practice quiz answers unit 3

8/12/2019 Practice Quiz Answers Unit 3

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Practice Quiz Answers

Unit 3

Question 1

A parent tells the pediatric nurse practitioner, “I’ve never told anyone this i nformation about myson.” This i s a n example of:

A) Identifying problems a nd goalsB) Building trustC) C larifying rolesD) Revealing

Correct Answer: B

Explanation: This r esponse is a n e xample of trust. Trusting a nother person involves r isk a ndvulnerability, but it also fosters o pen, therapeutic c ommunication and enhances t he expression offeelings, thoughts, and needs.A. This st atement is n ot an example of identifying problems a nd goals.C. This s tatement is n ot clarifying roles of the nurse and client.D. This st atement is n ot an example of revealing. Although the parent may have providedinformation that was n ever before revealed, in this s tatement the parent is i ndicating that there istrust between himself or herself and the nurse practitioner.

Question 2

Which of the following is t he best example of complete documentation?

A) “8:30 AM - Client received aspirin and oxycodone (Percodan; 1 tablet) PO”B) “12:15 PM - I gave t he client morphine 10 mg IM at 11:10 AM, but did n ot document it then”C) “2:45 PM - Acetylsalicylic a cid (ASA) gr X given for temperature of 38.1° C ”D) “8:30 PM - Abdominal dressing change a t 7:30 PM. No s/ s of infection, and wound edgesapproximating well”

Correct Answer: C

Explanation: This i s t he best example of a late entry. The time is i ndicated along with the actionand an objective observationA. This n otation is n ot complete. It does n ot indicate why the aspirin and oxycodone (Percodan)was g iven (i.e., what was t he client’s l evel of pain? W here was t he p ain located?)B. The nurse does n ot need to document about herself, only a bout the client. In this o ption, thenurse does n ot indicate why the morphine was g iven (such as t he c lient’s l evel of pain or locationof pain).



D. This e ntry i s n ot complete. It does n ot state the size of the wound, type of dressing used, or theclient’s t olerance of the procedure.

Question 3

“Client is w heezing and e xperiencing so me d yspnea o n e xertion.” This is an example o f:

A) The “S” in SOAP documentationB) FOCUS documentationC) The “P” of PIE

D) The “R” in DAR documentation

Correct Answer: C

Explanation: This d atum is a n example of the “P” of PIE because it describes t he problem.A. The “S” in SOAP documentation rep resents su bjective data (verbalizations o f the client).B. FOCUS charting does n ot concentrate on only p roblems. It is s tructured according to a client’sconcerns.D. The “R” in DAR documentation is t he response of the client. This s ituation describes t heclient’s p roblem, not the client’s res ponse.

Question 4

The c lient draws b ack w hen the nurse reaches o ver the side r ails t o take his b lood p ressure. Topromote e ffective c ommunication, the n urse should rst:

A) Tell the client that the blood pressure can be taken at a later timeB) Rotate the nurses w ho are assigned to take the client’s b lood pressureC) Continue to perform the procedure quickly a nd quietlyD) Apologize for startling the client and explain the need for con tact

Correct Answer: D

Explanation: Nurses o ften have to enter a client’s p ersonal space to provide care. The nurseshould convey co ndence, gentleness, and respect for pr ivacy. This r esponse demonstratesrespect and provides i nformation so the client may understand the need for personal contact.A. Telling the client that the blood pressure can be taken at a later time does n ot promote effectivecommunication.B. Rotating the nurses w ho are assigned to take the client’s b lood pressure impedes t he nurse’s



ability to form a therapeutic, h elping relationship.C. Continuing to perform the procedure quickly a nd quietly m ay send a negative nonverbalmessage. It also d oes no t promote e ffective co mmunication.

Question 5

Recording a nurse’s d escription of the teaching provided to the client on performance of self-medication administration is f ound in a(n):

A) KardexB) Incident reportC) Nursing history formD) Discharge summary form

Correct Answer: D

Explanation: A nurse’s d escription of the teaching provided to the client on performance of self-administration of medication is r ecorded in the discharge summary form.A. A Kardex is a written form that contains b asic c lient information. A Kardex contains a n activityand treatment section a nd a nursing care plan section that organizes i nformation for quickreference as n urses g ive change-of-shift report. It does n ot include a description of teaching thatwas p rovided to the client.B. An incident report concerns a ny e vent that is n ot consistent with the routine operation of ahealth care unit or r outine care of a client (e.g., a client falls).C. A nursing history form guides t he nurse through a complete assessment to identify relevantnursing diagnoses o r problems. It provides b aseline data about the client.

Question 6

The charge nurse is e valuating the documentation of the new staff nurse. On review of thecharting, the charge n urse notes t hat appropriate d ocumentation is e vident when the n ew staffnurse:

A) Uses a pencil to make the entriesB) Uses c orrection uid to correct written errorsC) Identies a n error made by the attending physicianD) Dates a nd signs a ll of the entries m ade in the record

Correct Answer: D

Explanation: E ach entry s hould begin with the time and end with the signature and title of theperson recording the entry.A. All entries s hould be recorded legibly a nd in black ink b ecause pencil can be erased.B. The nurse should never erase entries or use correction uid and never use a pencil. The use ofcorrection uid could make the charting become illegible, and it may appear as i f the nurse were



attempting to hide something or to deface the record.C. If the physician made an error, the nurse should not document it in the client’s c hart. It shouldbe d ocumented in a n incident report.

Question 7

The nurse is e stablishing a helping relationship with the client. In addressing the client, the nurseshould:

A) Use the client’s r st name.B) Touch the client right away to establish contact.C) Sit far enough away from the client.D) Knock before entering the client’s r oom.

Correct Answer: D

Explanation: Common courtesy i s p art of professional communication. To practice courtesy, thenurse says “ hello” and “goodbye,” knocks on doors b efore e ntering, and u ses se lf-introduction.Knocking on doors i s i mportant in addressing the client.A. Because using last names i s r espectful in most cultures, nurses u sually u se the client’s l astname in the initial interaction, and then use the rst name if the client requests i t.B. Touching the client right away would not be an appropriate action in establishing a helpingrelationship. It would more likely be interpreted as invading the client’s p ersonal space.C. Sitting far enough away from the client is i mportant, in that the nurse should not enter theclient’s p ersonal space when establishing a helping relationship. However, leaning toward theclient conveys that the nurse is i nvolved and interested in the client. Knocking on the door beforeentering the client’s r oom would be the rst step in addressing the client properly.

Question 8

In using communication skills w ith clients, the nurse evaluates w hich response as b eing the mosttherapeutic?

A) “Why don’t you stick to the special diet?”B) “I noticed that you didn’t eat lunch. Is so mething wrong?”C) “I think you need to nd another physician that’s better than this one.”D) “We can’t continue talking about your nancial problems ri ght now. It’s t ime for your bath.”

Correct Answer: B

Explanation: The n urse who is sh aring a n o bservation is u sing the most therapeutic response.Sharing observations o ften helps t he client communicate without the need for extensivequestioning, focusing, or cl arication.A. This i s a n example of a nontherapeutic r esponse. It is a sking for an explanation. “Why”questions ca n cause resentment, insecurity, and mistrust.



C. This i s n ot a therapeutic r esponse. It is g iving a personal opinion.D. Changing the subject is n ot therapeutic.

Question 9

In working with a client who is n ewly d iagnosed with diabetes m ellitus, the nurse providesfeedback to the client on her progress in learning the treatment regimen. Of the following, thenurse demonstrates t he u se of therapeutic co mmunication b y st ating:

A) “I believe that you have co me a long way i n learning how to m anage yo ur care.”B) “It didn’t look a s i f you were ever going to be able to get the injection technique.”C) “You really n eed to be checking your blood sugar more often unless yo u want to come backhere to the hospital.”D) “You don’t appear to have any interest in your dietary i ntake.”

Correct Answer: A

Explanation: The nurse is d emonstrating the use o f therapeutic co mmunication by s haring hope.The nurse is p ointing out that personal growth can come from illness e xperiences.B. This i s a negative statement. The nurse should n ot state observations t hat might embarrass o ranger the client.C. This r esponse does n ot demonstrate t he u se of therapeutic co mmunication. It impliesdisapproval and is an aggressive, threatening type of response.D. This is not a therapeutic statement. It is negative and aggressive in nature. If it is a trueobservation, it is o ne the nurse should not state, as i t could anger the client.

Question 10

Guidelines should be followed when documenting client care. The nurse recognizes t hat the

following is t he most appropriate notation:

A) 1230 Client’s v ital signs t akenB) 0700 Client drank a dequate amount of uidsC) 0900 Meperidine (Demerol) given for lower abdominal painD) 0830 Increased intravenous ( IV) uid rate to 100 ml per hour according t o p rotocol

Correct Answer: D



Explanation: Information within a recorded entry m ust be complete, containing appropriate andessential information. This notation provides the time and action taken by the nurse, including thereason for doing so.A. This e ntry d oes n ot indicate what the vital signs w ere.B. This e ntry d oes n ot provide a specic a mount the client drank. Stating “adequate” is su bjective,

not objective.C. This n otation does n ot have the client describe his o r her pain or rate it according to a painscale for comparison later. It also does n ot indicate whether the client’s p ain was i n the lower leftor lower right quadrant, or both. It does n ot provide route or dose of medication given.

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practice quiz answers unit 3

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