Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?

Interpersonal

Intrapersonal

Group

Small group

Answer and Explanation

The Correct Answer is A

A. Interpersonal: The nurse is engaging in interpersonal communication during the admission health history and physical assessment. This form of communication occurs between two individuals and involves a direct exchange of information, thoughts, and feelings. The nurse and the patient interact in a one-on-one setting to gather health information and build rapport.

B. Intrapersonal: Intrapersonal communication refers to communication that occurs within an individual, such as self-talk or internal dialogue. This is not the form of communication used during the nurse's interaction with the patient.

C. Group: Group communication involves interactions among multiple individuals, such as a discussion or meeting with several participants. This does not apply to the nurse's one-on-one interview with the patient.

D. Small group: Small group communication typically involves a few people discussing or working together on a task or topic. Although the nurse may participate in small group discussions, the specific interaction during the admission assessment is classified as interpersonal communication.

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Correct Answer is D

Explanation

A. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.

A. Obtain the provider's prescription renewal every 72 hr. B. Document restraint checks and client status every 2 hr. C. Implement passive range-of-motion exercises. D. Educate the client's family about restraint use. E. Release the restraint and reposition the client every 4 hr.

Correct Answer is ["A","B","C","D"]

Explanation

A. Obtain the provider's prescription renewal every 72 hr.: This is an essential intervention. Restraints must be prescribed by a provider and typically require renewal every 24 to 72 hours, depending on hospital policy and the client's needs. Continuous monitoring and justification for the use of restraints are necessary for ethical and legal compliance.

B. Document restraint checks and client status every 2 hr.: Regular documentation of restraint checks and the client’s status is vital for ensuring safety and monitoring for any potential complications, such as skin breakdown or circulatory issues. Frequent checks help ensure that restraints are being used appropriately and that the client’s needs are being met.

C. Implement passive range-of-motion exercises: Incorporating passive range-of-motion exercises is important for preventing joint stiffness, muscle atrophy, and promoting circulation in an immobile client. These exercises can help maintain some level of mobility and prevent complications associated with prolonged immobility.

D. Educate the client's family about restraint use: Providing education to the family about the rationale for using restraints, their purpose, and the monitoring process is essential for transparency and support. This helps the family understand the situation and the measures being taken to ensure the client’s safety.

E. Release the restraint and reposition the client every 4 hr.: This intervention is not sufficient, as restraints should typically be released more frequently, generally every 1 to 2 hours, to assess the client's condition, provide comfort, and allow for repositioning. Releasing restraints every 4 hours may increase the risk of complications and does not align with best practices for care.

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Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?

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