Ch 3

22問 • 3年前

問題一覧

1. The nurse is caring for an adult patient with a recent below-the-knee amputation. During shift report, the nurse reports that the patient has urinated in the bed multiple times since the surgery. The nurse knows which defense mechanism best describes this behavior?

d. Regression

2. A female patient is admitted to the emergency department after being raped by a neighbor. The patient refuses to discuss the circumstances surrounding the event with the sexual assault nurse examiner. The nurse identifies that the patient is utilizing which defense mechanism?

a. Suppression

3. A patient calls the nurse to report the smell of cigarette smoke in the bathroom. The nurse recognizes that this component of the communication process is identified by which term?

b. Referent

4. The nurse manager sends an e-mail to the nursing staff as a reminder for a scheduled monthly meeting. In doing so, the nurse manager understands that e-mail could result in which issue?

b. It has the potential for miscommunication.

5. The nursing student has been assigned to help feed patients at lunch time. Which nursing intervention would be most effective when assisting a blind patient to eat a meal?

b. Describe the food arrangement using the numbers on a clock.

6. The nurse observes a confused patient pacing back and forth in the dining room. The patient yells, “The doctor is going to make us all drink poison!” The most appropriate intervention by the nurse at this time would be to take what action?

d. Quietly ask the patient to explain the statement.

7. A patient with an inoperable brain tumor says to the nurse, “I just want to die now. It’s going to happen soon anyway.” Which would be the most appropriate response?

d. “Tell me why you are saying that.”

8. The nurse is caring for a patient with chronic lung disease. When the patient demands a cigarette after eating breakfast, the nurse responds, “If that was me, I wouldn’t be asking for a cigarette. That is what has made you so sick in the first place.” This nontherapeutic response is an example of what communication technique?

b. Giving advice

9. What physical distance should the nurse become comfortable with and sensitive to while providing direct patient care?

a. 0 to 1.5 feet

10. The nurse understands that based on a patient’s perception of professional competence and caring, the nurse should wear which item?

c. Clean, neatly pressed uniform

11. The nurse is admitting a patient with a foul-smelling leg wound. Which behavior by the nurse indicates an understanding of appropriate body language?

d. Gentle touching of the patient’s shoulder

12. Several nurses on a medical-surgical unit have been asked by the nurse manager to form a group and gather data regarding patient complaints of late meals. When the nurses meet and establish ground rules, this would be what phase of group development?

a. Forming

13. A nurse has been working with a patient for the entire shift. Which action by the nurse is unacceptable?

a. Sharing a personal mobile phone number

14. During a shift report, the nurse briefly describes the history of a patient admitted with chronic gastrointestinal bleeding. In which SBAR topical area would this information be presented?

b. Background

15. The nurse is performing an abdominal assessment on a postoperative surgical patient. The nurse notes that the dressing needs to be changed twice a day and discusses when the patient would like to have it done. The nurse then plans to change the dressing at that time. In which phase of the nurse–patient helping relationship would this process occur?

c. Working phase

16. The nurse is collaborating with a patient to determine interventions to ensure compliance with medication administration after the pending discharge. The nurse understands that the goals and nursing interventions would be agreed upon in which phase of the nurse–patient relationship?

d. Termination phase

17. A patient complains that several staff members entered the room during the morning bath without knocking. Which component of professional nursing communication has been violated in this scenario?

d. Respect

18. The nurse is caring for a patient who is unable to take oral medications because of persistent nausea and vomiting. When the nurse decides to call the primary care physician and ask for a different medication administration route, this is a demonstration of what act?

d. Advocacy

19. The nurse is assisting a co-worker who is preparing to change a deep wound dressing on a patient’s abdomen. Several of the patient’s out-of-town friends are at the bedside watching a football game. Which action is most appropriate for the nurse to consider prior to the dressing change?

a. Ask the friends to leave the room.

20. The nurse is conducting a presurgical screening interview with a patient at a local surgical center. When performing a health assessment, the nurse identifies which source should be the primary source of information?

d. Patient

21. A mother of a young child kicks a trashcan in anger and says to the nurse, “You just don’t understand! Why can’t the doctor find out what is wrong with my child?” The nurse understands that this behavior is most likely an example of which defense mechanism?

c. Displacement

22. The nurse is caring for a patient scheduled for a partial mastectomy resulting from advanced cancer. The patient tells the nurse, “I’m sure when the surgeon operates on me, he will not find any cancer in my breast. It looks just fine.” The nurse recognizes that the patient is using which defense mechanism to cope with the medical diagnosis?

d. Denial

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4