NR 222 EXAM 2 FULL SOLUTION STUDY GUIDE
◉ Preinteraction.
Answer: Planning and starting the preliminary nursing process
before the purposeful interaction with the person begins
◉ Working.
Answer: Mutual problem solving to accomplish therapeutic goals
◉ Termination.
Answer: Separating from the formal therapeutic relationship
◉ Situation.
Answer: Hello Dr. Jones: Your patient, Mr. Smith, is experiencing
chest pain and severe dyspnea.
◉ Background.
Answer: He was admitted to 6 South this morning following total
knee replacement (TKR) and his pulse is 140 and weak, respiration
are 50 and labored, with BP 108/56. He is extremely anxious and
appears bluish with clammy skin. 02 sat is 76%.
,◉ Assessment.
Answer: My assessment indicates that the patient is experiencing a
pulmonary embolism or cardiac event status post TKR.
◉ Recommendation.
Answer: Recommend starting 02 at 10 L/min, stat EKG, stat medical
consult, and further orders.
◉ Offering Self.
Answer: Making oneself available to clients in an unconditional
manner. Example: "I'll just sit with you for a while, whether or not
you would like to talk."
◉ Focusing.
Answer: Selecting a single topic or concept that the client has
expressed to explore further. Example: "Let's talk more about your
job."
◉ Broad Openings.
Answer: Allows the client to take the initiative in talking and
emphasizes his or her importance and control in the process.
Example: "What would you like to talk about today?"
◉ Reflecting.
,Answer: Referring questions or statements back to the client.
Example: "What do you think you should do about it?"
◉ Restating.
Answer: The content or main idea of what the client said is repeated
by the nurse, allowing the client to continue or correct perceptions.
Example: "You are concerned that this promotion may be beyond
your capabilities?"
◉ Voicing Doubt.
Answer: Expresses uncertainty about whether what the client has
said represents reality. Example: "Tell me more about how you see
these things happening today. I need to have a better understanding
of your perceptions."
◉ Presenting Reality.
Answer: The nurse defines reality or his or her perceptions in the
face of the client misconception of the environment. Example: "I
don't see anyone else in the room."
◉ Asking for Clarification.
Answer: Seeking the meaning of what has been said for mutual
understanding. Example: "Did I understand you correctly? That you
feel you may be fired because of your hospitalization?"
, ◉ Seeking Validation.
Answer: Similar to seeking clarification, the nurse confirms that
there is a mutual understanding of what the client has said.
Example: "Tell me if I understand what you have said."
◉ Summarizing.
Answer: Identifying key concepts for conclusion to the conversation
or development of an action plan. Example: "Today we have talked
about a plan for you to manage feelings of anger."
◉ Using Silence.
Answer: Demonstrates acceptance and allows the client an
opportunity to reflect on what has been said or to introduce
additional content. Example: Body language needs to be attentive
without dominating. Opportunities for reflecting on the
conversation are necessary. An uncomfortable period is therapeutic
to encourage the other person to expand on his or her thoughts.
◉ Making Observations.
Answer: Allowing the client to recognize his or her behaviors and to
compare the nurse's perceptions with the client's understanding.
Example: "You seem upset about something."
◉ Offering General Leads.
◉ Preinteraction.
Answer: Planning and starting the preliminary nursing process
before the purposeful interaction with the person begins
◉ Working.
Answer: Mutual problem solving to accomplish therapeutic goals
◉ Termination.
Answer: Separating from the formal therapeutic relationship
◉ Situation.
Answer: Hello Dr. Jones: Your patient, Mr. Smith, is experiencing
chest pain and severe dyspnea.
◉ Background.
Answer: He was admitted to 6 South this morning following total
knee replacement (TKR) and his pulse is 140 and weak, respiration
are 50 and labored, with BP 108/56. He is extremely anxious and
appears bluish with clammy skin. 02 sat is 76%.
,◉ Assessment.
Answer: My assessment indicates that the patient is experiencing a
pulmonary embolism or cardiac event status post TKR.
◉ Recommendation.
Answer: Recommend starting 02 at 10 L/min, stat EKG, stat medical
consult, and further orders.
◉ Offering Self.
Answer: Making oneself available to clients in an unconditional
manner. Example: "I'll just sit with you for a while, whether or not
you would like to talk."
◉ Focusing.
Answer: Selecting a single topic or concept that the client has
expressed to explore further. Example: "Let's talk more about your
job."
◉ Broad Openings.
Answer: Allows the client to take the initiative in talking and
emphasizes his or her importance and control in the process.
Example: "What would you like to talk about today?"
◉ Reflecting.
,Answer: Referring questions or statements back to the client.
Example: "What do you think you should do about it?"
◉ Restating.
Answer: The content or main idea of what the client said is repeated
by the nurse, allowing the client to continue or correct perceptions.
Example: "You are concerned that this promotion may be beyond
your capabilities?"
◉ Voicing Doubt.
Answer: Expresses uncertainty about whether what the client has
said represents reality. Example: "Tell me more about how you see
these things happening today. I need to have a better understanding
of your perceptions."
◉ Presenting Reality.
Answer: The nurse defines reality or his or her perceptions in the
face of the client misconception of the environment. Example: "I
don't see anyone else in the room."
◉ Asking for Clarification.
Answer: Seeking the meaning of what has been said for mutual
understanding. Example: "Did I understand you correctly? That you
feel you may be fired because of your hospitalization?"
, ◉ Seeking Validation.
Answer: Similar to seeking clarification, the nurse confirms that
there is a mutual understanding of what the client has said.
Example: "Tell me if I understand what you have said."
◉ Summarizing.
Answer: Identifying key concepts for conclusion to the conversation
or development of an action plan. Example: "Today we have talked
about a plan for you to manage feelings of anger."
◉ Using Silence.
Answer: Demonstrates acceptance and allows the client an
opportunity to reflect on what has been said or to introduce
additional content. Example: Body language needs to be attentive
without dominating. Opportunities for reflecting on the
conversation are necessary. An uncomfortable period is therapeutic
to encourage the other person to expand on his or her thoughts.
◉ Making Observations.
Answer: Allowing the client to recognize his or her behaviors and to
compare the nurse's perceptions with the client's understanding.
Example: "You seem upset about something."
◉ Offering General Leads.
