NUR 336 Exam Questions with Correct Answers

NUR 336 Exam Questions with Correct Answers

In which nurse interaction may SBAR be used?

• Nurse to social worker
• Nurse to doctor
• Nurse to nurse
• All of the above -ANS_ D

A nurse tells a doctor a patient has diabetes. Which part of the SBAR model is this statement?

• Situation
• Background
• Assessment
• Recommendation -ANS_ B (Parts of a patient's background include what they were

admitted for, their background history, labs and tests pertinent to the reason for the call, their current therapy, and their current vital signs.)

The nurse tells the doctor a patient felt warm when she checked him for a fever. What part of the SBAR model is this statement?

• Situation
• Background
• Assessment

d. Recommendation -ANS_ A (Parts of situation: Briefly state the issue, when it

happened or began, how severe the patient's response is--for example: changes in heart rate/rhythm, changes in vital signs, intake and output, change in assessment, uncontrolled pain, or change in level of consciousness.)

Your interpretation of what is happening to the patient would fall in what category of SBAR?

• Situation
• Background
• Assessment
• Recommendation -ANS_ C (The assessment part of SBAR includes telling the health

care provider what you think the problem is.)

A nurse calls the health care provider for their patient and suggests that an EKG be ordered for the patient. Which part of SBAR does this represent?

• Situation
• Background
• Assessment

• Recommendation -ANS_ D (Recommendation involves suggesting/requesting that

the HCP order certain tests, a change in the patient's treatment, a higher level of care is needed (Ex. referral to a specialist) and asking the HCP is they have any questions for you or if they need any other information.)

The nurse asks a newly admitted client, "What can we do to help you?" What is the purpose of this therapeutic communication technique?

• To reframe the client's thoughts about mental health treatment
• To put the client at ease
• To explore a subject, idea, experience, or relationship
• To communicate that the nurse is listening to the conversation -ANS_ C (This is an

example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.)

Which nursing statement is a good example of the therapeutic communication technique of focusing?

• "Describe one of the best things that happened to you this week."
• "I'm having a difficult time understanding what you mean."
• "Your counseling session is in 30 minutes. I'll stay with you until then."
• "You mentioned your relationship with your father. Let's discuss that further." -ANS_

D (This is an example of the therapeutic communication technique of focusing.Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another.)

During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns?

• "Don't worry. Everything will be alright."
• "You appear uptight."
• "I notice you have bitten your nails to the quick."
• "You are jumping to conclusions." -ANS_ A (This nursing statement is an example of

the nontherapeutic communication block of belittling feelings. Belittling feelings occur when the nurse misjudges the degree of the client's discomfort, thus a lack of empathy and understanding may be conveyed.)

A client on an inpatient psychiatric unit tells the nurse, "I should have died because I am totally worthless." In order to encourage the client to continue talking about feelings, which should be the nurse's initial response?

• "How would your family feel if you died?"
• "You feel worthless now, but that can change with time."
• "You've been feeling sad and alone for some time now?"

• "It is great that you have come in for help." -ANS_ C (This nursing statement is an

example of the therapeutic communication technique of reflection. When reflection is used, questions and feelings are referred back to the client so that they may be recognized and accepted.)

Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations?

• "My sister has the same diagnosis as you and she also hears voices."
• "I understand that the voices seem real to you, but I do not hear any voices."
• "Why not turn up the radio so that the voices are muted."
• "I wouldn't worry about these voices. The medication will make them disappear." -

ANS_ B (This is an example of the therapeutic communication technique of presenting reality. Presenting reality is when the client has a misperception of the environment. The nurse defines reality or indicates his or her perception of the situation for the client.)

A mother rescues two of her four children from a house fire. In the emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response?

• "The smoke was too thick. You couldn't have gone back in."
• "You're feeling guilty because you weren't able to save your children."
• "Focus on the fact that you could have lost all four of your children."
• "It's best if you try not to think about what happened. Try to move on." -ANS_ B (The

best response by the nurse is, "You're experiencing feelings of guilt because you weren't able to save your children." This response utilizes the therapeutic communication technique of reflection which identifies a client's emotional response and reflects these feelings back to the client so that they may be recognized and accepted.)

Which of the following are examples of objective data? (Select all that apply.)

• When asked to report their pain on a scale from 0 to 10, the patient reports a 6.
• The patient's liver is non palpable.
• The patient's scalp is round, symmetrical, and no bumps or lumps are present.
• The patient has had frequent headaches for the past few weeks.
• The patient's tympanic membrane is a pearly/gray white. -ANS_ B C E

The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient?

• On the patient's strong side
• On the patient's weak side
• Behind the patient
• In front of the patient -ANS_ B

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up?

• "I will be sure to put nonskid slippers on the patient before getting him up to

ambulate."

• "I will use the under-axillae technique to help him up to a standing position."
• "Rocking the heavier patient into a standing position seems to work really well for

me."

• "I will grasp the gait belt in the middle of the patient's back." -ANS_ B

The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk?

• Ask the patient how far she would like to go.
• Review the health care provider's order.
• Review the medical record to see how far the patient has walked during the past

several therapeutic ambulations.

• Review the records of other patients who are at a similar point in their stroke

rehabilitation. -ANS_ A (Setting mutual goals increases the likelihood of success in achieving the goal of ambulation. The health care provider's order will only state "ambulate"; it will not specify how far to ambulate the patient. The patient's circumstances or condition may not be similar to those he or she undertook during the past several ambulations. Patient care should be individualized. The status of other patients in stroke rehabilitation is not relevant to this patient.)

The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do?

• Return the patient to the bed or chair (whichever is closer).
• Encourage the patient to complete the distance of ambulation.
• Help him to the restroom.
• Ease him to the floor. -ANS_ A

The nurse has applied a gait belt to a postoperative patient to facilitate ambulation.Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response?

• Slowly lower the patient to the floor.
• Attempt to sit the patient down on a chair just a few steps away.
• Try to hold the patient up until the dizziness passes.
• Call for assistance in a loud but calm voice. -ANS_ A

The nurse is preparing to provide perineal care for a female patient who is on bed rest.Which patient position should the nurse use for this care?