Communication in Nursing 8th Edition Test Bank

Correct Answer: A

Rationale: The correct answer is A. Maintaining eye contact by looking at the client during introductions shows respect by acknowledging the client as an individual and demonstrating active listening. This helps establish trust and rapport. Incorrect choices: B: Avoiding touch may be necessary for infection control, but it does not necessarily show respect for the client. C: Staying 4 to 6 feet away may be necessary for infection control, but it does not demonstrate respect or engagement with the client. D: Briefly conversing about the weather is a social nicety but may not convey the same level of respect and attentiveness as making eye contact.

Correct Answer: B

Rationale: The correct answer is B: restatement. Restatement involves repeating the patient's words to confirm understanding. In this scenario, the nurse echoed the patient's statement to show empathy and acknowledge the patient's feelings. This technique helps build rapport and fosters therapeutic communication. Explanation of why other choices are incorrect: A: Open-ended question: This involves encouraging the patient to elaborate on their feelings or experiences, not just repeating what the patient said. C: Reflection: This involves restating the patient's feelings to show understanding, not simply repeating their words. D: Offering self: This involves offering oneself to the patient for support, which was not demonstrated in the scenario.

Correct Answer: A

Rationale: The correct answer is A because pulsation of the tracheostomy tube in synchrony with the heartbeat indicates a potential risk of arterial bleeding, a serious complication that requires immediate intervention. This finding suggests that there may be a nearby major blood vessel that is pulsating due to arterial bleed. Immediate action is needed to prevent further bleeding and ensure patient safety. Choice B is incorrect because increased secretions in and around the tracheostomy, while concerning, do not represent an immediate life-threatening situation like arterial bleeding. Choice C is incorrect as increased coughing with difficulty in expectorating secretions could be indicative of respiratory issues but is not as urgent as arterial bleeding. Choice D is incorrect as the presence of food particles in tracheal secretions may indicate aspiration or improper swallowing, but it is not as immediately life-threatening as arterial bleeding.

Correct Answer: B

Rationale: The correct answer is B: Maintaining belief, being with, doing for, and enabling. Swanson's theory of caring includes these four processes along with "knowing." Maintaining belief refers to having faith in the patient's ability to get through the situation. Being with involves being present and showing emotional support. Doing for means providing physical care and assistance. Enabling focuses on empowering the patient to make decisions and take control of their health. Choice A is incorrect because it includes communication, assertiveness, and responsibility, which are not part of Swanson's caring processes. Choice C is incorrect as it includes understanding, action, information, and comfort, which do not align with Swanson's theory. Choice D is incorrect because it includes supporting, which is not one of the caring processes identified by Swanson.

Correct Answer: C

Rationale: The correct answer is C: Assess for McBurney sign. The McBurney sign is indicative of appendicitis and involves tenderness at McBurney's point in the right lower quadrant. This assessment is crucial for identifying possible appendicitis in a patient presenting with abdominal pain. Assessing for Cullen sign (A) involves bruising around the umbilicus and is associated with intra-abdominal bleeding, not appendicitis. Grey-Turner sign (B) refers to bruising on the flanks and is also indicative of intra-abdominal bleeding. Chvostek sign (D) is a clinical sign of facial muscle twitching and is associated with hypocalcemia. Therefore, assessing for McBurney sign is the most appropriate choice in this scenario to help diagnose appendicitis.