NR-222 Health and Wellness - Set 3 - Part 2

Correct Answer: Demonstrate and request a return demonstration

Inhaler technique is a physical skill, and skills are built by watching a demonstration, practicing, and then performing without help. Return demonstration is the only method that proves the client can do it. Option a is incorrect because printed steps support recall but leave the two most common errors invisible. A client can follow the sheet and still fail to exhale first or inhale far too fast. Option b is incorrect because group discussion suits attitudes and shared experience. Talking about inhalers with other clients may normalize the diagnosis, but it puts no device in this client's hand before tomorrow. Option c is incorrect because a recorded lecture delivers facts in one direction only. Hearing the steps described builds knowledge about the device while leaving the coordination of breath and actuation entirely untrained.

Correct Answer: Use a curious tone and invite explanation

Tone can reverse a sentence's meaning, turning curiosity into accusation. Asking what made the cannula uncomfortable, in an even and interested voice, gets the same information without pushing the client into defending himself. Option b is incorrect because added firmness deepens the very reaction the nurse is trying to undo. A client who already feels accused will say less, not more, when pressed harder. Option c is incorrect because charting the event and calling the provider may both be needed later. Neither one repairs the exchange at the bedside or uncovers why the cannula came off. Option d is incorrect because more explanation answers a knowledge gap the stem never describes. The client withdrew because of how he was spoken to, and additional teaching does not touch that.

Correct Answer: Declining the request keeps the relationship professional.

Professional guidance is consistent: nurses do not friend, follow, or accept requests from clients on personal accounts. The boundary protects both parties, and the nurse carries responsibility for maintaining it. Option a is incorrect because the risk is not limited to what gets typed about his care. A personal account exposes the nurse's life to a client and converts a professional relationship into a social one. Option c is incorrect because this does not turn on local policy. Nursing and professional organizations set the same expectation everywhere, so checking with a manager suggests the answer might change. Option d is incorrect because waiting for discharge does not erase the power difference that existed during care. Continuing contact afterward for the nurse's own benefit is one of the recognized warning signs of drift.

Correct Answer: Paraphrasing, condensing it in different words

Paraphrasing restates a long message in the nurse's own words, condensed, so the client hears the essence and can confirm or correct it. It also shows the nurse is working to understand. Option a is incorrect because restating repeats the client's key words back almost exactly, as in saying you could not sleep at all last night. The nurse here chose different wording. Option b is incorrect because no emotion was named in the nurse's sentence. A reflection would have said something like, you sound worn out by all of this, which puts a feeling into words. Option d is incorrect because clarifying admits confusion and asks for an example or a rephrasing. The nurse understood perfectly well and demonstrated it, rather than requesting help with a vague statement.

Correct Answer: State the concern again and escalate if unheard

The two challenge rule requires the concern to be voiced at least twice, with explicit support the second time. If it is still not acknowledged, the nurse escalates up the chain of command and withholds the dose. Option a is incorrect because accountability for administering a medication does not transfer to whoever wrote the order. A nurse who gives a dose she believes is unsafe owns that decision. Option b is incorrect because withholding without speaking leaves the client with no insulin and the provider unaware of any problem. Silence at this point creates a second safety gap rather than closing one. Option c is incorrect because charting a worry does not protect the person receiving the drug. Documentation records what happened; it never substitutes for stopping an action the nurse judges dangerous.

Correct Answer: The man next door lost both of his legs.

Comparing his loss to someone worse off belittles the feeling and tells him he had no business mentioning it. Feelings are accepted rather than measured against another client's situation. Option b is incorrect because repeating his own word and inviting elaboration is a therapeutic restatement. Nothing in it judges him or ends the topic, so no correction is needed. Option c is incorrect because sharing an observation neutrally is the technique of choice with a withdrawn client. It opens a conversation without interrogation and gives him an easy way in. Option d is incorrect because acknowledging the weight of what he said and asking about his day keeps him at the center. That combination of empathy and an open question needs no intervention.

Correct Answer: An aide rearranged the bedside table without telling her

Moving a client's belongings without telling her removes her ability to find anything and creates a fall risk. Furniture and personal items stay where they were unless the client is told and agrees. Option a is incorrect because announcing entry by name is exactly what the client needs, since she cannot see who has come in. The matching rule is to say when you are leaving. Option b is incorrect because orienting her to the room, the bathroom, and the call light supports independence and safety. Describing the environment aloud replaces the information her eyes would ordinarily supply. Option d is incorrect because naming food positions by the face of a clock is a standard technique that lets her eat without hunting. It is helpful practice rather than something to correct.

Correct Answer: The client may have limited health literacy

Blank forms, an excuse about glasses, and identifying pills by color are classic concealment cues. The nurse responds by switching to plain language, pictures, and teach-back rather than naming the problem aloud. Option a is incorrect because refusal looks like a client who declines and says so. Reading this pattern as uncooperative labels a man who is protecting himself from embarrassment and closes off the real fix. Option b is incorrect because forgotten glasses is one of the standard cover stories, repeated so often that it functions as a signal. An eye appointment would leave the underlying reading difficulty in place. Option c is incorrect because three separate warning signs appeared within a single admission. Concluding that comprehension is fine would send this client home with written instructions nobody has confirmed he can use.

Correct Answer: Stop the infusion and remove the catheter

The rule that assessment comes first has limits, and this stem already supplies the findings. Redness, swelling, and pain at an infusing site call for stopping the fluid and taking the catheter out. Option a is incorrect because waiting lets more fluid enter inflamed tissue. An hour of continued infusion can turn a manageable problem into significant tissue damage, and nothing is gained by the delay. Option c is incorrect because more questions add nothing to what the nurse can already see and feel. Gathering data is right when the picture is incomplete, and here the picture is complete. Option d is incorrect because charting is required but belongs after the harm has been stopped. Writing a careful note while the solution keeps running leaves the client worse off than before.

Correct Answer: I am concerned this assignment is not safe.

Assertive communication states the nurse's own position directly and respectfully, and it is built on I statements. Declining or questioning an unsafe assignment this way is a professional obligation, not insubordination. Option b is incorrect because an accusation built around the word always attacks the other person. Aggressive wording may win the moment, then leaves resentment that damages how the team works. Option c is incorrect because agreeing while believing the load is unsafe is passive. Needs go unspoken, the workload stands, and the client who suffers is whoever gets the least attention. Option d is incorrect because that kind of surrender hands the decision away and hides the nurse's real judgment. Said with an edge, it also slides into the sarcasm typical of passive aggressive replies.

Correct Answer: Your leg is stronger than it was three weeks ago.

Genuine hope is anchored in something real about this client and never promises an outcome. Naming the measurable strength he has gained gives him a truthful reason to keep working without guaranteeing that he will walk. Option a is incorrect because no one can promise that recovery. If he does not regain walking, he will remember that his nurse was wrong, and the trust built so far collapses. Option b is incorrect because instructing a client to change his attitude dismisses the fear he just voiced. Being told to stay positive teaches him that discouragement is not something to mention here. Option c is incorrect because a sweeping claim about everyone is a cliche that treats him as a generic case. It also states something no unit can guarantee about every person who arrives.

Correct Answer: Recheck the blood pressure manually

Validation belongs to assessment, and any value that is unexpected or inconsistent gets confirmed before it drives a decision. A rechecked pressure prevents one bad number from reshaping the whole plan. Option a is incorrect because calling on unverified data risks orders built on an error. The client is alert and without symptoms, so there is time to confirm the value before involving the provider. Option b is incorrect because repositioning treats hypotension that has not been established. Intervening on a single questionable reading also removes the chance to learn whether the cuff or the technique caused it. Option d is incorrect because charting a suspect value without confirming it plants an error in the record. Every later comparison, and possibly a medication decision, would then rest on that number.

Correct Answer: Sit quietly with her and remain present

Silence and presence are the strongest interventions during grief. Staying without filling the space lets her think and feel at her own pace, and the nurse's steady presence communicates more than any sentence would. Option a is incorrect because procedural detail is exactly what a person in acute grief cannot absorb. Those arrangements matter, but they belong to a later conversation once the first wave passes. Option c is incorrect because a referral, however well meant, moves the nurse toward the door. Spiritual support can be offered soon; leaving to arrange it now abandons her in the worst minutes. Option d is incorrect because crying is a healthy release rather than a problem to be stopped. Asking her to contain it tells her the feeling is unwelcome and that she should manage it alone.

Correct Answer: Set the goals together with the client

Motivation is internal, and active participation is what brings it out. An adult who helps choose the goal owns it, while a plan handed down produces compliance that fades once supervision ends. Option b is incorrect because a ready-made plan leaves the client a passive recipient. It also ignores everything she learned from the diets she has already tried, which is the richest material an adult brings. Option c is incorrect because fear-based warnings tend to raise anxiety without raising engagement. Personalized risk information has a place, but leading with consequences rarely builds the internal drive this client needs. Option d is incorrect because assigning a number puts the nurse in charge of a decision the client has to live with daily. Adults resist direction they had no part in shaping and quietly drop it.

Correct Answer: A collaborative problem the team manages

A collaborative problem is a physiological complication the nurse watches for and the team treats together. The nurse monitors and acts on protocol while the provider prescribes what happens next. Option a is incorrect because nurses do not assign disease labels. Recognizing that a complication could develop is nursing judgment about risk, and it never converts into authority to diagnose the condition. Option b is incorrect because it names an action rather than the problem being addressed. Monitoring is indeed something the nurse starts without an order, but the question asks what the concern itself is called. Option d is incorrect because an outcome states the result the client should achieve by a set time. Nothing here describes a target for the client; it describes a complication the team is watching.

Correct Answer: The client's own description of the pain

The client is the best source of assessment data. Only he can describe what the burning feels like, and family, the chart, and other staff are all secondary sources for a symptom. Option b is incorrect because a spouse can describe what she observes but cannot feel his leg. Her account is secondhand and useful only when the client himself cannot communicate. Option c is incorrect because the admission history was written before this pain started. A record captures an earlier moment, so it cannot tell the nurse anything about a symptom that appeared today. Option d is incorrect because another nurse's note passes the client's words through a second person. Going to the source removes that filter, which matters most when the data are subjective.

Correct Answer: I will sit here with you until they come.

Offering self makes the nurse available without conditions and without demanding conversation. It tells a frightened client she is worth someone's time, which is often the only useful thing during a wait. Option a is incorrect because a time estimate is useful information but not an offer of presence. The nurse can give both, though this sentence alone still leaves the client sitting by herself. Option c is incorrect because telling a frightened person to rest is advice she cannot follow. It also implies her fear is a behavior to manage rather than something worth talking about. Option d is incorrect because no one yet knows how the scan will read. Promising a good result is false reassurance, and it will cost the nurse her credibility if the news is bad.

Correct Answer: You said that, but you do not sound convinced.

Metacommunication is the message about the message, carried by tone, expression, and timing. Naming the mismatch between her agreeable words and her flat, downcast delivery invites her to say what she actually thinks. Option a is incorrect because vouching for the surgeon answers only the surface sentence and quietly takes his side. The client is left with a doubt she has now been discouraged from voicing. Option b is incorrect because her questions were already covered, so this returns to information she has. What she is signaling is feeling, not a gap in knowledge about the operation. Option c is incorrect because labeling the emotion for her assumes nervousness when the flat tone may carry resentment or resignation. A generic reassurance also closes the topic before she describes it.

Correct Answer: Connotative meaning attached to the word

Connotative meaning is the personal or emotional shading a word carries for an individual. In everyday speech positive signals good news, so the client heard encouragement where the clinician meant an abnormal finding. Option b is incorrect because denotation is the literal dictionary sense that every speaker of a language shares. If both parties had used that shared sense, no misunderstanding would have occurred at all. Option c is incorrect because metacommunication is the message underneath the words, telling the listener how to take them. Here the confusion sits in one word itself, not in the relationship being signaled. Option d is incorrect because paralanguage covers sighs, moans, groans, and other vocal sounds that accompany speech. No such sound is described, and the client's error came from vocabulary alone.

Correct Answer: "How will I know if I am bleeding too much?"

A client who asks a specific question about the medication has turned attention toward the topic. Questions are the clearest signal that the client is willing and available to learn right now. Option a is incorrect because handing the task to a daughter deflects the teaching to someone else. It may also hint at low health literacy, and either way the client has not stepped toward the content. Option c is incorrect because that sentence is a refusal, and it usually reflects grief or fear rather than stubbornness. The nurse acknowledges the feeling, teaches only what cannot wait, and returns later. Option d is incorrect because putting off the reading is one of the classic ways clients conceal trouble with written material. Postponement of that kind calls for plain language and teach-back, not a stack of paper.