Nursing Fundamentals

Which question asked by the nurse is an example of open-ended questions?

"How has your health been?" Explanation: Open-ended questions prompt clients to describe a situation in more than one or two words. It includes asking the client about her or his health in general. Closed-ended questions require the clients to provide answers in one or two words. It includes asking the client about the pain at the moment. It may also include asking about medication that suits the client. Rating pain on a scale from 0 to 10 is a closed-ended question.

Which information would the nurse provide a nursing student about nursing malpractice? Select all that apply. One, some, or all responses may be correct.

"Includes willful acts that violate a client's rights" "Takes place when nursing care falls below the standards of care" "May be prevented by developing a caring rapport with the client" "May occur even when the nurses do not intend to harm the clients" Explanation: Nursing malpractice is also known as professional negligence. This takes place if the nursing care provided to the client falls below the expected standards of care. The nurse may avoid malpractice by developing a caring rapport with the client and communicating about treatment plans and tests. Nursing malpractice may take place even when nurses do not intend to harm clients but are unable to maintain proper standards of care. Nursing malpractice is an unintentional tort. Intentional torts are willful acts that violate a person's rights. Publishing false statements to damage a person's reputation is called defamation of character.

Which statement by the nurse reflects understanding of therapeutic communication with a client experiencing domestic violence? Select all that apply. One, some, or all responses may be correct.

"Tell me about your struggles." Explanation: "Tell me about your struggles," is therapeutic communication, as it encourages a client to describe their perception. Talking about feelings can help clients clarify their thoughts. "Everything is going to be okay" is falsely reassuring and underrates the client's feelings; it would be better to clarify the client's message. "Get out of the house right away" gives premature advice and assumes that the nurse knows best; it would be better to encourage the client to problem-solve. "You'll feel better after you leave" minimizes the client's feelings and indicates that the nurse is unable to empathize; the nurse would attempt to empathize and explore. "Why do you stay when he hits you?" is a value judgment that prevents problem-solving. The nurse would instead make observations. "Why did you return to him after the abuse?" implies criticism and may make the client defensive. The nurse would ask open-ended questions to avoid this.

Which are examples of invasion of privacy? Select all that apply. One, some, or all responses may be correct.

"The nurse states in a press conference that a famous singer is suffering from throat cancer." "A woman's husband has been informed by the nurse that she has had a miscarriage without consulting with the client." "The parents of a 19-year-old are told by the nurse that their child is addicted to drugs without waiting for consent." Explanation: All medical information of clients is confidential and would not be revealed to unauthorized personnel; a violation of this confidentiality is considered to be an invasion of privacy. Revealing information about a client's illness to media personnel is considered to be invasion of privacy. The nurse would not inform the client's husband about the miscarriage without consulting with the client. In addition, divulging information about an adult client's drug abuse to his or her parents without consent is an invasion of privacy. Informing the primary health care provider about the client's illness without waiting for the client's consent is not considered to be an invasion of privacy, because the information is being shared for the purpose of medical treatment. Entering false information in the client's electronic health recording may damage the reputation of the client. This is considered to be libel.

personal space (proxemics)

0-18" Intimate 18'-4ft Personal 4 ft-12ft Socio connotative 12ft public space

The registered nurse (RN) is teaching a nursing student about the skills to build a helping relationship with the client. Arrange the events of the helping relationship in chronological order.

1. Planning enough time for the initial interaction 2. Assessing the client's health status 3. Providing the information needed to understand and change behavior t4.Achieving a smooth transition for the client to other caregivers as needed Explanation: The first phase of the helping relationship is the pre-interaction phase, which involves planning enough time for the initial interaction. The second phase is the orientation phase, which involves the assessment of the client's health status. The third phase is the working phase, which involves giving the client information to understand and change his or her behavior. The fourth phase is the termination phase, which involves the achievement of a smooth transition to other caregivers as needed.

Misdomeanor

A minor crime usually punished by a short jail term and/or a fine.

State Board of Nursing

A state board of nursing holds the legal authority for nursing practice and regulates nursing practice through: Establishing the requirements to obtain a nursing license Issuing nursing licenses Determining the scope of practice Setting minimum education standards Managing disciplinary procedures

Malpractice

A type of negligence by a professional. criteria Nurse owned a duty of care to pt Nurse breached that duty Pt was injured as a result State law "make the person whole" May be intentional or unintentional Involves failure to follow standard of care

Libel

A written defamation of a person's character, reputation, business, or property rights.

Negligence

Conduct that falls below the generally accepted standard of care of a reasonably prudent person. Ex. hanging a wrong IV bag resulting in a physically harmed pt. Dispensary action by The state board of nursing and employer and lawsuit results.

Which are the core roles for an advanced practice registered nurse (APRN)? Select all that apply.

APN (advanced practice nurse).... Nurse practitioner (DSN) (NP) Clinical nurse specialist (CNS) Certified nurse midwife (CNM) Certified registered nurse anesthetist (CRNA)

ACEN

Accreditation Commission for Education in Nursing accredits all nursing programs and is the gatekeeper for Title IV **Federal Funds for all types of programs VOLUNTARY

Battery

Any intentional offensive touching without intent of lawful justification.

How would the nurse prepare a factual record when performing client documentation?

By recording descriptive and objective information of what he or she sees, hears, feels, and smells Explanation: A factual record contains descriptive and objective information about what the nurse sees, hears, feels, and smells. An organized record communicates the information in a logical order. The use of exact measurements establishes accuracy. The nurse prepares a complete record by providing a comprehensive record that includes all essential information.

How would the nurse incorporate the quality of accuracy into client documentation?

By using exact measurements for each client's activity Explanation: The use of exact measurements establishes accuracy. The nurse follows the principle of organization by communicating the information in a logical order. The nurse incorporates the guideline of completion by providing a complete and appropriate record with all the essential information. A factual record contains descriptive and objective information about what the nurse sees, hears, feels, and smells.

The nurse is gathering a client's health history. Which information would the nurse classify as biographical information? Select all that apply. One, some, or all responses may be correct.

Client's age Type of insurance Occupation status Explanation: Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

Which program is an example of a continuing education program?

Correct1 A program on caring for the elderly with dementia offered by a university. Explanation The program on caring for the elderly with dementia offered by a university is an example of a continuing education program. Such programs are formal, organized educational programs offered by universities, hospitals, or professional nursing organizations. An in-service education program is held in the institution or health care agency to increase the competencies of the nurses employed there. The programs on culturally sensitive approaches in health care, use of computers, and safe principles for administering chemotherapy are in-service educational programs.

Which describes the purpose of the Nurse Practice Acts?

Correct1 Describe and define the legal boundaries of nursing practice within each state Explanation: The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.

The nurse's coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. Which response by the nurse would be correct?

Decline to discuss the friend's medical condition.

ANA Code of Ethics for Nurses

Describes the most fundamental values and commitments of the nurse; boundaries of duty and loyalty; and aspects of duties beyond individual patient encounters •Accountability •Responsibility •Confidentiality •Veracity (Truthfulness)

Which statements have been correctly stated about Nightingale's theory of nursing? Select all that apply. One, some, or all responses may be correct.

Focus of nursing is caring through the environment Oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition Focuses on helping the client deal with the symptoms and changes in function related to an illness Explanation: Nightingale's theory of nursing focuses on nursing by caring through the environment. Nightingale's theory is oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Nightingale's theory focuses on helping the client deal with the symptoms and changes in function related to an illness. Nightingale's theory does not limit nursing to the administration of medications and treatment. Nightingale's theory suggests that nurses do not need to know all about the disease process, which differentiates nursing from medicine.

Which of these is an ethical issue related to the long-term care setting? Select all that apply. One, some, or all responses may be correct.

Guardianship Power of attorney Advance directives Responsible party designation Do-not-resuscitate (DNR) orders Adherence to a patient's bill of rights Explanation: Resident rights are a universal priority in all long-term care settings. Guardianship, power of attorney, advance directives, responsible party designation, do-not-resuscitate orders, and adherence to a patient's bill of rights are all ethical issues related to the long-term care setting.

Assault

Intentional threat made against a person that places them in reasonable fear or harmful imminent unwelcomed contact.

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?

Making eye contact with the client Explanation: The nurse would make eye contact with the client to show interest in starting a conversation with a client with hearing loss. Smiling while seeing the client would help build a positive relationship. Nodding in front of the client helps regulate the conversation. Leaning forward towards the client shows attention and awareness.

Which client assessment finding would the nurse document as subjective data?

Pain rating of 5 Explanation: Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing intervention?

Sitting quietly with the client Explanation: Sitting quietly with the client conveys the message that the nurse cares and accepts the client's feelings; this helps establish trust. Telling the client that crying is not helpful negates feelings and the client's right to cry when upset. Distraction (suggesting that the client play a board game) closes the door on further communication of feelings. After a trusting relationship has been established, the nurse can help the client explore the problem in more depth.

In the orientation phase, the nurse and the client meet and get to know each other. Which actions would the nurse follow in this phase? Select all that apply. One, some, or all responses may be correct.

Prioritizing the client's problems Clarifying the client's and nurse's roles Encouraging and helping the client with self-exploration Explanation: In the orientation phase, the nurse and the client meet and get to know each other. During this phase, the nurse prioritizes the client's problems and clarifies the client's and the nurse's roles. In the termination phase, the nurse evaluates goal achievement with the client. In the working phase, the nurse encourages and helps clients set goals and take action to meet those goals.

Which statement best describes the nurse's role as an advocate?

Protects the client's human and legal rights and helps assert these rights Explanation: The nurse's role as advocate is to protect the client's human and legal rights and provide assistance in asserting these rights if the need arises. The nurse acts on behalf of the client. The role of caregiver is to help the client maintain and regain health, manage disease and symptoms, and attain a maximal level of function and independence through the healing process. The role of educator is carried out by explaining concepts and facts about health, describing reasons for routine care activities, demonstrating procedures such as self-injections, reinforcing learning or client behavior, and evaluating the client's progress in learning. The role of manager involves establishing an environment for collaborative client-centered care to provide safe, quality care with positive client outcomes.

Which therapeutic communication technique would be useful for a client with major depressive disorder? Select all that apply. One, some, or all responses may be correct.

Reflecting Offering self Using silence Paraphrasing Asking open-ended questions Encouraging comparison Explanation: Reflection helps clients better understand their own thoughts and feelings. Offering self means the nurse demonstrates interest and desire to understand. Silence gives clients time to collect their thoughts. Paraphrasing means to restate the basic content of a client's message in different, usually fewer, words. The nurse may confirm an interpretation of the client's message by using simple, precise, and culturally relevant terms, before the interview continues. Open-ended questions encourage clients to share information about experiences. Encouraging comparison brings out recurring themes and helps clients clarify similarities and differences. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.

Slander

The action or crime of making a false spoken statement damaging to a person's reputation.

NLNAC (National League for Nursing Accrediting Commission)

Voluntary -

Which consideration would the nurse make when obtaining an informed consent from a 17-year-old?

Whether the client is allowed to give consent Explanation A person is legally unable to sign a consent until the age of 18 or 19 years (depending on individual state or provincial laws) unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.

Felony

a crime, typically one involving violence, regarded as more serious than a misdemeanor, and usually punishable by imprisonment for more than one year or by death.

American Association of Nursing (ANA)

•Describes "official" standards of professional performance •Sets "Standards of Practice" for general and specialized nursing practices (Each state looks to these standards to write their own Scope of Practice) •Describes a competent level of behavior in role as a professional •Maintains a "Code of Ethics" (Each state looks at these to create their own Code of Ethics)