A nurse is observing a client’s nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?

Nonverbal communication conveys less truth than what the client states verbally.

The client enacts nonverbal communication consciously.

The client’s sociocultural background influences nonverbal communication.

Nonverbal communication is a poor reflection of what the client feels.

Answer and Explanation

The Correct Answer is C

Choice A reason:

The statement that nonverbal communication conveys less truth than what the client states verbally is incorrect. Nonverbal communication often conveys more truth than verbal communication because it includes body language, facial expressions, and other cues that can reveal a person’s true feelings and intentions. People may say one thing but their nonverbal cues can indicate something different.

Choice B reason:

The statement that the client enacts nonverbal communication consciously is not entirely accurate. While some nonverbal behaviors are conscious, many are subconscious and automatic. For example, facial expressions and body posture often occur without conscious thought and can provide genuine insights into a person’s emotions and state of mind.

Choice C reason:

The client’s sociocultural background influences nonverbal communication is correct. Different cultures have varying norms and interpretations for nonverbal behaviors. For instance, eye contact, gestures, and personal space can have different meanings across cultures. Understanding a client’s sociocultural background helps in accurately interpreting their nonverbal cues.

Choice D reason:

The statement that nonverbal communication is a poor reflection of what the client feels is incorrect. Nonverbal communication is often a very accurate reflection of a person’s feelings. It includes subtle cues like tone of voice, facial expressions, and body language, which can provide deeper insights into a person’s emotional state than words alone.

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Correct Answer is D

Explanation

Choice A reason:

Calling the lab to verify the client’s results is a reasonable step if there is any doubt about the accuracy of the lab results. However, in this scenario, the potassium level of 5.2 mEq/L is already documented, and the nurse should act on this information. Verifying the results would delay necessary actions and could potentially harm the patient if the high potassium level is not addressed promptly.

Choice B reason:

Omitting the KCL dose and documenting it as not given is a prudent action because administering potassium chloride to a patient with an elevated potassium level (5.2 mEq/L) could exacerbate hyperkalemia, which can lead to serious cardiac issues. However, this action alone is not sufficient. The nurse must also inform the prescribing physician to reassess the patient’s treatment plan.

Choice C reason:

Giving the ordered KCL as prescribed would be inappropriate in this situation. The patient’s potassium level is already elevated, and administering additional potassium could lead to hyperkalemia, which can cause dangerous cardiac arrhythmias or even cardiac arrest. Therefore, this option should be avoided.

Choice D reason:

Calling the prescribing physician and informing her of the client’s serum potassium level results is the most appropriate action. The physician needs to be aware of the elevated potassium level to make an informed decision about the patient’s treatment plan. The physician may decide to withhold the potassium chloride, order additional tests, or take other actions to manage the patient’s potassium levels safely.

A. Reinforce discharge teaching to clients. B. Instruct the assistive personnel (AP) to focus on clients’ ADLs. C. Stock additional unit supplies. D. Focus on providing care that prevents life-threatening emergencies.

Correct Answer is D

Explanation

Choice A reason: Reinforce discharge teaching to clients

While reinforcing discharge teaching is important, it is not the immediate priority during a disaster situation with limited staff. The focus should be on addressing urgent and life-threatening needs first. Discharge teaching can be addressed once the immediate crisis is managed and resources are more available.

Choice B reason: Instruct the assistive personnel (AP) to focus on clients’ ADLs

Instructing assistive personnel to focus on clients’ activities of daily living (ADLs) is important for maintaining basic care, but it is not the highest priority in a disaster situation. The primary focus should be on preventing life-threatening emergencies and ensuring the safety of all clients.

Choice C reason: Stock additional unit supplies

Stocking additional unit supplies is a proactive measure, but it is not the immediate priority during a disaster with limited staff. Ensuring that clients are safe and that life-threatening emergencies are prevented takes precedence over restocking supplies.

Choice D reason: Focus on providing care that prevents life-threatening emergencies

Focusing on providing care that prevents life-threatening emergencies is the highest priority in a disaster situation. With limited staff, it is crucial to prioritize interventions that ensure the immediate safety and well-being of clients. This includes monitoring for and addressing any critical changes in clients’ conditions and providing necessary emergency care.

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A nurse is observing a client’s nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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