The nurse is preparing a teaching plan for a client who is learning to use the incentive spirometer. The nurse identifies the following action as part of the evaluation step in the teaching plan.

Assess the clients pain level

Ask the client to demonstrate use of the incentive spirometer

Develop a short-term goal for the client

Provide instructions on how to use the incentive spirometer

Answer and Explanation

The Correct Answer is B

A. Assess the client's pain level: Assessing the client's pain level is part of the assessment step, not the evaluation step.
B. Ask the client to demonstrate use of the incentive spirometer: Asking the client to demonstrate use of the incentive spirometer is a way to evaluate whether the client has understood and can perform the skill.
C. Develop a short-term goal for the client: Developing a short-term goal is part of the planning step, not the evaluation step.
D. Provide instructions on how to use the incentive spirometer: Providing instructions is part of the implementation step, not the evaluation step.

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Correct Answer is C

Explanation

A. "I think you should talk with your family about your anger." This response shifts the focus to action without first exploring the client's feelings, which may not be therapeutic initially.
B. "You are probably very depressed, which is understandable with such a diagnosis." This response labels the client's emotions and may not be helpful in allowing the client to explore their feelings further.
C. "Tell me more about how you are feeling." This response uses therapeutic communication by encouraging the client to express feelings and concerns, providing emotional support and validation.
D. "Why haven't you shared your feelings with your family?" This response can sound accusatory and may not encourage open communication.

A. "The vital signs are stable" B. "The client has a history of high blood pressure" C. "The client is disoriented. Pupils are slow to respond to light." D. "The client should be seen by a neurologist."

Correct Answer is C

Explanation

A. "The vital signs are stable." This statement belongs in the Assessment (A) step, as it provides information about the client’s current clinical condition.
B. "The client has a history of high blood pressure." This statement belongs in the Background (B) step, providing relevant medical history.
C. "The client is disoriented. Pupils are slow to respond to light." The S (Situation) step involves stating the immediate problem or reason for the communication. Describing the client's disorientation and pupil response directly addresses the current issue that prompted the call.
D. "The client should be seen by a neurologist." This statement belongs in the Recommendation (R) step, suggesting the next course of action.

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The nurse is preparing a teaching plan for a client who is learning to use the incentive spirometer. The nurse identifies the following action as part of the evaluation step in the teaching plan.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with terminal cancer says to the nurse "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?

Correct Answer is C

Explanation

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the S step?

Correct Answer is C

Explanation

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