A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship?

1. Working phase
2. Preinteraction phase
3. Termination phase
4. Orientation phase

The nurse asks a patient, “Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview?

1. Orientation
2. Working phase
3. Data validation
4. Termination

Which of the following is represented by the letter " $\mathrm{S}$ " in the SOAP method of recording information in a patient's medical record?

A. surgical history

B. subjective impressions

C. self-assessment

D. socioeconomic status

E. signs and symptoms

Discriminate between normal and abnormal assessment findings identified by inspection, palpation, percussion, and auscultation of the respiratory system.

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of:

1. Collaborative data set.
2. Diagnostic label.
3. Related factors.
4. Data cluster.

During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.)

1. Collaboration between staff members from sending and receiving departments
2. Requiring that the patient visit the facility before a transfer is arranged
3. Using a standardized transfer policy and transfer tool
4. Arranging all patient transfers during the same time each day
5. Relying on family members to share information with the new facility

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings?

1. Activity Intolerance
2. Impaired Bed Mobility
3. Acute Pain
4. Risk for Falls

A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take?

1. Arrange for a Spanish-speaking social worker to explain the procedure
2. Ask a fellow Spanish-speaking patient to help explain the procedure
3. Use a professional interpreter to provide wound care education in Spanish
4. Ask the patient to write down questions that he or she has for the nurse

A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic?

1. “Why did you drive after you had been drinking?”
2. “We have multiple patients to see tonight as a result of this accident.”
3. “Tell me what happened before, during, and after the automobile accident tonight.”
4. “It will be okay. No one was seriously hurt in the accident.”

A pregnant patient reports to the nurse "I feel like my abdominal muscles are being stretched." Which criteria of the PQRST method of pain assessment does the patient's statement address?

A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication?

1. Include communication while performing tasks such as changing dressings and checking vital signs.
2. Ask the patient if you can talk during the last few minutes of visiting hours.
3. Ask Pastoral care to come back a little later in the day.
4. Remind the nurse to complete all her tasks and then set up remaining time for communication.

A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to “tell his story.” This is an example of which step of the nursing process?

1. Planning
2. Assessment
3. Intervention
4. Evaluation

What does a nurse do during the orientation phase of a helping relationship?