or better.

DIF: Cognitive Level: Application REF: p. 389 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. A client is admitted to a psychiatric unit for crisis intervention. When caring for this client, the

nurse recognizes that crisis intervention is a. a long-term treatment to improve coping skills. b. a system for focusing on future problem-solving skills. c. a method of intervention with a goal of returning the client to a level of functioning higher than their precrisis level. d. a time-limited treatment focused on the immediate problem and its resolution.

ANS: C

Crisis intervention is a time-limited treatment that focuses only on the immediate problem and its resolution. The goal of crisis intervention is to return the client to his or her precrisis level of functioning.

DIF: Cognitive Level: Application REF: p. 404 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 6. A client who is experiencing a crisis is admitted to a nursing unit. When entering the client’s

room, the nurse should attempt to establish rapport and engage the client by a. offering a brief introductory statement to quickly orient the client to the purpose of crisis questions. b. demonstrating an inflexible approach when caring for the client. c. placing the client in a dimly lit room close to the nursing unit. d. delegating to several nurses the role as primary contact for information.

ANS: A

Clients in crisis look to health professionals to structure interactions. Introduce yourself briefly, and quickly orient the client to the purpose of the crisis questions and how the information will be used. Clients and families experiencing a crisis state require a compassionate, flexible, but clearly directive calm approach from nurses. The client should be placed in a quiet, lighted room with no shadows, away from the mainstream of activity.

Ideally, one nurse should be the primary contact for information.

DIF: Cognitive Level: Application REF: p. 390 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity

7. A client states, “I feel like I have no control over my life.” The nurse determines the client is

experiencing a sense of powerlessness. Which strategy most likely assisted the nurse in the identification of powerlessness? a. Looking for central emotional themes in the client’s story b. Keeping the focus on the future c. Providing lengthy responses when interacting with the client d. Ignoring vocal inflections as the client speaks ANS: A

A guideline for identifying major problems is to identify central emotional themes in the client’s story (e.g., powerlessness, shame, hopelessness) to provide a focus for intervention.

Another guideline for identifying major problems is to keep the focus on the here and now.

Questions should be short and relevant to the crisis. Responses to the client should be brief, empathetic, and clearly related to the client’s story. Note changes in expression, body posture, and vocal inflections as clients tell their story and at what points they occur.

DIF: Cognitive Level: Application REF: p. 391 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 8. The nurse is caring for a family that is experiencing a crisis. The nurse recognizes that

interventions for initial family responses to crisis include a. minimizing the family’s sense of control within the hospital environment. b. prohibiting extreme expression of feelings. c. providing the family with information that is lengthy and abstract. d. repeating and frequently reinforcing information.

ANS: D

Interventions for initial family responses to crisis include repeating information and frequently reinforcing it. They also include the following: maximizing control within the hospital environment; providing for and encouraging or allowing expression of feelings, even if they are extreme; and giving information that is brief, concise, explicit, and concrete.

DIF: Cognitive Level: Application REF: p. 395 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. When a disaster strikes within a community, the shock of the disaster pulls people together

and outside resources are brought in. This is known as which phase of the community response to disaster? a. Reconstruction b. Honeymoon c. Heroic d. Disillusionment ANS: B

The honeymoon phase occurs when the “community pulls together and outside resources are brought in” after an initial search and recovery phase. The final reconstruction phase occurs when the survivors begin to take the primary responsibility for rebuilding their life. The heroic phase consists of initial search and recovery. The disillusionment phase usually appears as the initial emergency response starts to subside. The “shared community” feeling starts to leave as people begin to realize the extent of their losses and the limitations of external support.

Survivors can experience anger, resentment, and bitterness at the loss of support, particularly if it is sudden and complete.

DIF: Cognitive Level: Knowledge REF: p. 402 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Psychosocial Integrity 10. An older adult client who is mourning the death of her spouse comes to the health clinic for

follow-up care for an irregular heartbeat. During the examination the client tells the nurse, “I don’t care about my irregular heartbeat; I will be with my husband soon.” The best response by the nurse is, a. “It sounds as if you would like to see your husband again.” b. “Your husband is dead and you have so much to live for.” c. “Your heartbeat was good today. The medication seems to be working.” d. “Have you talked to your children recently about how you’re doing?”

ANS: A

When a nurse responds with “It sounds as if you would like to see your husband again,” it is an example of a reflective listening response used to identify applicable feelings. Responses that focus on what the client has to live for, the medication, or her children are not examples of therapeutic communication.

DIF: Cognitive Level: Analysis REF: p. 391 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 11. A client is admitted to a psychiatric unit with severe depression and thoughts of suicide. The

client is placed on suicide precautions. When caring for this client, the nurse recognizes that a. people who talk about harming themselves are at less risk. b. clients who verbalize or behaviorally demonstrate “a weight being lifted off the shoulders” are no longer at risk. c. once the acute crisis has subsided, the client is no longer at risk. d. a major goal in evaluating suicidal risk is to assess for imminent danger of doing harm to self.

ANS: D

A major goal in evaluating suicidal risk is to assess whether the client is imminent danger of doing harm to self. It is a myth that people who talk about harming themselves are at less risk.

Clients who verbalize or behaviorally demonstrate “a weight being lifted off the shoulders” should be watched carefully. Suicidal ideation waxes and wanes, so careful observation is critical even after the acute crisis has subsided.

DIF: Cognitive Level: Application REF: p. 398 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

12. The nurse is performing an initial assessment on a mental health client in the emergency

department. The client is uncooperative, and the nurse recognizes the client’s behavior is escalating. The most appropriate response by the nurse is to a. use a vulnerable stance. b. maintain constant eye contact. c. move quickly with hands hidden behind back. d. ignore provocative statements.

ANS: D

Deescalation tips for mental health emergencies: • Use a nonthreatening stance—open, but not vulnerable. Have them "take a seat" • Eye contact—not constant, brief to show concern • Commands—brief, slow, with simple vocabulary, only as loud as needed, repeat as needed • Movement—not sudden, announce actions when possible, keep hands where they can be seen • Attitude—calm, interested, firm, patient, reassuring, respectful, truthful • Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client ("I understand you are seeing or feeling this, but I am not") • Remove distractions, upsetting influences • Keep the client talking/focused on the here and now • Ignore, rather than argue with, provocative statements • Allow verbal venting, within reason • Be sensitive to personal space/comfort zone • Remove client to a quiet space; remove others from immediate area (avoid the "group spectators") • Give some choices or options, if possible • Set limits, if necessary • Limit interaction to just one professional and let that person do the talking • Avoid rushing—slow things down • Give yourself an out; don't put the client between yourself and the door DIF: Cognitive Level: Application REF: p. 397 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 13. The nurse is communicating with a client who is experiencing a crisis related to marital

difficulties. Which of the following statements made by the nurse is the best example of therapeutic communication when working with this client? a. “I think we should work toward fixing your marital difficulties immediately.” b. “I’m going to call the counselor and make an appointment for you.” c. “What would happen if you chose to go for counseling compared to seeking a divorce?” d. “I think you and your spouse need to go for counseling as soon as possible.”

ANS: C

Clients in crisis generally feel powerless. Nurses can introduce alternative methods that the client may not have considered. Helping a client examine the consequences of proposed solutions and breaking tasks down into small, achievable parts empowers clients. Proposed solutions should accommodate both the problem and client resources. It’s helpful to assist clients in discussing the consequences, costs, and benefits of choosing of one action versus another (e.g., “What would happen if you chose this course of action as compared to…?” or “What is the worst that could happen if you decided to…?”). The locus of control for decision making should always remain with the client to whatever extent is possible. Making autonomous choices encourages clients to become invested in the solution-finding process and hopeful about finding a resolution to a crisis situation.

DIF: Cognitive Level: Application REF: p. 392 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 14. The nurse is caring for an older adult client who has recently lost his job, is experiencing a

major physical illness, and lives alone. The client states, “I sometimes wish I wasn’t here.”

When working with this client, the nurse recognizes that a. an increase in the client’s energy level indicates the client is coping better. b. older adult clients have a lower rate of suicide. c. the client should be assessed for imminent danger of doing harm to self. d. when the client begins giving away possessions, it is a positive sign.

ANS: C

Verbal indicators of potential suicide include statements such as “I don’t think I can go on without . . .”; “I sometimes wish I wasn’t here”; or “People would be better off without me.”

Risk factors for suicide include a major physical illness, social isolation, and a recent major loss. A major goal in evaluating suicidal risk is to assess whether the client is in imminent danger of doing harm to self. Irrational behaviors, drug and alcohol abuse, previous suicide attempts, and verbal threats are matters of concern, as is a sudden mood change—especially if the client demonstrates much more energy. Suicide rates are higher for older adults, especially for white males. Behavioral indicators of escalating suicidal ideation include giving away possessions.

DIF: Cognitive Level: Application REF: p. 398 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 15. A client enters the emergency department. When performing the initial admission assessment,

the nurse recognizes which client behavior as an indicator that the client may become violent? a. Coherent speech b. Flat affect c. A relaxed posture d. Confusion ANS: D

Confusion, paranoid ideation, disorganization, and organic impairment are all mental status behavioral categories that indicate potential for violence. Rapid and pressured speech, incoherent speech, menacing tones, raised voice, and verbal threats are all speech pattern behavioral categories that indicate potential for violence. A belligerent, labile, or angry affect is an indicator of potential violence. Eyes darting, prolonged (staring) eye contact, spitting, pale or red (flushed) face, and a menacing posture are indicators of potential violence.

DIF: Cognitive Level: Application REF: p. 397 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 16. A client with a history of violence is admitted to a psychiatric unit. The nurse observes the

client pacing the halls and speaking to other clients in a menacing way. The nurse is concerned that the client will become physically violent. The nurse should initially a. encourage the client to stop pacing and sit down. b. increase environmental stimuli by promoting more sensory input c. call the client by name using a low, calm tone of voice d. refrain from medicating the client ANS: C

Deescalation tips for mental health emergencies: • Use a nonthreatening stance—open, but not vulnerable. Have them "take a seat" • Eye contact—not constant, brief to show concern • Commands—brief, slow, with simple vocabulary, only as loud as needed, repeat as needed • Movement—not sudden, announce actions when possible, keep hands where they can be seen • Attitude—calm, interested, firm, patient, reassuring, respectful, truthful • Acknowledge legitimacy of feelings, delusions, hallucinations as being real to the client ("I understand you are seeing or feeling this, but I am not") • Remove distractions, upsetting influences • Keep the client talking/focused on the here and now • Ignore, rather than argue with, provocative statements • Allow verbal venting, within reason • Be sensitive to personal space/comfort zone • Remove client to a quiet space; remove others from immediate area (avoid the "group spectators") • Give some choices or options, if possible • Set limits, if necessary • Limit interaction to just one professional and let that person do the talking • Avoid rushing—slow things down • Give yourself an out; don't put the client between yourself and the door DIF: Cognitive Level: Application REF: p. 397 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE

1. When working on a psychiatric unit, the nurse recognizes that indicators of potential violence

include which of the following? (Select all that apply.) a. Confusion b. Orientation c. Coherent speech d. Exaggerated gestures e. Prolonged eye contact ANS: A, D, E

Indicators of potential violence include confusion, exaggerated gestures, and prolonged eye contact. Confusion (not orientation) is an indicator of potential violence. Incoherent (not coherent) speech is an indicator of potential violence.

DIF: Cognitive Level: Application REF: p. 397 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. When collecting assessment data, the nurse recognizes that a client might be more prone to

violent behavior when having a history of which of the following? (Select all that apply.) a. Psychosis b. Childhood abuse c. Lack of impulsivity d. Mental retardation e. Delirium ANS: A, B, D, E

A history of violence, childhood abuse, substance abuse, mental retardation, problems with impulse control, and psychosis, particularly when accompanied by command hallucinations, are common contributing factors to violent behavior. Problems with impulse control (not lack of impulsivity) is a common contributing factor to violent behavior.

DIF: Cognitive Level: Application REF: p. 396 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Chapter 22: Communication Approaches in Palliative Care Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following statements is true about grief? a. Grief always occurs immediately after a loss. b. Support for a grieving client includes closed communication. c. Recurring, wavelike feelings of sadness and loss are common feelings in a client

who is grieving. d. It is normal for grief to be exaggerated.

ANS: C

The concept of grief describes the personal emotions and adaptive process a person goes through in recovering from loss. Common feelings include sadness and an acute awareness of the void accompanied by recurring, wavelike feelings of sadness and loss. Grief can occur immediately after a loss or it can be delayed. Open, empathetic communication is a component of support for a client who is grieving. When the symptoms of grief are exaggerated or absent, it is considered pathologic or complicated grief. People experiencing complicated grief may require psychologic treatment to resolve their grief and move into life again.

DIF: Cognitive Level: Comprehension REF: p. 410 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. Which of the following best describes anticipatory grief? a. It occurs after the actual death. b. It occurs when death was sudden and unexpected. c. Only the family of the dying client experiences it. d. It can be colored by ambivalent feelings.

ANS: D

Anticipatory grief is an emotional response that occurs before the actual death around a family member with a degenerative or terminal disorder. A person anticipating his or her own death also experiences it. Symptoms can be similar to those experienced after death and can be colored by ambivalent feelings. Anticipatory grief is an emotional response that occurs before the actual death. Anticipatory grief is encountered when an individual has a degenerative or terminal disorder. A person anticipating his or her own death also experiences anticipatory grief.

DIF: Cognitive Level: Comprehension REF: p. 411 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 3. The nurse is caring for a client who is expected to die within a month. The client states, “I

can’t go on anymore, help me!” Which of the following best describes this client’s stage of dying? a. Anger b. Denial

c. Acceptance d. Depression ANS: D

Kübler-Ross characterizes the depression stage as the “Yes, me” stage, accompanied by depressive feelings. Mood swings and depressive feelings are hard for families to tolerate but very common. Kübler-Ross refers to anger as the “Why me?” stage, associated with feelings about the unfairness of life or anger with God. Kübler-Ross characterizes the denial stage as the “No, not me” stage. The acceptance stage is characterized by an acknowledgment of the inevitable end of life. As the client approaches death, there is a gradual detachment from the world, and the person is almost “void of feeling.” Because of this, there can be a sense of peace.

DIF: Cognitive Level: Analysis REF: p. 409 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. Which of the following is defined as a normal grief response associated with an ongoing

living loss that is permanent, progressive, recurring, and cyclic in nature? a. Somatization disorder b. Chronic sorrow c. Chronic grief d. Absent grief ANS: B

Chronic sorrow is defined as “a normal grief response associated with an ongoing living loss that is permanent, progressive, recurring, and cyclic in nature.” Many parents of children with a physical, developmental, emotional, or chronic disorder will experience chronic grief.

Families need nurses to affirm their coping efforts and acknowledge the legitimacy of their sadness. Providing timely support for families when there is an exacerbation of symptoms can make the situation more manageable. Somatization disorder, chronic sorrow, and absent grief are all examples of complicated grief.

DIF: Cognitive Level: Comprehension REF: p. 411 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. The nurse is caring for a client who has been given 6 months to live after being diagnosed

with stage 4 cancer of the lung. Evidence that the client is in the bargaining stage of death and dying is demonstrated by which of the following statements? a. “Not me.” b. “Why me?” c. “Yes, me.” d. “Let me.”

ANS: C

Kübler-Ross refers to the bargaining stage as the “Yes, me, but…I need just a little more time.” The bargaining state involves pleading for time extension or special consideration.

“Not me.” represents the denial stage. “Why me?” represents the anger stage. “Let me.” represents the acceptance stage.

DIF:

Cognitive Level: Application

REF: p. 408

TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 6. The nurse is caring for a client who has just received biopsy reports that indicate recurrence of

metastatic stage IV breast cancer. The client’s statement that indicates the acceptance stage of death and dying is, a. “The test results are incredible.” b. “The test results are positive.” c. “The test results are negative.” d. “The test results will be repeated next week.”

ANS: B

The acceptance stage is characterized by an acknowledgment of the inevitable end of life.

“The test results are incredible” indicates the anger stage. “The test results are negative” indicates the denial stage. “The test results will be repeated next week” indicates bargaining or denial.

DIF: Cognitive Level: Application REF: p. 409 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 7. Stoicism and denial of grief are examples of how a family coping with death is affected by a. Kübler-Ross. b. culture. c. developmental level. d. prior experience.

ANS: B

Different cultures have distinctive expressions of grief responses. Kübler-Ross is an author who wrote about death and dying. Developmental level and prior experience will influence a family’s ability to cope, but stoicism and denial specifically are affected by cultural influences.

DIF: Cognitive Level: Knowledge REF: p. 419 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 8. A client has just been transferred to a new facility from another hospital at his insistence. The

client is demanding a second opinion because he feels that “They must have made a mistake.”

The nurse recognizes that the best communication technique to use with this client is to a. clarify the client’s response. b. reflect the client’s behavior. c. summarize the client’s behavior. d. acknowledge the client’s feelings.

ANS: B

Denial is a coping mechanism being used by this client. Personal reflections are critical sources of assessment data. Once rapport is established, the nurse should ask the client how he learned of his diagnosis. The nurse must accept the client’s way of dealing with the stress and readiness to talk. Feelings are blocked during denial.

DIF:

Cognitive Level: Application

REF: p. 425

TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 9. The nurse is caring for an 8-year-old child in the school nurse’s office because the child

received a bloody nose in a scuffle with another child during recess. The nurse discovers that the child’s parents have recently divorced. The nurse recognizes that the child a. still has both parents and should not be experiencing a sense of loss. b. has gotten over his grief because he is able to play outside. c. needs to be referred for grief counseling. d. demonstrates behavior that is a common response when grieving.

ANS: D

Children don’t express their grief in the same way as adults. Acting out, anger, fear, and crying are common responses, which appear spontaneously. Divorce is a significant loss to a child. Children express their grief differently from adults; they can be sad one minute and then playing the next. The child may need counseling in the future if the behavior continues and if the parents are unable to help him work through the emotional turmoil, but this is not an initial intervention.

DIF: Cognitive Level: Analysis REF: p. 421 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 10. When evaluating care of dying clients, the nurse recognizes that interventions have been

unsuccessful if the a. client does not get past the stage of denial. b. client dies in peace surrounded by loved ones. c. client dies while experiencing pain. d. nurse refuses to allow the client to be sad.

ANS: D

The concept of grief describes the personal emotions and adaptive process a person goes through in recovering from loss. Common feelings include sadness and an acute awareness of the void accompanied by recurring, wavelike feelings of sadness and loss. Some clients cope by remaining in the denial stage. This is the client’s right. When a client dies in peace surrounded by loved ones, it is evidence of successful interventions. Sometimes a peaceful death is not possible, but that does not mean the intervention was ineffective.

DIF: Cognitive Level: Comprehension REF: p. 411 TOP: Step of the Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 11. The nurse is caring for a 15-year-old client who is dying. The client tells the nurse, “I know I

am not going home again. I think it is harder for my parents than me. Will you talk to them for me?” Which of the following is the best response by the nurse? a. “It is true that you will be dying soon, but you must be honest with your parents.” b. “That’s not true, but I will talk to your parents.” c. “You are having a bad day, so I will be back later to see if you need anything else.” d. “Yes, I will talk to your parents, but you need to talk to them also. I will help you with that.”

ANS: D

Nurses are key informants about client status and changes in the client’s condition. There are fundamental differences in the level of information an individual or family will desire. The response of the client should determine the content and pace of sharing information. Talking with families about care details and potential outcomes should happen often, but even more frequently when the client’s health status begins to decline or show a change. It is often difficult for families to talk about death, and the nurse can facilitate communication. It is important to be honest; false information and reassurances can increase feelings of isolation.

DIF: Cognitive Level: Analysis REF: p. 422 TOP: Step of the Nursing Process: Intervention MSC: Client Needs: Psychosocial Integrity 12. Which of the following is an inappropriate intervention for communicating with terminally ill

clients? a. Allowing the client to lead discussions about the future b. Offering automatic responses and trite reassurances c. Respecting the individual’s pattern of communication d. Maintaining a sense of calm ANS: B

Guidelines for communicating with dying clients include avoiding automatic responses and trite reassurances. Allowing the client to lead discussions about the future, respecting the individual’s pattern of communication, and maintaining a sense of calm are all guidelines for communicating with terminally ill clients DIF: Cognitive Level: Comprehension REF: p. 417 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 13. Which of the following is a dimension of palliative care? a. It involves only care of the client. b. It provides grief support for family only while the client is alive. c. It bears no resemblance to hospice care. d. It intends neither to hasten nor postpone death.

ANS: D

Dimensions of Palliative Care • Provides relief from pain and other distressing symptoms • Affirms life and regards dying as a normal process • Intends neither to hasten nor postpone death • Integrates the psychologic and spiritual aspects of client care • Offers a support system to help clients live as actively as possible until death • Offers a support system to help the family cope during the client’s illness and in their own bereavement • Uses a team approach to address the needs of clients and their families, including bereavement counseling, if indicated • Will enhance quality of life and may also positively influence the course of illness

• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications DIF: Cognitive Level: Application REF: p. 413 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 14. An 89-year-old client recently lost his wife of 69 years to cancer. He reports “I had the

strangest thing happen to me last night. I woke up and saw my wife sitting in her chair.” The nurse’s best response would be: a. “How long have you been hallucinating?” b. “Hallucinations are often caused by disturbance in brain chemicals.” c. “Hearing or seeing things that are not real can be a normal response to extreme stress.” d. “I recommend you speak to your doctor to review your medications.”

ANS: C

In the shock and disbelief phase, a newly bereaved person may feel alienated or detached from normal—“literally numb with shock; no tears, no feelings, just absolute numbness.” Seeing or hearing the lost person, or sensing his or her presence, is a normal, temporary altered sensory experience related to the loss, which should not be confused with psychotic hallucinations.

DIF: Cognitive Level: Analysis REF: p. 409 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 15. A 21-year-old client informs the nurse that he is not sleeping. The nurse learns that the client’s

girlfriend was killed in a car accident 1 month ago. Which statement would be of most concern to the nurse? a. “I am moving on and plan to start dating again.” b. “It’s my fault. I shouldn’t have let her go out that night.” c. “I wish I died in the car accident instead of her.” d. “I cannot sleep because I keep reliving the car accident.”

ANS: A

Complicated grief can appear as an absence of grief in situations where it would be expected.

When deaths and important losses are not mourned, the feelings don’t just disappear; they reappear in unexpected ways, sometimes years later. Subsequent losses trigger an extreme reaction to a current loss. Complicated grief can result in clinical symptoms such as depression or anxiety disorders that require professional help. Blaming oneself, wanting to take the place of those who dies, and having sleep problems are normal grief reactions that occur in sudden or traumatic situations.

DIF: Cognitive Level: Analysis REF: p. 409 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 16. Which of the following individuals is most likely experiencing a delayed grief reaction? a. A 22-year-old army pilot on leave from the Iraq war who talks about the death of

his crew member

b. A 93-year-old women, whose husband of 73 years died 1 year ago, who reminisces

about their life together c. A 54-year-old man suffering from alcoholism who just completed a 28-day

inpatient rehabilitation talking about the death of his wife 3 years ago d. A child whose parents were divorced 3 months ago and is acting out at school ANS: C

Eric Lindemann pioneered the concepts of grief work based on interviews with bereaved persons suffering a sudden tragic loss. He described patterns of grief and the physical and emotional changes that accompany significant losses. Lindemann observed that grief can occur immediately after a loss, or it can be delayed. When symptoms of grief are exaggerated or absent, it is considered pathologic or complicated grief. People experiencing complicated grief may require psychologic treatment to resolve their grief and move into life again. The pilot is talking about the death; there is no evidence symptoms of grief are absent.

Anniversaries will often trigger memories. Children often show regressive behavior, anger, or fear in response to the loss of a parent.

DIF: Cognitive Level: Application REF: p. 409 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 17. The nurse is caring for a client who has just experienced the death of her mother. The nurse

best demonstrates support for the client by a. sitting quietly with the client and not discussing the loss. b. reminding the client that her mother lived a long life. c. changing the subject so the client won’t get upset. d. offering spiritual support for the client and family.

ANS: D

Spiritual support for clients and family should be offered. Sitting quietly with the grieving client is supportive, but the grieving client should be encouraged to talk about the loss. Trite reassurances are not supportive.

DIF: Cognitive Level: Application REF: p. 424 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 18. A client’s adult children call the nurse hourly with concerns about their mother’s death and

end-of-life care. The nurse’s best response is to a. provide detailed, scientific information. b. discuss physical symptoms. c. withhold information to avoid unnecessary fears. d. provide frequent updates.

ANS: D

Immanent Death: Family Communication Needs • Honest and complete answers to questions; repetition and further explanation, if needed • Updates about the client's condition and changes as they occur • Clear, understandable explanations, delivered with empathy and respect • Frequent opportunities to express concerns and feelings in a supportive, unhurried environment

• Information about what to expect—physical, emotional, spiritual—as death approaches • Discussion of whom to call, legal issues, memorial or funeral planning • Conversation about cultural and/or religious rituals at time of and after death • Appreciation of the conflicts that families experience when the illness dictates that few options exist; for example, a frequent dilemma is whether life support measures are extending life or prolonging the dying phase • Short, private times to be present and/or minister to the client • Permission to leave the dying client for short periods with the knowledge that the nurse will contact the family member if there is a change in status DIF: Cognitive Level: Application REF: p. 424 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

Chapter 23: Role Relationship Communication Within Nursing Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which aspect of role standards is influenced by institutional norms and may vary depending

on the work environment? a. Role pressures b. Role performance c. Role relationship d. Role socialization ANS: B

Role is defined as a traditional pattern of behavior and self-expression performed by or expected of an individual within a given society. People develop social and professional roles throughout life. Some are conferred at birth (ascribed roles) and some are attained (acquired roles) during a lifetime. Work role relationships have structural components—for example, direct reports, student, nursing, and interdisciplinary professional. Other role relationships are collegial, based on friendship or common interests. Personal role performance standards reflect personal, social, cultural, gender, institutional, and family expectations. Standards for role performance tend to mirror differentiated practice roles, as supported by education, professional licensure, and certifications. Role performance standards are also influenced by institutional norms and may vary depending on the work environment. Features of professional role relationships are recognizable through differences in work responsibilities, cooperative activities, education, and social affiliations. Stronger personal and professional role expectations are held for those holding public trust roles, such as elected political and religious leaders, health care professionals, and teachers.

DIF: Cognitive Level: Knowledge REF: p. 428 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 2. A nurse, who has been practicing for 4 years, demonstrates competence, speed, and flexibility

when performing clinical skills. According to Benner, the nurse is practicing at which developmental stage? a. Advanced beginner b. Competency c. Proficiency d. Expert ANS: C

The proficiency stage occurs 3 to 5 years into practice. Nurses in this stage are self-confident about their clinical skills and perform them with competence, speed, and flexibility. The proficient nurse sees the clinical situation as a whole, has well-developed psychosocial skills, and knows from experience what needs to be modified in response to a given situation.

DIF: Cognitive Level: Application REF: p. 436 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. The new graduate nurse is unsure how to operate a new intravenous pump After reading the

directions, the new graduate nurse seeks the assistance of a more experienced nurse and asks for a demonstration on how to operate the new intravenous pump. The behavior exhibited by the new graduate nurse is a. role pressure. b. role clarity. c. role conflict. d. role overload.

ANS: B

Professional role clarity is an essential quality of effective leadership. If nurses aren’t clear about their professional roles, it becomes very difficult for them communicate their value as health care providers to other professionals. Role clarity about professional competencies is necessary to support client safety initiatives and lead to improved client outcomes. Influencing change and making difficult decisions becomes easier when nurses have a clear vision that emanates from their understanding of their professional role because they are better able to stimulate confidence in others.

DIF: Cognitive Level: Knowledge REF: p. 432 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 4. The economics of health care and diminishing numbers of health care providers led to

legislative passage of the Patient Protection and Affordable Care Act (PPAC). This legislation is designed to a. provide high-quality health care to a smaller number of people. b. make health care accessibility a reality for all. c. provide high-quality health care at a slightly increased cost. d. make health care accessibility a reality for individuals with the means to pay.

ANS: B

The economics of health care and diminishing numbers of health care providers led to legislative passage of the PPAC. This legislation is designed to make health care accessibility a reality for all. In 2012, the Supreme Court issued a historic decision to uphold this legislation. With this legislation comes a mandate for providing high-quality health care to a greater number of people at a lower cost, all at a time when there is a growing shortage of nurses and physicians. The shortage is expected to increase dramatically over the next decade.

DIF: Cognitive Level: Application REF: p. 429 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 5. A novice nurse decides to attend a diabetes workshop after a client was admitted to the unit

with an insulin pump that the nurse was not familiar with. This is an example of a. role performance. b. client advocacy. c. collaboration. d. professional self-awareness.

ANS: D

Professional self-awareness promotes recognition of the need for continuing education, the acceptance of accountability for one’s own actions, the capacity to be assertive with professional colleagues, and the capability to serve as a client advocate when the situation warrants it, even if it is uncomfortable to do so. Role performance is role functioning. Client advocacy is protecting client rights. Collaboration is sharing responsibility.

DIF: Cognitive Level: Application REF: p. 440 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 6. The nurse is caring for a client on a rehabilitation unit who sustained a back injury in an auto

accident, resulting in disability status from his job as a truck driver. The nurse should help the client to identify skills transferable to a future position by stating which of the following? a. “I am sorry to learn about your job loss.” b. “Your wife stated you were a reliable, trustworthy worker.” c. “Think of your strengths associated with your previous job position.” d. “The career office really considers you employable.”

ANS: C

Collaborative professional teams represent a coordinated form of care delivery. Each team member pools his or her expertise with that of other team members to achieve common, agreed upon treatment outcomes. The precise role and involvement of each discipline-specific team member depends on team member expertise and the individualized needs of clients. The setting, professional, and system resources enable or hinder team functioning. For example, in the ICU, care will focus on the life-threatening nature of the client’s condition, requiring the concentrated assistance of specialists. In rehabilitation and home care settings, the composition of team members would be different. However, similar overarching goals of achieving health outcomes and improving a client’s quality of life underscore clinical team efforts.

DIF: Cognitive Level: Analysis REF: pp. 434-435 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 7. The nurse offers a client’s family a list of community resources and support groups and

encourages them to become involved in the local Lupus chapter. This is an example of which professional nursing role responsibility? a. Client advocate role b. Teaching role c. Caregiver role d. Consultant role ANS: A

Nursing actions that constitute client advocacy include facilitating access to essential health care services for clients, ensuring high-quality care, protecting client rights, and acting as a liaison between clients and the health care system to procure high-quality care.

DIF: Cognitive Level: Application REF: p. 445 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

8. The nurse is caring for an older client with a fractured hip. The client asks the nurse about the

nature of her condition. The nurse’s response should be, a. “You have a fractured femur,” stated in a loud voice. b. “You will have to speak to your physician about your diagnosis.” c. “Do you wish to call your son to discuss it with him because he talked with the MD?” d. “When you fell at home, you broke your hip.”

ANS: D

Clear communication, altruism, caring, and professional ethics are essential components of interprofessional professionalism. In saying loudly that the patient has a fractured femur, the nurse is stereotyping the client as hard of hearing and providing information she may not understand. The patient has the right to receive information from a direct caregiver other than the physician. The client’s confidentiality may have been breached when the son was informed of her condition without her knowledge.

DIF: Cognitive Level: Application REF: p. 439 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 9. The nurse is conducting an interview with the family of a client who has just been diagnosed

with Alzheimer disease. The nurse wants to assess family role relationships. What would be an appropriate question? a. “What are your likes and dislikes?” b. “Who assumes responsibility for decision making?” c. “How would you describe your job?” d. “How do you like to be treated?”

ANS: B

Sometimes the nurse serves as dual advocate for both client and family members. It is important to assess the impact on the family of the illness. It is necessary to find out who the decision maker is in the family. If it is the client, the diagnosis will have more of an impact on the family. Asking about likes/dislikes, employment, and how the family members wish to be treated does not address family role relationships.

DIF: Cognitive Level: Analysis REF: p. 446 TOP: Step of the Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 10. Essential components of interprofessional professionalism are clear communication, caring,

professional ethics, and a. aesthetics. b. altruism. c. justice. d. truth.

ANS: B

Clear communication, altruism, caring, and professional ethics are essential components of interprofessional professionalism. Truth is faithfulness to fact or reality.

DIF: Cognitive Level: Knowledge REF: p. 439 TOP: Step of the Nursing Process: All phases

MSC: Client Needs: Psychosocial Integrity 11. When looking toward the future of nursing, it is important for nurse educators to teach student

nurses that the wave of the future in nursing is in a. bedside nursing. b. hospice nursing and home health care. c. advanced practice and leadership roles. d. nurses possessing a diploma degree.

ANS: C

Advanced practice and leadership roles for nurses are the wave of the future.

DIF: Cognitive Level: Application REF: p. 429 TOP: Step of the Nursing Process: Intervention MSC: Client Needs: Management of Care 12. Which of the following is a nursing diagnosis associated with the effects of alteration in role

relationships within the family and work environment? a. Sleep pattern disturbance b. Ineffective role performance c. Altered thought processes d. Impaired communication ANS: B

Personal role performance standards reflect personal, social, cultural, gender, institutional, and family expectations. Standards for role performance tend to mirror differentiated practice roles as supported by education, professional licensure, and certifications. Role performance standards are also influenced by institutional norms and may vary depending on the work environment.

DIF: Cognitive Level: Comprehension REF: p. 428 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity 13. When documenting nursing care in the client’s chart, the nurse does so accurately and

honestly. The nurse is demonstrating which essential value of professionalism in nursing? a. Altruism b. Integrity c. Human dignity d. Asepsis ANS: B

Individual nurses identify moral integrity, purpose, and commitment as key components of professionalism. Nurses demonstrate professionalism through accountability for the care they provide, using recognized professional practice standards and operating within ethical and regulatory professional frameworks.

DIF: Cognitive Level: Application REF: p. 437 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity

14. The nurse is caring for a client who has just refused to undergo an invasive procedure that

could possibly extend his life by a few months. The nurse supports the client’s decision based on which essential value? a. Equality b. Truth c. Human dignity d. Autonomy ANS: D

Advocacy should support client autonomy. Clients need to be in control of their own destiny, even when the decision reached is not what you as the nurse would recommend for the client's health and well-being.

DIF: Cognitive Level: Application REF: p. 445 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care 15. The nurse contacts the client’s case manager to provide information about the client’s hospital

treatment plan. This is an example of which type of advocacy? a. Role modeling b. Educational informing c. Collaboration d. Anticipatory guidance ANS: C

Important differences emphasize a stronger focus on primary care, meaningful use of technology, empowering nursing leadership, shared leadership, and interdisciplinary collaboration competencies in health care. Role modeling refers to demonstrating appropriate behaviors. Educational informing is teaching clients about health problems and choices.

Anticipatory guidance helps the client foresee potential difficulties.

DIF: Cognitive Level: Application REF: p. 439 TOP: Step of the Nursing Process: Planning MSC: Client Needs: Management of Care

Chapter 24: Interprofessional Communication Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. The charge nurse is working with a group of staff nurses on a hospital unit. When delegating

to the staff nurses, the charge nurse determines that there is conflict among the group. The charge nurse should a. wait for the staff nurses to discuss the problems that are related to the conflict. b. perform simultaneous activities when listening to the staff nurses. c. present the staff nurses with documented data that is irrelevant to the conflict. d. briefly summarize when providing the staff nurses with feedback.

ANS: D

Strategies to turn conflict into collaboration include using a brief summary to provide feedback, recognizing and confronting disruptive behaviors by taking the initiative to discuss problems, using active listening skills (refraining from simultaneous activities that interrupt communication), and presenting documented data relevant to the issue.

DIF: Cognitive Level: Application REF: pp. 450-451 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. Which of the following is true about the relationship between physicians and nurses? a. Only the physician is responsible for fostering good physician-client

communication. b. The physician and nurse should not engage in open dialogue. c. The relationship between the physician and the nurse remains an evolving process. d. Few nurses encounter problems in the physician-nurse relationship.

ANS: C

The relationship between the physician and the nurse remains an evolving process. Changes in the physician-nurse communication process are occurring as nurses become more empowered, more assertive, and better educated. Nurses have a responsibility to foster good physician-client communication. When applying principles of conflict resolution, a commitment to open dialogue is recommended. Most nurses occasionally encounter problems in the physician-nurse relationship.

DIF: Cognitive Level: Comprehension REF: p. 453 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. The nurse is scheduled for a yearly evaluation by the nursing supervisor. When planning for

this meeting, the nurse should recognize the importance of a. scheduling the evaluation during a time when anxiety level is high. b. becoming reactive when faced with constructive criticism. c. demonstrating defensiveness when discussing the evaluation with the supervisor. d. listening carefully during the evaluation and paraphrasing constructive criticism.

ANS: D

When a supervisor gives constructive criticism, some type of response from the person receiving it is indicated. To help handle constructive criticism, the nurse should listen carefully to the criticism and then paraphrase it. The nurse should also schedule a time when she is calm, develop a plan for dealing with similar situations, and become proactive rather than reactive. The nurse should also discuss the facts of the situation but avoid becoming defensive.

DIF: Cognitive Level: Analysis REF: pp. 464-465 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Psychosocial Integrity 4. When supervising an unlicensed assistive personnel (UAP), the nurse offers unwarranted

criticism that causes the UAP to feel defensive. The initial response by the UAP should be to a. verbally defend against the unwarranted criticism. b. allow the nurse to continue to project unwarranted criticism. c. recognize the unwarranted criticism. d. recognize that the unwarranted criticism must be directly related to the actual behavior that is being criticized.

ANS: C

Recognizing a putdown or unwarranted criticism is the first step toward dealing effectively with it. If a comment from a coworker or authority figure generates defensiveness or embarrassment, it is likely that the comment represents more than just factual information about performance. When faced with unwarranted criticism, the automatic response of many individuals is to become defensive and embarrassed and in some way actually begin to feel inadequate, thus allowing the speaker to project unwarranted feelings onto the nurse. The putdown or criticism may be handed out because the speaker is feeling inadequate or threatened. Often it has little to do with the actual behavior of the nurse to whom it is delivered.

DIF: Cognitive Level: Application REF: p. 463 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. When involved in conflict, the nurse recognizes that a. sharing feelings about the conflict with others will increase its intensity. b. conflict generally decreases anxiety. c. differences in age can cause friction and make relationships less collaborative. d. it is always appropriate to seek peer negotiation when conflict is personal in

nature.

ANS: C

Conflict behaviors can occur as a result of age differences, differences in values, philosophical approaches to life, ways of handling problems, lifestyles, definitions of a problem, goals, or strategies to resolve a problem. These differences cause friction and turn relationships from collaborative to competitive. Sharing feelings about a conflict with others helps to reduce its intensity. Generally, conflict increases anxiety. When interaction with a certain peer or peer group stimulates anxious or angry feelings, the presence of conflict should be considered.

Once it is determined that conflict is present, a person should look for the basis of the conflict and label it as personal or professional. If it is personal in nature, it may not be appropriate to seek peer negotiation.

DIF: Cognitive Level: Application REF: p. 465 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. The nurse manager is working on strategies to turn conflict into collaboration by creating a

climate in which participants view negotiation as a collaborative effort. In order to accomplish this goal, the nurse manager works to promote a. offering of feedback on an infrequent basis. b. clarification of role expectations. c. minimal participation in organizational interdisciplinary groups. d. absence of role-modeling behaviors related to communication.

ANS: B

Strategies to turn conflict into collaboration include creating a climate in which participants view negotiation as a collaborative effort through clarification of role expectations; soliciting and giving feedback on a regular, periodic basis; participation in organizational interdisciplinary groups; and modeling of communications with staff in a respectful, courteous manner.

DIF: Cognitive Level: Application REF: p. 456 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. The nurse manager recognizes a need to take steps to promote conflict resolution among

health care team members on a nursing unit. In order to promote conflict resolution, the nurse manager should a. solicit the perspectives of only the nurses. b. encourage manipulation among group members. c. promote criticism of individuals within the group. d. depersonalize conflict situations.

ANS: D

Steps to promote conflict resolution among health care team members include depersonalization of conflict situations. Steps to promote conflict resolution among health care team members also include maintaining a respectful, nonpunitive atmosphere through soliciting the perspectives of each individual, allowing group members to be assertive but not manipulative, and remembering to criticize ideas, not people.

DIF: Cognitive Level: Application REF: p. 464 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 8. The charge nurse is working on a unit where a nurse is frequently late for work. The charge

nurse addresses the behavior by telling the nurse, “It is necessary for you to be here on time from now on.” This is an example of what type of constructive criticism? a. Expressing sympathy b. Describing the behavior c. Stating expectations d. Listing consequences ANS: C

Constructive criticism includes stating expectations. An example of this is the statement: “It is necessary for you to be here on time from now on.” Constructive criticism includes expressing sympathy. An example of this is the statement: “I understand that things are difficult at home.” Constructive criticism includes describing the behavior. An example of this is the statement: “But I see that you have been late coming to work three times during this pay period.” Constructive criticism includes listing consequences. An example of this is the statement: “If you get here on time, we’ll all start off the shift better. If you are late again, I will have to report you to the personnel department.”

DIF: Cognitive Level: Application REF: p. 465 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. The nurse manager is working with staff members to promote conflict resolution. The nurse

manager recognizes that additional teaching is warranted when a staff member states, a. “I will solicit the perspectives of others.” b. “I will remember to criticize ideas, not people.” c. “I will demonstrate manipulation when working with others.” d. “I will avoid becoming emotional when discussing the conflict.”

ANS: C

Steps to promote conflict resolution among health care team members include maintaining a respectful, nonpunitive atmosphere through team members demonstrating assertiveness, not manipulation; soliciting the perspectives of others; and remembering to criticize ideas, not people. Steps to promote conflict resolution among health care team members also include discussion in which emotion is avoided.

DIF: Cognitive Level: Application REF: p. 462 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. When modifying barriers to professional communication, the nurse manager focuses on which

of the following? a. Collaboration and coordination b. Negotiation and conflict resolution c. Coordination and networking d. Collaboration and negotiation ANS: B

Modification of barriers to professional communication includes negotiation and conflict resolution. Building bridges to professional communication with colleagues involves concepts of collaboration, coordination, and networking.

DIF: Cognitive Level: Application REF: p. 466 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. A student nurse is learning about strategies to remove barriers to communication with other

professionals and how to deal with disrespectful or disruptive behaviors. The nursing instructor recognizes that additional instruction is needed when the student nurse states which of the following?

a. “I will learn conflict resolution skills.” b. “I will establish common communication expectations and skills.” c. “I will work toward creating a culture of mutual respect when working within the

health care system.” d. “I will engage in distorted, rather than open, communication to avoid offending

others.”

ANS: D

Communication can become distorted, rather than open, when a person is concerned about offending a more powerful individual. Strategies for dealing with disrespectful or disruptive behaviors include: establishing common communication expectations and skills, teaching conflict resolution skills, and creating a culture of mutual respect within the health care system.

DIF: Cognitive Level: Application REF: p. 461 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. The nurse recruiter recognizes that collegial relationships are an important determinant of

success as professionals enter nursing practice. When interviewing candidates for nursing careers, the nurse recruiter focuses on communication qualities that are important in developing a support system. Which of the following attributes best demonstrate desirable communication qualities? (Select all that apply.) a. Integrity b. Internalizing c. Respect for others d. Dependence e. A good sense of humor ANS: A, C, E

Integrity, respect for others, dependability, a good sense of humor, and an openness to sharing with others are communication qualities people look for in developing a support system. An openness to sharing with others, not internalizing, helps promote collegial relationships.

Dependability, not dependence, is an interpersonal strategy to use in developing a support system.

DIF: Cognitive Level: Application REF: p. 465 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 25: Communicating for Continuity of Care Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. Which of the following best describes continuity of care? a. It involves only clients with acute physical conditions. b. It involves client-centered high-quality care across clinical settings. c. It should focus on episodic hospital care of seriously ill clients. d. Relational, informational, and functional are its key components.

ANS: B

Continuity of care (COC) is the term used to describe a multidimensional longitudinal construct in health care that emphasizes seamless provision, and coordination of client-centered quality care across clinical settings. Health care systems organized around acute, episodic care no longer suffice as a primary service model. The complexity of contemporary health care requires a different care process to match new health realities. There are several reasons: demographics of the population with greater ethnic and racial diversity, longer life spans, serious economic challenges, and health disparities associated with social determinants of health, globalization, and significant skilled provider shortages, most notably physicians and nurses. Technical and scientific advances have revolutionized the prevention, diagnosis, and treatment of acute illness. As people live longer, however, there is a higher incidence of chronic conditions requiring an array of supportive health care services. For these reasons, and more, focus on care provision has shifted from the hospital to the community and a public health emphasis. The three key features of relational, informational, and managerial continuity provide a conceptual framework for study and application of COC strategies.

DIF: Cognitive Level: Application REF: p. 471 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. A nurse has been employed as a staff nurse for 20 years. When comparing her current clients

to those she cared for at the beginning of her career, the nurse finds that clients today are a. being discharged later. b. coping with being discharged earlier. c. dealing with simpler medication and treatment regimens. d. significantly healthier at the time of discharge.

ANS: B

Clients are discharged earlier and sicker, often with complex medication and treatment regimens to be followed in the community in primary care settings.

DIF: Cognitive Level: Application REF: p. 469 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. A nursing instructor is educating a student nurse about bridging the gap between diminishing

financial support for chronic care and multifaceted health care demands that can be long lasting. The instructor recognizes that further teaching is warranted when the student nurse lists which of the following as an indispensable means for accomplishing this?

a. b. c. d.

Self-management Family involvement Shared decision making Family nonengagement

ANS: D

Empowering individuals and families to assume primary responsibility for self-management of chronic illness in partnership with ongoing professional support is a critical means of bridging the gap between diminishing financial support for chronic care and multifaceted care demands that can last for years. Relevant primary care strategies focus on client-centered care, collaborative goal setting, problem solving, and coordinated follow up.

DIF: Cognitive Level: Application REF: p. 481 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. The nurse is caring for a client with a chronic health condition. The nurse recognizes that in

order to achieve high-quality health outcomes for this client, which of the following should occur? a. Clients and families must have consistency of personnel. b. Clients and families must have irresponsible relationships. c. Clients and families should be provided with vague information. d. Ongoing collaborative support from coordinated health services is discouraged.

ANS: A

Consistency of personnel over time allows clients and the professional team to share a stronger investment in achieving personalized, high-quality health outcomes. Providers and clients learn to know, value, and respect each other.

DIF: Cognitive Level: Application REF: p. 475 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. The nurse is caring for a client who will be transferred from the hospital unit to an acute

rehabilitation facility. In order to ensure continuity of care for the client, the nurse should a. manage continuity through a rigid approach. b. communicate infrequently with the health care team. c. use a shared management plan when providing health services. d. prohibit sharing information about the client in order to abide by HIPAA regulations.

ANS: C

Continuity of care contributes to the development of: • Increased accessibility to coordinated health care services with a smoother flow of care from one service area to another • Personalization of care to meet a client's changing needs across delivery systems • Informational data sharing of various elements of personal and medical data electronically over time and place, which contributes to appropriate care delivery • Health services provided in an organized, logical, and timely manner, using a shared management plan

DIF: Cognitive Level: Application REF: p. 470 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. A home health nurse visits a client and his spouse once per week to change the client’s wound

dressing. By visiting the client and his spouse weekly, the nurse develops a sense of clinical responsibility and an accumulated knowledge of the client and spouse’s personal and medical circumstances. This situation describes which component of continuity of care (COC)? a. Internal continuity b. Relational continuity c. Management continuity d. Informational continuity ANS: B

Relational continuity refers to the interpersonal elements of the COC model across time and care settings. The term applies to nurse client/family relationships, team relationships, and relationships between health system providers and community-based supports. The stronger the relationships, the greater are the potential for quality-coordinated care. Respect for client and family values, beliefs, knowledge, cultural background, and preferences are fundamental aspects of client-centered relational continuity. Trusting relationships with a primary provider or “medical home” health care team gives clients confidence that their care needs will be consistently met.

DIF: Cognitive Level: Application REF: p. 470 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. The nurse demonstrates understanding of continuity of care (COC) when doing which of the

following? a. Providing care in an untimely manner b. Utilizing management plans that are inconsistent c. Encouraging a longitudinal construct in health care d. Demonstrating inflexibility when managing the client’s care ANS: C

COC is the term used to describe a multidimensional longitudinal construct in health care that emphasizes seamless provision and coordination of client-centered high-quality care across clinical settings. COC operates across three dimensions: (1) relational, (2) informational, and (3) management continuity. These dimensions are interdependent, essential components of client care.

DIF: Cognitive Level: Application REF: p. 470 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 8. The nurse is teaching at a community center about how the focus on care provision has shifted

from the hospital to the community and a public health focus. The nurse teaches the community members that health care systems organized around acute, episodic care no longer suffice as a primary service model due to the complexity of contemporary health care, which requires a different care process to match new health realities. The nurse lists which of the following reasons for this?

a. b. c. d.

Decreased ethnic and racial diversity Overall shorter life spans secondary to superinfections Oversupply of highly skilled physicians and registered nurses Higher incidence of chronic health conditions

ANS: D

Health care systems organized around acute, episodic care no longer suffice as a primary service model. The complexity of contemporary health care requires a different care process to match new health realities. There are several reasons: demographics of the population with greater ethnic and racial diversity, longer life spans, serious economic challenges, and health disparities associated with social determinants of health, globalization, and significant skilled provider shortages, most notably physicians and nurses. Technical and scientific advances have revolutionized the prevention and diagnosis and treatment of acute illness. As people live longer, however, there is a higher incidence of chronic conditions requiring an array of supportive health care services. For these reasons, and more, focus on care provision has shifted from the hospital to the community and a public health focus.

DIF: Cognitive Level: Application REF: p. 470 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. The nurse is working within an interdisciplinary team. The nurse recognizes that

interdisciplinary teams are characterized by a. only formal interactions. b. individual problem solving. c. absence of overlapping of professional roles. d. a common mission of working together to resolve complex clinical problems.

ANS: D

Team communication takes place informally and in structured formal team meetings.

Interdisciplinary team relationships take into account diverse standards and behaviors associated with each clinical discipline, while emphasizing a common mission of working together to resolve complex clinical problems.

DIF: Cognitive Level: Application REF: p. 474 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. A staff nurse educates a nursing student about collaborative health care teams. The staff nurse

recognizes that additional teaching is warranted when the nursing student lists which of the following as a characteristic of a collaborative health care team? a. They are composed of a single health care discipline in order to maintain cost effectiveness. b. They are broadly classified as multidisciplinary, interdisciplinary, and transdisciplinary teams. c. Two or more skilled clinical practitioners will combine efforts in providing care. d. There is an expectation that care will be provided collaboratively.

ANS: B

Collaborative health care teams are broadly classified as multidisciplinary, interdisciplinary, and transdisciplinary teams, with the expectation that care will be provided through the combined collaborative efforts of two or more skilled clinical practitioners.

DIF: Cognitive Level: Application REF: p. 474 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. A client asks a nurse to explain the Affordable Care Act. When explaining it to the client, the

nurse tells the client a. it will begin in the year 2018. b. it is state legislation for health care. c. it emphasizes disease promotion and health prevention. d. it provides new consumer protections.

ANS: D

In 2010, passage of the Affordable Care Act brought unprecedented attention to the debate on how to best transform the nation’s health care system. This historic federal legislation mandates increased access to affordable care, emphasizing the importance of disease prevention and health promotion in primary care settings and providing new consumer protections.

DIF: Cognitive Level: Application REF: p. 470 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 12. The nurse recognizes that a potential barrier to effective team communication includes which

of the following? a. Team role clarity b. Lack of territoriality c. Professional rivalries d. Transparent job responsibilities ANS: C

Team role confusion (not clarity), fueled by professional rivalries, territoriality (not lack of territoriality), and lack of clarification about job responsibilities (not transparent job responsibilities, is a potential barrier to effective team communication.

DIF: Cognitive Level: Application REF: p. 477 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 13. The nurse recognizes that a characteristic of effective team collaboration includes which of

the following? a. It promotes inclusion of the client and family. b. It increases fragmentation of client care. c. It discourages synergistic creativity among professionals. d. Its goal is to duplicate efforts to promote safe, high-quality care.

ANS: A

Shared goals are an essential product of effective team collaboration. The client and family should be team members involved in determining, refining, and updating goals. Their inclusion as a collaborative team member allows for a more realistic assessment of a client’s needs, preferences, resources, and personal goals. They can provide important input into the development and evaluation of care and can sensitize providers to realistic needs and priorities.

DIF: Cognitive Level: Application REF: p. 476 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 14. When working on a hospital unit, the nurse should begin the discharge planning process at

which time? a. With a careful review of initial admission data. b. Within 24 hours of the hospital admission. c. Just prior to the client’s hospital admission. d. Immediately before the client is discharged.

ANS: A

A complex discharge planning process begins with a careful review of initial admission data and continues as a thread with each subsequent review. Starting early in the hospitalization allows time for clients and families to become physically and emotionally prepared for transition and to have needed supports available postdischarge.

DIF: Cognitive Level: Application REF: p. 482 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 15. To build relational continuity with each client, the nurse strives for a. the use of data to tailor current treatment and care to each client’s evidenced needs. b. accurate record sharing and technology to allow real-time communication

exchanges between providers and with clients in remote sites. c. a consistent, coherent care management approach that can be flexibly adjusted as

client needs change. d. a therapeutic relationship with a practitioner that spans more than one episode of

care and leads, in the practitioner, to a sense of clinical responsibility and an accumulated knowledge of the client's personal and medical circumstances ANS: D

Relational continuity is "a therapeutic relationship with a practitioner that spans more than one episode of care and leads, in the practitioner, to a sense of clinical responsibility and an accumulated knowledge of the client's personal and medical circumstances." Frequent team communication about all aspects of care helps ensure relational continuity among treatment teams. Informational continuity refers to the use of data to tailor current treatment and care to each client’s evidenced needs. The concept includes accurate record sharing and technology that allows real-time communication exchanges between providers and with clients in remote sites. It is a primary communication vehicle during care transitions and is used to help clients and families make high-quality client care decisions. Management continuity refers to a consistent, coherent care management approach that can be flexibly adjusted as client needs change. Care coordination and case management have emerged as significant methodologies associated with management continuity.

DIF: Cognitive Level: Application REF: p. 470 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 16. A nurse manager educates a group of staff nurses about primary care. Which of the following

should the nurse manager list as a key feature of primary care? a. It lacks the characteristic of person centeredness. b. It functions as the final contact point for common health care problems. c. The focus is on comprehensive care, which can meet many client needs without referral. d. The underlying goal is to offer a highly depersonalized form of care related to a stronger knowledge about individual health care needs and responses over time.

ANS: C

Clients are considered active agents in a dynamic health care delivery process. The expectation is that most clients will be able to self-manage the care of their chronic health conditions in the community, with coordinated, readily accessible health care network supports available in primary care settings. Key features of primary care include: • Person centeredness, with sustained continuity of relationships between provider and client • Functions as a first contact point with easy access services for common health care problems • Comprehensive care, which can meet many client needs without referral • A highly personalized form of care related to a stronger knowledge about individual health care needs and responses over time DIF: Cognitive Level: Application REF: p. 471 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. A nursing instructor educates a class of student nurses about informational continuity. The

nursing instructor lists which of the following as characteristics of informational continuity?

(Select all that apply.) a. It allows for the same client information to be available to providers throughout the health care system. b. It allows for specific information to follow the client from primary to secondary care settings, but not vice versa. c. It promotes interrupted flow of data and clinical impressions between health care providers and agencies. d. Its purpose is to provide continuously coordinated, high-quality care. e. It refers to data exchanges among providers and provider systems and between providers and clients.

ANS: A, D, E

Informational continuity refers to data exchanges among providers and provider systems and between providers and clients for the purpose of providing continuously coordinated, high-quality care. Instant electronic transmission of data "links provider to provider, and health care event to health care event." Ideally there is an uninterrupted flow of data and clinical impressions between health care providers and agencies, with clients and their families, over time and space. Specific information follows the client from primary to secondary care settings and vice versa. The same client information is available to providers throughout the health care system.

DIF: Cognitive Level: Application REF: pp. 479-480 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. The nurse manager conducts an in-service for staff nurses about the importance of

client-centered care. When educating staff nurses about characteristics of client-centered care, the nurse manager lists which of the following characteristics? (Select all that apply.) a. It promotes dependence within clients. b. It supports allowing the client time for questions. c. It considers whom information should be provided to. d. It respects the amount of information desired by clients. e. It encourages providing clients with sufficient information.

ANS: B, C, D, E

Clients should be key informants, active negotiators, final decision makers, and engaged participants in evaluating treatment outcomes. They need to be actively involved in defining and updating realistic treatment goals. Client centeredness is evidenced in a partnership characterized by mutual valuing and safeguarding of the legitimate interests of the provider and the client in creating and managing health care decisions.

Joint decision making is a key element. The decision-making process starts with providing each client with sufficient information, tailored to his or her unique circumstances, to make an informed decision. Information should be relevant to each client's diagnosis, treatments, and treatment options. The first question to consider is, “What essential information does this client need to have in order to make an informed decision?” Some clients value knowing as much as possible; others want just the basic facts. Another may need to have essential information developed in steps and spread over several encounters to allow for better processing and formulation of related questions. Cultural norms can dictate levels of information and to whom the information should be given.

DIF: Cognitive Level: Application REF: pp. 474-475 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 26: e-Documentation in Health Information Technology Systems Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. The process of obtaining, organizing, and conveying client health information to others in

print or electronic format is referred to as a. narration. b. documentation. c. care coordination. d. order entry.

ANS: B

The process of obtaining, organizing, and conveying client health information to others in print or electronic format is referred to as documentation.

DIF: Cognitive Level: Application REF: p. 492 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. One major advantage of an electronic health information technology system is a. lack of integration. b. accessibility of health records. c. it is not easily transferable. d. it consists of imaging files that allow for delayed access.

ANS: B

Advantages of an electronic health information technology system include that it is an integrated, accessible electronic repository of client data with easy access by a variety of health care providers for exchange of information. It contains and records changes in: Updated Problem list Hx; Dx; VS; PE data Medication list Allergy list (crosschecks for drug-drug allergy problems and sends “ALERTS” to providers) Imaging files with real-time access at the point of care DIF: Cognitive Level: Knowledge REF: p. 494 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. Which of the following is a disadvantage of computerized charting? a. Ability to aggregate data b. Improved access to health record c. Standardized charting d. Preset activities that can be coded ANS: C

A major drawback for nursing is that use of computerized documentation systems based on medical code numbers often forces nurses to use classification systems designed to describe medical practice instead of describing nursing assessment and care of clients. With this method of charting, the richness of the nursing care provided often goes undocumented.

Ability to aggregate data, improved access to health record, and preset activities that can be coded are advantages of computerized charting.

DIF: Cognitive Level: Knowledge REF: p. 506 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. The nurse is caring for a client who is recovering from an appendectomy. Which of the

following coding systems should the nurse use for documenting changing of the client’s postoperative abdominal dressing? a. Nursing outcomes classification (NOC) b. Diagnostic-related groups c. Nursing intervention classification d. North American Nursing Diagnosis (NANDA) ANS: C

The nursing intervention classification organizes nursing interventions under domains. NOC is used to classify outcomes. Diagnostic-related groups code for diagnostic procedures.

NANDA describes nursing diagnoses.

DIF: Cognitive Level: Application REF: p. 505 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Management of Care 5. The nursing diagnosis for a client is immobility related to a stroke. Which classification

system can be readily used with this diagnosis? a. Omaha system of client problems b. Clinical pathways c. Nursing intervention classification d. International classification of disease (ICD) ANS: C

The nursing intervention classification organizes nursing interventions under domains. The Omaha classification system is used in health departments and home health agencies. Clinical pathways are standards of practice protocols. ICD describes medical practice.

DIF: Cognitive Level: Analysis REF: p. 505 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Management of Care 6. A client is 3 days postoperative from gallbladder surgery secondary to gallstones. Domain:

Physiological. Class: Fluid and electrolyte balance. Activity: Check intravenous fluid rate intake every hour. Which of the following nursing coding systems is represented in this situation? a. North American Nursing Diagnosis (NANDA) b. Nursing intervention classification c. Nursing outcome classification

d. Omaha system of client problems ANS: B

The nursing intervention classification identifies nursing interventions that are classified under domains and classes. NANDA is a classification of nursing diagnoses. Nursing outcome classification identifies and classifies nursing-sensitive outcomes of client care. The Omaha system classifies problems under four levels: (1) major domains, (2) specific problems, (3) modifiers, and (4) signs and symptoms.

DIF: Cognitive Level: Analysis REF: p. 505 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Management of Care 7. All of the following are true about electronic records except a. they are portable. b. they are less durable than paper charting. c. they are easily transferable. d. they are more durable than paper charting.

ANS: B

Electronic records are more durable than paper charting and are portable. They are easily transferable.

DIF: Cognitive Level: Knowledge REF: p. 496 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 8. Review the charting sample and determine which documentation error occurred.

1000: Hygienic care given 1100: Complaint of leg pain 1300: Appetite good, resting comfortably a. Recording on the wrong chart b. Failure to document an intervention c. Failure to document a discontinued medication d. Failure to record outcome of an intervention ANS: B

The nurse failed to document an intervention for the client’s complaint of leg pain. The interventions are actions that nurses perform in settings relevant to illness prevention, illness treatment, and health promotion. There is no evidence the nurse has recorded on the wrong chart. There is no evidence the nurse has failed to document a discontinued medication. The nurse has recorded the outcome of an intervention by stating the client has a good appetite and is resting comfortably.

DIF: Cognitive Level: Application REF: pp. 501-502 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. Which of the following is a computer charting system related to predicting client outcomes in

home health care? a. EHR b. OASIS

c. NANDA d. HIPAA ANS: B

Beginning in 1998, home care agencies phased in a new requirement to complete a functional health assessment on all Medicare clients before they begin care. The results of the assessment feed into a standardized database. The Health Care Financing Administration (HCFA) developed the Outcome and Assessment Information Set (OASIS) assessment for the purpose of describing home care clients, developing outcome benchmarks, and providing feedback regarding quality of care to home health agencies. The OASIS assessment is required for home health agencies to receive reimbursement for the care provided to Medicare recipients.

The acronym EHR stands for electronic health record. NANDA stands for North American Nursing Diagnosis. HIPAA is the Health Insurance Portability and Accountability Act. DIF: Cognitive Level: Knowledge REF: p. 507 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. Which classification system is a comprehensive practice, documentation, and information

management tool? a. NANDA b. NIC c. NOC d. Omaha system ANS: D

The Omaha System is a comprehensive practice, documentation, and information management tool.

DIF: Cognitive Level: Knowledge REF: pp. 505-506 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. When documenting client care, the nurse recognizes that which of the following is true about

documentation of care? a. Every nurse should anticipate having clients’ records subpoenaed at some time during his or her nursing career. b. There is a need for quicker documentation that does not reflect the nursing process. c. The legal assumption is that care was given even if it is not documented. d. Any method of documentation that provides comprehensive, factual information is legally unacceptable.

ANS: A

Every nurse should anticipate having clients’ records subpoenaed at some time during his or her nursing career. Management literature emphasizes the need for quicker documentation that still reflects the nursing process. The legal assumption is that the care was not given unless it is documented in the client’s record. Any method of documentation that provides comprehensive, factual information is legally acceptable.

DIF: Cognitive Level: Application REF: p. 500 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

12. A client slipped and fell in the bathroom. When filling out an incident report, the nurse should a. record complete, pertinent health information. b. write about the incident report in the client record. c. store the incident report in the client record. d. make untimely entries.

ANS: A

A mistake to avoid is failing to record complete, pertinent health information. Other mistakes to avoid include making untimely entries and writing about mistakes or incident reports in the client record. Incident reports are stored separately.

DIF: Cognitive Level: Application REF: p. 501 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. The nurse recognizes which of the following as a true statement about a nursing classification

system? (Select all that apply.) a. It provides a standard language for nursing care. b. It promotes visibility and defines professional practice of nursing contributions to client care. c. It lacks standardized terminologies that promote best practices within nursing. d. It has not been thoroughly incorporated into many agencies’ electronic clinical records. e. It provides a common language for nursing care.

ANS: A, B, D, E

Nursing classification systems provide a standard and common language for nursing care so that nursing contributions to client care become visible and define professional practice.

Standardized terminologies allow nursing research to explore nursing interventions and outcomes for common problems to identify “best practices.” The ANA says that standards for terminology are an essential requirement for a computer-based patient record. Standardized nursing languages need to convince the business and medical interests managing health care agencies of the need to incorporate nursing classification codes as part of their information technology systems. The greatest problem has been that nursing classifications have not been thoroughly incorporated into many agencies’ electronic clinical records.

DIF: Cognitive Level: Analysis REF: p. 506 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. When completing documentation on each client, the nurse recognizes that documentation

serves what purposes? (Select all that apply.) a. It communicates to others whether or not care was received. b. It conveys pertinent information about the client’s condition and response to treatment interventions. c. It substantiates the quality of care by showing adherence to care standards. d. It provides evidence for reimbursement. e. It serves as a source of data that can be compiled or aggregated and then analyzed

f.

to establish “best practice” interventions.

It is not a source for communicating care to others due to HIPAA rules and regulations.

ANS: A, B, C, D, E

Documentation serves five purposes: • It communicates to others care received or not received.

• It conveys pertinent information about the client's condition and response to treatment interventions.

• It substantiates the quality of care by showing adherence to care standards.

• It provides evidence for reimbursement.

• It serves as source of data that can be compiled or aggregated and then analyzed to establish “best practice” interventions. This includes electronic data, which can be aggregated to monitor outcomes of care processes for quality improvement, a QSEN competency.

DIF: Cognitive Level: Knowledge REF: p. 492 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 27: Digital Health and Communication Technology Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. When working on a hospital unit, the nurse uses a wireless handheld computer. The nurse

recognizes that an advantage of using a wireless handheld computer is a. the nurse cannot view the entire page of client information. b. it can be used at the point of care. c. it has a long learning curve. d. it poses potential threats to the client’s legal privacy rights.

ANS: B

An advantage to using wireless handheld computers is that they are easily portable and can be used at the point of care (e.g., at client’s bedside, in the home). Disadvantages to using wireless handheld computers include the nurse not being able to view the entire page of client information, a long learning curve, and the potential threat to the client’s legal privacy rights.

DIF: Cognitive Level: Application REF: p. 509 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. When working on a hospital unit, the nurse uses a cellular telephone as an aid to giving client

care. When using a cellular telephone, the nurse recognizes that a barrier to this type of technology is a. cellular telephones lead to less productivity. b. cellular telephones can lead to a higher rate of hospital errors. c. some hospitals prohibit using cellular telephones. d. cellular telephones complicate information retrieval at the point of care.

ANS: C

Although just about every nursing student has seen or used a wireless or cellular telephone, not everyone has used them as an aid to giving client care. There are still hospitals that prohibit nurses from using cell phones, even though studies show these devices can save time, decrease errors, and simplify information retrieval at the point of care. Nursing is just beginning to deal with guidelines. Ethically, you do not use electronic devices in your workplace for personal, nonprofessional use. All information needs to be HIPAA secure.

DIF: Cognitive Level: Application REF: p. 512 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. When working on a hospital unit, the nurses use a voice communication system that uses the

existing wireless network to support instant voice communication and messaging among staff within the agency. Using this device allows nurses to connect to the telephone system and to access other users of the system through a small, one-button, voice-access, lightweight badge.

This device is known as a. a PDA. b. Vocera.

c. a smartphone. d. telehealth.

ANS: B

Voice communication systems use wearable, hands-free devices that use the existing wireless network to support instant voice communication and messaging among staff within an agency.

The nurse wears a small, lightweight badge that permits one-button voice access to other users of the system. It also will connect to the telephone system. One example is Vocera. It is said to reduce the time for key communications, such as looking for the medication keys, looking for others (a 45% reduction), paging doctors, or walking to the nursing station telephone (a 25% reduction). Nurses report that voice-activated communication facilitates communication, results in fewer interruptions, promotes better continuity of care, and improves their workflow. Personal digital assistants (PDAs) are handheld electronic devices that may contain multiple databases, possibly including a language translator for use when interviewing a patient from another culture. Smartphones represent the convergence of cellular mobile phones and mobile computers. These devices, such as the Blackberry, have three functions.

They enable one to download and access PDA-type information resources, provide Internet access to client information [new lab results or physician orders], and make and receive telephone calls or instant messages. Telehealth provides live, real-time audio and visual transmissions from one care provider to another or to a client. This technology is hailed as a boon to rural practitioners, facilitating long-distance consultations by expert specialists.

Telehealth nursing communicates monitoring data to the nurse from the client.

DIF: Cognitive Level: Application REF: p. 515 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. When caring for a client who is at risk for falls, the nurse recognizes that a system that

communicates whether the client falls and does not get up via sensors embedded in the hospital room is referred to as a. telecare. b. health information technology. c. radio frequency identity chips. d. a personal digital assistant.

ANS: A

Telecare refers to telemetry that communicates client vital signs, monitors whether nurses wash hands, or signals if a client falls and does not get up via sensors embedded in the hospital room or client's house. Families in America and England are using such sensors placed throughout the client's home to monitor for potential problems such as stove burners left on, doors left open, a too cold house, or a client crisis, such as an epileptic seizure. In the literature, these are referred to as Smart Rooms, a form of automated medical technology.

DIF: Cognitive Level: Knowledge REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. The nurse is teaching a group of nursing students about an umbrella term for services that use

communications technology, defined as any real-time interactive use of the Internet for delivery of health care from a distance using telecommunications technologies. This term is known as all of the following except

a. b. c. d.

telehealth. telenursing. telemetry. telemedicine.

ANS: C

Telehealth is also called telemedicine, telenursing, or eHealth (in England). It is an umbrella term for services that use communications technology, defined as any real-time interactive use of the Internet for delivery of health care from a distance using telecommunications technologies.

DIF: Cognitive Level: Knowledge REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. Which of the following is true about electronic mail communication? a. Most physicians use e-mail to schedule appointments. b. E-mail is a means of ensuring confidentiality. c. Physicians expressed concerns about lack of income generation. d. Paper copies can be eliminated.

ANS: C

E-mail can be a convenient, rapid, inexpensive method of communicating between providers and clients. Yet, while most clients express a desire to communicate with their health care providers via e-mail, only about 72% of physicians in large medical centers reported using this method of communication. Barriers include concern about lack of income generation, confidentiality, malpractice, and time factors. Office nurses use e-mail for scheduling appointments, posting test results, providing prescription refills, and other health reminders.

Nurses also use e-mail for education or follow-up—for example in tracking the response of clients who are on new medication, instead of waiting until their next office appointment.

AMA guidelines suggest that electronic or paper copies be made of e-mail messages sent to clients.

DIF: Cognitive Level: Comprehension REF: p. 517 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. A nursing instructor educates a student nurse about standards of effective communication. The

nursing instructor recognizes that additional teaching is warranted when the student nurse lists which of the following as a standard of effective communication? a. Clear b. Timely c. Lengthy d. Complete ANS: C

Standards of effective communication include communication that is complete, clear, brief (not lengthy), and timely.

DIF: Cognitive Level: Application REF: p. 511 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

8. The nurse is teaching a class on stroke prevention. Which of the following statements is

accurate about studies conducted on telehealth decision-making and diagnosing of strokes? a. Several studies show telehealth decision making and diagnosing of strokes are just as effective and may be more cost effective. b. Studies conducted on telehealth decision making and diagnosing of strokes have been inconclusive. c. Studies show telehealth decision making and diagnosing of strokes are less effective and less cost effective. d. Several studies show telehealth decision making and diagnosing of strokes are just as effective but less cost effective.

ANS: A

Several studies show telehealth decision making and diagnosing of strokes are just as effective and may be more cost effective.

DIF: Cognitive Level: Application REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. The nurse is using a personal digital assistant (PDA) to store client assessment data. When

using a PDA, the nurse recognizes that the PDA a. is unable to recognize the nurse’s handwriting. b. can provide language translation. c. stores only references for nursing and drug information. d. cannot be used in client’s rooms due to HIPPA regulations.

ANS: B

Personal digital assistant (PDA) is a generic term for any of several brands of small, handheld computerized electronic devices that fit in the palm of the nurse's hand. PDA apps can check for drug interactions, calculate dosages, analyze laboratory results, schedule procedures, order prescriptions, serve as a dictionary, or provide language translation, among other functions. It is easy to download reference sources, such as the latest medication information or disease treatment protocols. PDAs can be taken to wherever the client is located. Most nurses seem to prefer use of smartphones, which do all of the above but also make phone calls.

DIF: Cognitive Level: Application REF: p. 512 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. Which of the following best describes a laptop computer? a. It is less powerful than a tablet. b. It should not be taken into a client’s home. c. It is used to chart and transmit a client’s care. d. It does not allow for information to be transmitted in a wireless fashion.

ANS: C

Laptop computers are used to chart and transmit a client’s care. Laptop computers are more powerful than tablets yet both are still small and portable enough to be taken into the client’s home. If a devise has Internet access, information can be sent or nursing documentation completed.

DIF: Cognitive Level: Application REF: p. 513 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. The nurse uses an electronic information technology-based system that is designed to improve

clinical decision making to enhance client care and safety. This system is referred to as a a. personal digital assistant. b. handheld wireless device. c. point of care information and documentation system. d. computerized clinical decision support system.

ANS: D

An important asset of HIT adoption is the provision of a computerized clinical decision support system, which is referred to as CDS. A CDS is defined as an electronic information technology-based system designed to improve clinical decision making to enhance client care and safety. Personal digital assistant (PDA) is a generic term for any of several brands of small, handheld computerized electronic devices that fit in the palm of the nurse’s hand.

Handheld wireless devices allow continual real-time exchange of information. Nursing practice now incorporates point of care information and documentation, allowing continual use of updated client information and reference material at any client location via the Internet.

DIF: Cognitive Level: Application REF: p. 515 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 12. AHRQ’s analysis of 146 studies of the impact of computer health modules on client outcomes

found that these programs a. failed to engage client attention. b. succeeded in engaging client attention. c. caused a decline in client clinical health. d. had no significant impact on client outcomes.

ANS: B

AHRQ’s analysis of 146 studies of the impact of computer health modules on client outcomes found that these programs succeeded in engaging client attention, but more significantly they improved client clinical health.

DIF: Cognitive Level: Application REF: p. 519 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. Major transformations occurring in use of Health Information Technology (HIT) that will

greatly change traditional patterns of nursing communication include which of the following?

(Select all that apply.) a. Electronic health record (EHR) b. Centralized access to client information c. Handheld wireless devices to provide continual information d. Point of care information e. Continual real time exchange of information

ANS: A, C, D, E

Major transformations are occurring in use of HIT that will greatly change traditional patterns of nursing communication: EHR and accompanying ordering and taxonomy; decentralized access to client information at the point of care; and handheld wireless devices allowing continual real-time exchange of information. A major transformation occurring in the use of HIT is decentralized access to client information at the point of care.

DIF: Cognitive Level: Knowledge REF: p. 511 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. Advantages of using wireless handheld computers include which of the following? (Select all

that apply.) a. Portability b. Quick charting c. Learning curve d. Quick access to records e. Small screen ANS: A, B, D

Wireless handheld computers are easily portable, allow quick charting, and permit quick access to client records. There may be a long learning curve until the person becomes familiar with use. The small screen does not allow the user to view the entire page of information.

DIF: Cognitive Level: Knowledge REF: p. 512 TOP: Client Needs: Management of Care MSC: Step of the Nursing Process: All phases 3. A group of clients is signing up for a Telehealth company called ISelectMD. The nurse

educates them about ISelectMD by telling them which of the following? (Select all that apply.) a. The employer’s health insurance charges a minimal additional health premium fee monthly. b. Each employee has 24/7 access to a physician via Telemedicine by signing onto a website and entering his symptoms, and paying a “visit” fee. c. A follow-up call is made 2 days later to determine whether the health issue was resolved. d. The physician “on call” reviews client’s medical history and current symptoms, makes a diagnosis, and e-mails in a prescription, if needed. e. Minor conditions such as urinary tract infections or respiratory illness can be treated in this remote technology fashion. f. Acute conditions such as chest pain or deep vein thrombosis can be treated in this remote technology fashion.

ANS: A, B, C, D, E

Telehealth allows experts to be accessed remotely to diagnose and treat illness, provide preventive health care, or provide medical consultation. It initially was used to provide care to clients in rural areas but is now also used in urban areas. At first it originated at health facilities, but now Telehealth often originates from the client’s home. The company ISelectMD is one example: the employer’s health insurance charges a minimal additional health premium fee monthly, and then each employee has 24/7 access to a physician via Telemedicine by signing onto a website and entering his symptoms and paying a “visit” fee.

The physician “on call” reviews client’s medical history and current symptoms, makes a diagnosis, and e-mails in a prescription, if needed. A follow-up call is made 2 days later to determine whether the health issue was resolved. Obviously, only minor conditions such as urinary tract infections or respiratory illness can be treated in this remote technology fashion.

DIF: Cognitive Level: Application REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

DIF: Cognitive Level: Application REF: p. 470 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 16. A nurse manager educates a group of staff nurses about primary care. Which of the following

should the nurse manager list as a key feature of primary care? a. It lacks the characteristic of person centeredness. b. It functions as the final contact point for common health care problems. c. The focus is on comprehensive care, which can meet many client needs without referral. d. The underlying goal is to offer a highly depersonalized form of care related to a stronger knowledge about individual health care needs and responses over time.

ANS: C

Clients are considered active agents in a dynamic health care delivery process. The expectation is that most clients will be able to self-manage the care of their chronic health conditions in the community, with coordinated, readily accessible health care network supports available in primary care settings. Key features of primary care include: • Person centeredness, with sustained continuity of relationships between provider and client • Functions as a first contact point with easy access services for common health care problems • Comprehensive care, which can meet many client needs without referral • A highly personalized form of care related to a stronger knowledge about individual health care needs and responses over time DIF: Cognitive Level: Application REF: p. 471 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. A nursing instructor educates a class of student nurses about informational continuity. The

nursing instructor lists which of the following as characteristics of informational continuity?

(Select all that apply.) a. It allows for the same client information to be available to providers throughout the health care system. b. It allows for specific information to follow the client from primary to secondary care settings, but not vice versa. c. It promotes interrupted flow of data and clinical impressions between health care providers and agencies. d. Its purpose is to provide continuously coordinated, high-quality care. e. It refers to data exchanges among providers and provider systems and between providers and clients.

ANS: A, D, E

Informational continuity refers to data exchanges among providers and provider systems and between providers and clients for the purpose of providing continuously coordinated, high-quality care. Instant electronic transmission of data "links provider to provider, and health care event to health care event." Ideally there is an uninterrupted flow of data and clinical impressions between health care providers and agencies, with clients and their families, over time and space. Specific information follows the client from primary to secondary care settings and vice versa. The same client information is available to providers throughout the health care system.

DIF: Cognitive Level: Application REF: pp. 479-480 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. The nurse manager conducts an in-service for staff nurses about the importance of

client-centered care. When educating staff nurses about characteristics of client-centered care, the nurse manager lists which of the following characteristics? (Select all that apply.) a. It promotes dependence within clients. b. It supports allowing the client time for questions. c. It considers whom information should be provided to. d. It respects the amount of information desired by clients. e. It encourages providing clients with sufficient information.

ANS: B, C, D, E

Clients should be key informants, active negotiators, final decision makers, and engaged participants in evaluating treatment outcomes. They need to be actively involved in defining and updating realistic treatment goals. Client centeredness is evidenced in a partnership characterized by mutual valuing and safeguarding of the legitimate interests of the provider and the client in creating and managing health care decisions.

Joint decision making is a key element. The decision-making process starts with providing each client with sufficient information, tailored to his or her unique circumstances, to make an informed decision. Information should be relevant to each client's diagnosis, treatments, and treatment options. The first question to consider is, “What essential information does this client need to have in order to make an informed decision?” Some clients value knowing as much as possible; others want just the basic facts. Another may need to have essential information developed in steps and spread over several encounters to allow for better processing and formulation of related questions. Cultural norms can dictate levels of information and to whom the information should be given.

DIF: Cognitive Level: Application REF: pp. 474-475 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 26: e-Documentation in Health Information Technology Systems Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. The process of obtaining, organizing, and conveying client health information to others in

print or electronic format is referred to as a. narration. b. documentation. c. care coordination. d. order entry.

ANS: B

The process of obtaining, organizing, and conveying client health information to others in print or electronic format is referred to as documentation.

DIF: Cognitive Level: Application REF: p. 492 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. One major advantage of an electronic health information technology system is a. lack of integration. b. accessibility of health records. c. it is not easily transferable. d. it consists of imaging files that allow for delayed access.

ANS: B

Advantages of an electronic health information technology system include that it is an integrated, accessible electronic repository of client data with easy access by a variety of health care providers for exchange of information. It contains and records changes in: Updated Problem list Hx; Dx; VS; PE data Medication list Allergy list (crosschecks for drug-drug allergy problems and sends “ALERTS” to providers) Imaging files with real-time access at the point of care DIF: Cognitive Level: Knowledge REF: p. 494 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. Which of the following is a disadvantage of computerized charting? a. Ability to aggregate data b. Improved access to health record c. Standardized charting d. Preset activities that can be coded ANS: C

A major drawback for nursing is that use of computerized documentation systems based on medical code numbers often forces nurses to use classification systems designed to describe medical practice instead of describing nursing assessment and care of clients. With this method of charting, the richness of the nursing care provided often goes undocumented.

Ability to aggregate data, improved access to health record, and preset activities that can be coded are advantages of computerized charting.

DIF: Cognitive Level: Knowledge REF: p. 506 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. The nurse is caring for a client who is recovering from an appendectomy. Which of the

following coding systems should the nurse use for documenting changing of the client’s postoperative abdominal dressing? a. Nursing outcomes classification (NOC) b. Diagnostic-related groups c. Nursing intervention classification d. North American Nursing Diagnosis (NANDA) ANS: C

The nursing intervention classification organizes nursing interventions under domains. NOC is used to classify outcomes. Diagnostic-related groups code for diagnostic procedures.

NANDA describes nursing diagnoses.

DIF: Cognitive Level: Application REF: p. 505 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Management of Care 5. The nursing diagnosis for a client is immobility related to a stroke. Which classification

system can be readily used with this diagnosis? a. Omaha system of client problems b. Clinical pathways c. Nursing intervention classification d. International classification of disease (ICD) ANS: C

The nursing intervention classification organizes nursing interventions under domains. The Omaha classification system is used in health departments and home health agencies. Clinical pathways are standards of practice protocols. ICD describes medical practice.

DIF: Cognitive Level: Analysis REF: p. 505 TOP: Step of the Nursing Process: Diagnosis MSC: Client Needs: Management of Care 6. A client is 3 days postoperative from gallbladder surgery secondary to gallstones. Domain:

Physiological. Class: Fluid and electrolyte balance. Activity: Check intravenous fluid rate intake every hour. Which of the following nursing coding systems is represented in this situation? a. North American Nursing Diagnosis (NANDA) b. Nursing intervention classification c. Nursing outcome classification

d. Omaha system of client problems ANS: B

The nursing intervention classification identifies nursing interventions that are classified under domains and classes. NANDA is a classification of nursing diagnoses. Nursing outcome classification identifies and classifies nursing-sensitive outcomes of client care. The Omaha system classifies problems under four levels: (1) major domains, (2) specific problems, (3) modifiers, and (4) signs and symptoms.

DIF: Cognitive Level: Analysis REF: p. 505 TOP: Step of the Nursing Process: Interventions MSC: Client Needs: Management of Care 7. All of the following are true about electronic records except a. they are portable. b. they are less durable than paper charting. c. they are easily transferable. d. they are more durable than paper charting.

ANS: B

Electronic records are more durable than paper charting and are portable. They are easily transferable.

DIF: Cognitive Level: Knowledge REF: p. 496 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 8. Review the charting sample and determine which documentation error occurred.

1000: Hygienic care given 1100: Complaint of leg pain 1300: Appetite good, resting comfortably a. Recording on the wrong chart b. Failure to document an intervention c. Failure to document a discontinued medication d. Failure to record outcome of an intervention ANS: B

The nurse failed to document an intervention for the client’s complaint of leg pain. The interventions are actions that nurses perform in settings relevant to illness prevention, illness treatment, and health promotion. There is no evidence the nurse has recorded on the wrong chart. There is no evidence the nurse has failed to document a discontinued medication. The nurse has recorded the outcome of an intervention by stating the client has a good appetite and is resting comfortably.

DIF: Cognitive Level: Application REF: pp. 501-502 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. Which of the following is a computer charting system related to predicting client outcomes in

home health care? a. EHR b. OASIS

c. NANDA d. HIPAA ANS: B

Beginning in 1998, home care agencies phased in a new requirement to complete a functional health assessment on all Medicare clients before they begin care. The results of the assessment feed into a standardized database. The Health Care Financing Administration (HCFA) developed the Outcome and Assessment Information Set (OASIS) assessment for the purpose of describing home care clients, developing outcome benchmarks, and providing feedback regarding quality of care to home health agencies. The OASIS assessment is required for home health agencies to receive reimbursement for the care provided to Medicare recipients.

The acronym EHR stands for electronic health record. NANDA stands for North American Nursing Diagnosis. HIPAA is the Health Insurance Portability and Accountability Act. DIF: Cognitive Level: Knowledge REF: p. 507 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. Which classification system is a comprehensive practice, documentation, and information

management tool? a. NANDA b. NIC c. NOC d. Omaha system ANS: D

The Omaha System is a comprehensive practice, documentation, and information management tool.

DIF: Cognitive Level: Knowledge REF: pp. 505-506 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. When documenting client care, the nurse recognizes that which of the following is true about

documentation of care? a. Every nurse should anticipate having clients’ records subpoenaed at some time during his or her nursing career. b. There is a need for quicker documentation that does not reflect the nursing process. c. The legal assumption is that care was given even if it is not documented. d. Any method of documentation that provides comprehensive, factual information is legally unacceptable.

ANS: A

Every nurse should anticipate having clients’ records subpoenaed at some time during his or her nursing career. Management literature emphasizes the need for quicker documentation that still reflects the nursing process. The legal assumption is that the care was not given unless it is documented in the client’s record. Any method of documentation that provides comprehensive, factual information is legally acceptable.

DIF: Cognitive Level: Application REF: p. 500 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

12. A client slipped and fell in the bathroom. When filling out an incident report, the nurse should a. record complete, pertinent health information. b. write about the incident report in the client record. c. store the incident report in the client record. d. make untimely entries.

ANS: A

A mistake to avoid is failing to record complete, pertinent health information. Other mistakes to avoid include making untimely entries and writing about mistakes or incident reports in the client record. Incident reports are stored separately.

DIF: Cognitive Level: Application REF: p. 501 TOP: Step of the Nursing Process: Implementation MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. The nurse recognizes which of the following as a true statement about a nursing classification

system? (Select all that apply.) a. It provides a standard language for nursing care. b. It promotes visibility and defines professional practice of nursing contributions to client care. c. It lacks standardized terminologies that promote best practices within nursing. d. It has not been thoroughly incorporated into many agencies’ electronic clinical records. e. It provides a common language for nursing care.

ANS: A, B, D, E

Nursing classification systems provide a standard and common language for nursing care so that nursing contributions to client care become visible and define professional practice.

Standardized terminologies allow nursing research to explore nursing interventions and outcomes for common problems to identify “best practices.” The ANA says that standards for terminology are an essential requirement for a computer-based patient record. Standardized nursing languages need to convince the business and medical interests managing health care agencies of the need to incorporate nursing classification codes as part of their information technology systems. The greatest problem has been that nursing classifications have not been thoroughly incorporated into many agencies’ electronic clinical records.

DIF: Cognitive Level: Analysis REF: p. 506 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. When completing documentation on each client, the nurse recognizes that documentation

serves what purposes? (Select all that apply.) a. It communicates to others whether or not care was received. b. It conveys pertinent information about the client’s condition and response to treatment interventions. c. It substantiates the quality of care by showing adherence to care standards. d. It provides evidence for reimbursement. e. It serves as a source of data that can be compiled or aggregated and then analyzed

f.

to establish “best practice” interventions.

It is not a source for communicating care to others due to HIPAA rules and regulations.

ANS: A, B, C, D, E

Documentation serves five purposes: • It communicates to others care received or not received.

• It conveys pertinent information about the client's condition and response to treatment interventions.

• It substantiates the quality of care by showing adherence to care standards.

• It provides evidence for reimbursement.

• It serves as source of data that can be compiled or aggregated and then analyzed to establish “best practice” interventions. This includes electronic data, which can be aggregated to monitor outcomes of care processes for quality improvement, a QSEN competency.

DIF: Cognitive Level: Knowledge REF: p. 492 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

Chapter 27: Digital Health and Communication Technology Arnold and Boggs’s: Interpersonal Relationships, 1st Edition MULTIPLE CHOICE 1. When working on a hospital unit, the nurse uses a wireless handheld computer. The nurse

recognizes that an advantage of using a wireless handheld computer is a. the nurse cannot view the entire page of client information. b. it can be used at the point of care. c. it has a long learning curve. d. it poses potential threats to the client’s legal privacy rights.

ANS: B

An advantage to using wireless handheld computers is that they are easily portable and can be used at the point of care (e.g., at client’s bedside, in the home). Disadvantages to using wireless handheld computers include the nurse not being able to view the entire page of client information, a long learning curve, and the potential threat to the client’s legal privacy rights.

DIF: Cognitive Level: Application REF: p. 509 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. When working on a hospital unit, the nurse uses a cellular telephone as an aid to giving client

care. When using a cellular telephone, the nurse recognizes that a barrier to this type of technology is a. cellular telephones lead to less productivity. b. cellular telephones can lead to a higher rate of hospital errors. c. some hospitals prohibit using cellular telephones. d. cellular telephones complicate information retrieval at the point of care.

ANS: C

Although just about every nursing student has seen or used a wireless or cellular telephone, not everyone has used them as an aid to giving client care. There are still hospitals that prohibit nurses from using cell phones, even though studies show these devices can save time, decrease errors, and simplify information retrieval at the point of care. Nursing is just beginning to deal with guidelines. Ethically, you do not use electronic devices in your workplace for personal, nonprofessional use. All information needs to be HIPAA secure.

DIF: Cognitive Level: Application REF: p. 512 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 3. When working on a hospital unit, the nurses use a voice communication system that uses the

existing wireless network to support instant voice communication and messaging among staff within the agency. Using this device allows nurses to connect to the telephone system and to access other users of the system through a small, one-button, voice-access, lightweight badge.

This device is known as a. a PDA. b. Vocera.

c. a smartphone. d. telehealth.

ANS: B

Voice communication systems use wearable, hands-free devices that use the existing wireless network to support instant voice communication and messaging among staff within an agency.

The nurse wears a small, lightweight badge that permits one-button voice access to other users of the system. It also will connect to the telephone system. One example is Vocera. It is said to reduce the time for key communications, such as looking for the medication keys, looking for others (a 45% reduction), paging doctors, or walking to the nursing station telephone (a 25% reduction). Nurses report that voice-activated communication facilitates communication, results in fewer interruptions, promotes better continuity of care, and improves their workflow. Personal digital assistants (PDAs) are handheld electronic devices that may contain multiple databases, possibly including a language translator for use when interviewing a patient from another culture. Smartphones represent the convergence of cellular mobile phones and mobile computers. These devices, such as the Blackberry, have three functions.

They enable one to download and access PDA-type information resources, provide Internet access to client information [new lab results or physician orders], and make and receive telephone calls or instant messages. Telehealth provides live, real-time audio and visual transmissions from one care provider to another or to a client. This technology is hailed as a boon to rural practitioners, facilitating long-distance consultations by expert specialists.

Telehealth nursing communicates monitoring data to the nurse from the client.

DIF: Cognitive Level: Application REF: p. 515 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 4. When caring for a client who is at risk for falls, the nurse recognizes that a system that

communicates whether the client falls and does not get up via sensors embedded in the hospital room is referred to as a. telecare. b. health information technology. c. radio frequency identity chips. d. a personal digital assistant.

ANS: A

Telecare refers to telemetry that communicates client vital signs, monitors whether nurses wash hands, or signals if a client falls and does not get up via sensors embedded in the hospital room or client's house. Families in America and England are using such sensors placed throughout the client's home to monitor for potential problems such as stove burners left on, doors left open, a too cold house, or a client crisis, such as an epileptic seizure. In the literature, these are referred to as Smart Rooms, a form of automated medical technology.

DIF: Cognitive Level: Knowledge REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 5. The nurse is teaching a group of nursing students about an umbrella term for services that use

communications technology, defined as any real-time interactive use of the Internet for delivery of health care from a distance using telecommunications technologies. This term is known as all of the following except

a. b. c. d.

telehealth. telenursing. telemetry. telemedicine.

ANS: C

Telehealth is also called telemedicine, telenursing, or eHealth (in England). It is an umbrella term for services that use communications technology, defined as any real-time interactive use of the Internet for delivery of health care from a distance using telecommunications technologies.

DIF: Cognitive Level: Knowledge REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 6. Which of the following is true about electronic mail communication? a. Most physicians use e-mail to schedule appointments. b. E-mail is a means of ensuring confidentiality. c. Physicians expressed concerns about lack of income generation. d. Paper copies can be eliminated.

ANS: C

E-mail can be a convenient, rapid, inexpensive method of communicating between providers and clients. Yet, while most clients express a desire to communicate with their health care providers via e-mail, only about 72% of physicians in large medical centers reported using this method of communication. Barriers include concern about lack of income generation, confidentiality, malpractice, and time factors. Office nurses use e-mail for scheduling appointments, posting test results, providing prescription refills, and other health reminders.

Nurses also use e-mail for education or follow-up—for example in tracking the response of clients who are on new medication, instead of waiting until their next office appointment.

AMA guidelines suggest that electronic or paper copies be made of e-mail messages sent to clients.

DIF: Cognitive Level: Comprehension REF: p. 517 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 7. A nursing instructor educates a student nurse about standards of effective communication. The

nursing instructor recognizes that additional teaching is warranted when the student nurse lists which of the following as a standard of effective communication? a. Clear b. Timely c. Lengthy d. Complete ANS: C

Standards of effective communication include communication that is complete, clear, brief (not lengthy), and timely.

DIF: Cognitive Level: Application REF: p. 511 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care

8. The nurse is teaching a class on stroke prevention. Which of the following statements is

accurate about studies conducted on telehealth decision-making and diagnosing of strokes? a. Several studies show telehealth decision making and diagnosing of strokes are just as effective and may be more cost effective. b. Studies conducted on telehealth decision making and diagnosing of strokes have been inconclusive. c. Studies show telehealth decision making and diagnosing of strokes are less effective and less cost effective. d. Several studies show telehealth decision making and diagnosing of strokes are just as effective but less cost effective.

ANS: A

Several studies show telehealth decision making and diagnosing of strokes are just as effective and may be more cost effective.

DIF: Cognitive Level: Application REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 9. The nurse is using a personal digital assistant (PDA) to store client assessment data. When

using a PDA, the nurse recognizes that the PDA a. is unable to recognize the nurse’s handwriting. b. can provide language translation. c. stores only references for nursing and drug information. d. cannot be used in client’s rooms due to HIPPA regulations.

ANS: B

Personal digital assistant (PDA) is a generic term for any of several brands of small, handheld computerized electronic devices that fit in the palm of the nurse's hand. PDA apps can check for drug interactions, calculate dosages, analyze laboratory results, schedule procedures, order prescriptions, serve as a dictionary, or provide language translation, among other functions. It is easy to download reference sources, such as the latest medication information or disease treatment protocols. PDAs can be taken to wherever the client is located. Most nurses seem to prefer use of smartphones, which do all of the above but also make phone calls.

DIF: Cognitive Level: Application REF: p. 512 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 10. Which of the following best describes a laptop computer? a. It is less powerful than a tablet. b. It should not be taken into a client’s home. c. It is used to chart and transmit a client’s care. d. It does not allow for information to be transmitted in a wireless fashion.

ANS: C

Laptop computers are used to chart and transmit a client’s care. Laptop computers are more powerful than tablets yet both are still small and portable enough to be taken into the client’s home. If a devise has Internet access, information can be sent or nursing documentation completed.

DIF: Cognitive Level: Application REF: p. 513 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 11. The nurse uses an electronic information technology-based system that is designed to improve

clinical decision making to enhance client care and safety. This system is referred to as a a. personal digital assistant. b. handheld wireless device. c. point of care information and documentation system. d. computerized clinical decision support system.

ANS: D

An important asset of HIT adoption is the provision of a computerized clinical decision support system, which is referred to as CDS. A CDS is defined as an electronic information technology-based system designed to improve clinical decision making to enhance client care and safety. Personal digital assistant (PDA) is a generic term for any of several brands of small, handheld computerized electronic devices that fit in the palm of the nurse’s hand.

Handheld wireless devices allow continual real-time exchange of information. Nursing practice now incorporates point of care information and documentation, allowing continual use of updated client information and reference material at any client location via the Internet.

DIF: Cognitive Level: Application REF: p. 515 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 12. AHRQ’s analysis of 146 studies of the impact of computer health modules on client outcomes

found that these programs a. failed to engage client attention. b. succeeded in engaging client attention. c. caused a decline in client clinical health. d. had no significant impact on client outcomes.

ANS: B

AHRQ’s analysis of 146 studies of the impact of computer health modules on client outcomes found that these programs succeeded in engaging client attention, but more significantly they improved client clinical health.

DIF: Cognitive Level: Application REF: p. 519 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care MULTIPLE RESPONSE 1. Major transformations occurring in use of Health Information Technology (HIT) that will

greatly change traditional patterns of nursing communication include which of the following?

(Select all that apply.) a. Electronic health record (EHR) b. Centralized access to client information c. Handheld wireless devices to provide continual information d. Point of care information e. Continual real time exchange of information

ANS: A, C, D, E

Major transformations are occurring in use of HIT that will greatly change traditional patterns of nursing communication: EHR and accompanying ordering and taxonomy; decentralized access to client information at the point of care; and handheld wireless devices allowing continual real-time exchange of information. A major transformation occurring in the use of HIT is decentralized access to client information at the point of care.

DIF: Cognitive Level: Knowledge REF: p. 511 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care 2. Advantages of using wireless handheld computers include which of the following? (Select all

that apply.) a. Portability b. Quick charting c. Learning curve d. Quick access to records e. Small screen ANS: A, B, D

Wireless handheld computers are easily portable, allow quick charting, and permit quick access to client records. There may be a long learning curve until the person becomes familiar with use. The small screen does not allow the user to view the entire page of information.

DIF: Cognitive Level: Knowledge REF: p. 512 TOP: Client Needs: Management of Care MSC: Step of the Nursing Process: All phases 3. A group of clients is signing up for a Telehealth company called ISelectMD. The nurse

educates them about ISelectMD by telling them which of the following? (Select all that apply.) a. The employer’s health insurance charges a minimal additional health premium fee monthly. b. Each employee has 24/7 access to a physician via Telemedicine by signing onto a website and entering his symptoms, and paying a “visit” fee. c. A follow-up call is made 2 days later to determine whether the health issue was resolved. d. The physician “on call” reviews client’s medical history and current symptoms, makes a diagnosis, and e-mails in a prescription, if needed. e. Minor conditions such as urinary tract infections or respiratory illness can be treated in this remote technology fashion. f. Acute conditions such as chest pain or deep vein thrombosis can be treated in this remote technology fashion.

ANS: A, B, C, D, E

Telehealth allows experts to be accessed remotely to diagnose and treat illness, provide preventive health care, or provide medical consultation. It initially was used to provide care to clients in rural areas but is now also used in urban areas. At first it originated at health facilities, but now Telehealth often originates from the client’s home. The company ISelectMD is one example: the employer’s health insurance charges a minimal additional health premium fee monthly, and then each employee has 24/7 access to a physician via Telemedicine by signing onto a website and entering his symptoms and paying a “visit” fee.

The physician “on call” reviews client’s medical history and current symptoms, makes a diagnosis, and e-mails in a prescription, if needed. A follow-up call is made 2 days later to determine whether the health issue was resolved. Obviously, only minor conditions such as urinary tract infections or respiratory illness can be treated in this remote technology fashion.

DIF: Cognitive Level: Application REF: p. 514 TOP: Step of the Nursing Process: All phases MSC: Client Needs: Management of Care