Basic nursing skills-Communication, interview, recording and reporting
Time: 15:00
A nurse is interviewing a new patient. Which of the following is an example of an open-ended question?
[a] "Are you in pain right now?"
[b] "Have you taken your blood pressure medication today?"
[c] "What can you tell me about the symptoms you've been having?"
[d] "Is your pain level a 7 out of 10?"
When documenting a patient's chief complaint during an admission interview, the nurse should:
[a] Restate the complaint using precise medical terminology.
[b] Summarize the complaint based on the admitting diagnosis.
[c] Ask a family member to state the reason for the visit.
[d] Record the patient's statement exactly as it was stated, using quotation marks.
Which action is a violation of patient confidentiality under HIPAA regulations?
[a] Giving a hand-off report to the oncoming nurse at the bedside.
[b] Discussing a patient's diagnosis with a colleague in the hospital cafeteria.
[c] Calling a patient's lab results to their primary care provider's office.
[d] Using a password-protected computer to access the patient's record.
A patient is scheduled for a surgical procedure tomorrow and says, "I'm worried about the surgery." Which response by the nurse is non-therapeutic?
[a] "Tell me more about what is worrying you."
[b] "Don't worry, you have the best surgeon and everything will be fine."
[c] "It's normal to feel worried before surgery."
[d] "I'll sit with you for a while."
When giving a hand-off report using the SBAR format, what information does the nurse provide under "A" for Assessment?
[a] The patient's admitting diagnosis and past medical history.
[b] What the nurse believes needs to be done for the patient.
[c] The situation that is currently happening with the patient.
[d] The nurse's clinical conclusion based on the current data (e.g., vital signs, lab results).
Which of the following is considered subjective data obtained during a patient interview?
[a] Blood pressure reading of 140/90 mmHg.
[b] A heart rate of 92 beats per minute.
[c] The patient's report of feeling nauseous.
[d] A red rash observed on the patient's arm.
A nurse says to a patient, "So, if I understand you correctly, you are saying that the pain gets worse when you walk." This is an example of which therapeutic communication technique?
[a] Providing information.
[b] Giving recognition.
[c] Clarifying or paraphrasing.
[d] Focusing.
A nurse makes an error while documenting on a paper record. What is the correct procedure for fixing the mistake?
[a] Erase the error completely or use correction fluid.
[b] Black out the entry with a marker and write "error" next to it.
[c] Draw a single line through the error, write "mistaken entry," and add the nurse's initials.
[d] Rewrite the entire note on a new page and discard the original.
The "working phase" of the patient interview is when the nurse:
[a] Reviews the medical record before entering the room.
[b] Gathers subjective and objective data for the health history.
[c] Summarizes the key points and asks if the patient has questions.
[d] Introduces themselves and explains the purpose of the interview.
Which statement is an example of objective documentation?
[a] "Patient appears to be anxious this morning."
[b] "Patient's abdominal wound is 5 cm in length with clean, dry edges."
[c] "Patient's family seems unconcerned about the diagnosis."
[d] "Patient had a good day and tolerated the diet well."
Using silence during a patient interview is a therapeutic technique primarily because it allows the patient to:
[a] End the conversation if they are uncomfortable.
[b] Recognize that the nurse is busy.
[c] Ask the nurse for personal advice.
[d] Organize their thoughts and provide more complete information.
In which situation would it be most appropriate for a nurse to use closed-ended questions?
[a] When exploring the patient's feelings about their illness.
[b] At the beginning of the interview to build rapport.
[c] In an emergency situation when specific information is needed quickly.
[d] When trying to understand the patient's cultural background.
The legal principle "if it was not documented, it was not done" highlights the importance of:
[a] Using only approved medical abbreviations.
[b] Timely, accurate, and comprehensive charting.
[c] Giving a thorough verbal report.
[d] Keeping the patient's medical record secure.
A patient is grimacing, guarding their abdomen, and has a tense body posture. These observations are examples of what type of communication?
[a] Verbal.
[b] Therapeutic.
[c] Intrapersonal.
[d] Non-verbal.
What is the primary goal of the introductory phase of the patient interview?
[a] To obtain the patient's vital signs.
[b] To conduct the physical examination.
[c] To establish rapport and explain the nurse's role.
[d] To summarize the patient's health concerns.
In a SOAP documentation format, which information would be recorded under "S"?
[a] The patient's temperature is 101.2°F (38.4°C).
[b] The nursing plan is to administer antipyretics and monitor temperature.
[c] The patient states, "I have a headache and I feel achy all over."
[d] The patient is diaphoretic and flushed.
A nurse showing empathy towards a patient who has just received a poor prognosis would say:
[a] "I know exactly how you feel; my father went through the same thing."
[b] "You should get a second opinion."
[c] "This must be a very difficult and scary time for you."
[d] "Let's look on the bright side, at least there are treatments available."
Which question is a leading question and should be avoided during a patient interview?
[a] "How many alcoholic drinks do you have in a typical week?"
[b] "You don't have any thoughts of harming yourself, do you?"
[c] "Can you describe the location of your pain?"
[d] "When did your symptoms first start?"
The primary purpose of a verbal shift-to-shift report is to:
[a] Allow nurses to socialize with their colleagues.
[b] Fulfill a legal requirement for hospital accreditation.
[c] Ensure continuity of care and patient safety between shifts.
[d] Provide a time for nurses to complain about their workload.
When communicating with an older adult who is hearing-impaired, the nurse should:
[a] Over-articulate words and shout loudly.
[b] Face the patient directly and speak clearly in a normal tone of voice.
[c] Reduce communication to only essential medical information.
[d] Write everything down to avoid having to speak.
An ideal environment for conducting a patient health interview would be:
[a] In the hallway where it is easy to access equipment.
[b] In the waiting room with the patient's family present for support.
[c] At the main nurses' station for easy access to the chart.
[d] In a private, quiet room with the door closed.
Which of the following documentation entries is unacceptable because it is too vague?
[a] "Patient ambulated 50 feet in the hallway with steady gait."
[b] "Administered 650 mg acetaminophen PO for headache."
[c] "Voided 350 mL clear, yellow urine."
[d] "Patient appears to be in a better mood today."
The main purpose of the summary phase of the patient interview is to:
[a] Perform the physical assessment.
[b] Gather new information about the patient's family history.
[c] Verify the accuracy of the information collected and allow for patient questions.
[d] Establish the nurse's authority and control over the interview.
Timeliness in charting is critical because:
[a] It prevents nurses from having to do all their charting at the end of the shift.
[b] It communicates the most current patient information to the entire health care team.
[c] It is the only way to ensure the patient is billed correctly.
[d] It helps nurses remember what they did during the shift.
A patient states, "I'm so upset, I don't know what to do." The nurse's best initial response to encourage the patient to elaborate would be:
[a] "Here is a pamphlet that might help you."
[b] "I recommend that you talk to your family."
[c] "Why are you so upset?"
[d] "It sounds like you're feeling overwhelmed. Tell me more about it."
No comments: