Fundamentals of Nursing Ch 20 PrepU
and NCLEX
All of the victims got themselves out of the car?" - Paramedics arrive in the emergency
department with a victim of a motor vehicle collision. The paramedic reports the driver was
restrained, the car was traveling about 30 miles per hour, and the air bags were not deployed.
The paramedic continues to report the car was struck from behind and that all individuals in the
car were able to self-extricate. Which statement made by the nurse is verifying the report from
the paramedic?
"Can you tell me why your physician sent you here to be admitted?" - During an admission
intake assessment, a nurse uses open-ended questions to gather information. An example of an
open-ended question is:
"Do you have any questions about your cholecystectomy?" - The newly hired nurse is collecting
assessment data for an upcoming surgical procedure from a client who speaks English as a
second language. Which statement made by the newly hired nurse would indicate to the nurse
educator that intervention is needed?
"Have you ever thought of laser surgery?" - A nurse is discussing cataract treatment with a
client. Which statement by the nurse would be most therapeutic?
"I know this is hard for you. Is there any way I can help?" - A nurse is caring for a client who is
newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client
sitting in the dark crying. Which of the following statements conveys empathy on part of the
nurse?
"Sir, I understand this is uncomfortable but I assure you I am experienced with this task and
would like to continue." - A client comes into the urgent care center to have sutures removed on
his right arm. The nurse assesses the sutures and finds significant crusting along the suture
, line. The client indicates he didn't have time to get his sutures removed a week prior as
directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts
the suture removal, the client frequently pulls his arm away and tells the nurse, "you do not
know what you are doing." In response, the nurse should answer:
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and
will help you hold your position." - A client is scheduled for thoracentesis. The nurse assesses
that the client appears anxious about the procedure and needs honest support and
reassurance. What is the most appropriate response by the nurse to this client?
"This must be very difficult for you to hear. How do you feel right now?" - A nurse has developed
strong rapport with the wife of a client who has been receiving rehabilitation following a
debilitating stroke. The wife has just been informed that her husband will be unlikely to return
home and will require care that can only be provided in a facility with constant nursing care. The
client's wife tells the nurse, "I can't believe it's come to this." How should the nurse best
respond?
"Were you tired and depressed before starting the new medication?" - A client with a cardiac
dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the
cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to
exercise." To determine a cause-and-effect relationship, the nurse should ask:
"What questions do you have about the surgery?" - A client scheduled to have hip replacement
surgery states, "I am so scared of the surgery and of the anesthetic." What is the best response
by the nurse?
"Why did the health care provider prescribe this medication for you?" - The nurse faculty is
observing a student nurse gather data from a client. Which question, if asked by the student,
would indicate to the faculty that the student has a clear understanding of open-ended
questions?
• "Cheer up. Tomorrow is another day."
• "Your doctor knows best."
• "Don't worry. You will be just fine in another day or two."
and NCLEX
All of the victims got themselves out of the car?" - Paramedics arrive in the emergency
department with a victim of a motor vehicle collision. The paramedic reports the driver was
restrained, the car was traveling about 30 miles per hour, and the air bags were not deployed.
The paramedic continues to report the car was struck from behind and that all individuals in the
car were able to self-extricate. Which statement made by the nurse is verifying the report from
the paramedic?
"Can you tell me why your physician sent you here to be admitted?" - During an admission
intake assessment, a nurse uses open-ended questions to gather information. An example of an
open-ended question is:
"Do you have any questions about your cholecystectomy?" - The newly hired nurse is collecting
assessment data for an upcoming surgical procedure from a client who speaks English as a
second language. Which statement made by the newly hired nurse would indicate to the nurse
educator that intervention is needed?
"Have you ever thought of laser surgery?" - A nurse is discussing cataract treatment with a
client. Which statement by the nurse would be most therapeutic?
"I know this is hard for you. Is there any way I can help?" - A nurse is caring for a client who is
newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client
sitting in the dark crying. Which of the following statements conveys empathy on part of the
nurse?
"Sir, I understand this is uncomfortable but I assure you I am experienced with this task and
would like to continue." - A client comes into the urgent care center to have sutures removed on
his right arm. The nurse assesses the sutures and finds significant crusting along the suture
, line. The client indicates he didn't have time to get his sutures removed a week prior as
directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts
the suture removal, the client frequently pulls his arm away and tells the nurse, "you do not
know what you are doing." In response, the nurse should answer:
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and
will help you hold your position." - A client is scheduled for thoracentesis. The nurse assesses
that the client appears anxious about the procedure and needs honest support and
reassurance. What is the most appropriate response by the nurse to this client?
"This must be very difficult for you to hear. How do you feel right now?" - A nurse has developed
strong rapport with the wife of a client who has been receiving rehabilitation following a
debilitating stroke. The wife has just been informed that her husband will be unlikely to return
home and will require care that can only be provided in a facility with constant nursing care. The
client's wife tells the nurse, "I can't believe it's come to this." How should the nurse best
respond?
"Were you tired and depressed before starting the new medication?" - A client with a cardiac
dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the
cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to
exercise." To determine a cause-and-effect relationship, the nurse should ask:
"What questions do you have about the surgery?" - A client scheduled to have hip replacement
surgery states, "I am so scared of the surgery and of the anesthetic." What is the best response
by the nurse?
"Why did the health care provider prescribe this medication for you?" - The nurse faculty is
observing a student nurse gather data from a client. Which question, if asked by the student,
would indicate to the faculty that the student has a clear understanding of open-ended
questions?
• "Cheer up. Tomorrow is another day."
• "Your doctor knows best."
• "Don't worry. You will be just fine in another day or two."
