Quiz #2 Patient communication/education, physical assessment

Inspection, Olfaction, Auscultation, Palpation, Percussion

5 Skills of Physical Assessment

1. cultural factor

A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request? 1. cultural factor 2. developmental factor 3. environmental factor 4. physiological factor

Metacomunication

A message within a message that conveys a sender's attitude toward the self and toward the listener

3) Rectal temperature of 101 F

A nurse concludes that a patient is experiencing pyrexia. Which assessment precipitated this conclusion?1) Mental confusion 2) Increased appetite 3) Rectal temperature of 101 F 4) Heart rate of 50 beats per minute

1. I'm glad you decided to continue your fitness routine

A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes.Which of the following statements by the nurse is an example of the use of affirmation. 1. I'm glad you decided to continue your fitness routine 2. You could achieve better results if you applied yourself more 3. You are adjusting well for your age 4. Reducing your caffeine intake is good, but you really need to stop completely

A. Capillary refill less than 3 seconds D. Thick skin on the soles of feet E. Numerous macules on the face darker than surrounding skin color

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of feet E. Numerous macules on the face darker than surrounding skin color

C. Resonance E. Bronchovesicular sounds

A nurse in a provider's office is preparing to auscultate and percus a client's thorax as part of the comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

2. Use an alternative method for determining the client's pain level

A nurse in the PACU is determining if a client has pain. The client is drowsy and opens the eyes to verbal stimuli but is unable to communicate their pain level. Which of the following action should the nurse take? 1. Administer an antagonist to reverse effects of anesthesia 2. Use an alternative method for determining the client's pain level 3. Administer medication for severe pain 4. Wait until the client is awake, alert, and able to vocalize pain level.

B. Skin color C.Edema E.Skin temperature

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test on which of the following? (Select all that apply) A. Range of motion B. Skin color C.Edema D.Skin lesions E.Skin temperature

1. Ensure the room is well lit

A nurse is assisting with the planning of a presentation about skincare for a group of older adults at a senior center. Which of the following actions should the nurse recommend to enhance client learning? 1. Ensure the room is well lit 2. Have soft music playing in the background 3. Hand out examples of products during teaching 4. SPeak quickly during teaching

1. psychosocial factors 3. situational factors

A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking and explains that he works two jobs to support their family. The client also states "I don't know how I'm going to have time for dialysis. Which of the following factors is influencing the client's communication? (select all that apply) 1. psychosocial factors 2. cognitive factors 3. situational factors 4. environmental factors 5. physiological factors

restating

A nurse is caring for a client who has refused to have a biopsy. The client states" I don't need a biopsy; I wouldn't do anything about it anyway if it's cancer". The nurse replies, "You don't want to have a biopsy because you would not seek treatment if it was cancer. Is that correct?. Which of the following therapeutic communication techniques is the nurse using? 1. affirmation 2. open-ended question 3. reflection 4. restating

c. "Your daily routines will be different when you get home". d."Tell me about the support system you'll have after you leave the hospital.' e. "It sounds like you are not sure how having a colostomy will affect swimming.'

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (select all that apply) a."You will do great! You just have to get used to it" b. "Why are you worried about going home? c. "Your daily routines will be different when you get home". d."Tell me about the support system you'll have after you leave the hospital.' e. "It sounds like you are not sure how having a colostomy will affect swimming.'

b. reflecting

A nurse is caring for a client who states, " I have to check with my partner and see if they think I am ready to go home". The nurse replies," How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?a. pacing b. reflecting c. paraphrasing d. restating

4. Speak to the client clearly and at a slow pace

A nurse is caring for a patient with dementia. Which of the following therapeutic communication should the nurse implement to communicate? 1. Explain the daily schedule to the client in detail 2. Turn the overhead lights on the client's room when speaking with them 3. Speak in a loud voice to clients 4. Speak to the client clearly and at a slow pace

b. sit at eye level with the child

A nurse is caring for a school-age child who is sitting in a chair.To faccilitate effective communication, which of the following actions should the nurse take? a. Touch the child's arm b. sit at eye level with the child c. Stand facing the child d. Stand with a relaxed posture

1. Move the client to a quiet area or private room 2. speak at a slower pace 6. Avoid using medical terminology

A nurse is collecting data from a client who was admitted for surgery. The client tells the nurse they have hearing loss and forgot to bring their hearing device. Which of the following actions should the nurse take to improve communication with the client? (select all that apply) 1. Move the client to a quiet area or private room 2. speak at a slower pace 3. delay collecting data until client's family bring hearing aid 4. have a sign language interpreter translate 5. Stand next to the client while talking 6. Avoid using medical terminology

Explotation

A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship? 1. Identification 2.Orientation 3. Explotation 4.Resolutiion

4. the client has a BMI within the expected reference range

A nurse is performing a general client survey and finds that the client has a body mass (BMI) of 23. Which of the following should the nurse document .1. The client has no nutritional issues or deficits 2. The client is at high risk for obesity-related health problems 3. The client will need a referral to a dietitian 4. the client has a BMI within the expected reference range

2. Kyphosis

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? 1. Lordosis 2. kyphosis 3.ankylosis 4.scoliosis

D.Herpes simplex E.Varicella

A nurse is performing a skin assessment on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply) A. Acne B.Warts C.Psoriasis D.Herpes simplex E.Varicella

4. Balance

A nurse is performing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following? 1. gait 2. hearing 3. vision 4. balance

Ensure the client is wearing their glasses

A nurse is planning to reinforce teaching with a client about wound care. Which of the following actions should the nurse take? 1. Use medical terminology while reinforcing teaching 2. Sit across from the client at a table in the cafeteria while reinforcing teaching 3. Ensure the client is wearing their glasses 4. Use the communication technique of probing.

1. verbal 2.written 4.nonbervak

A nurse is planning to reinforce teaching with new assistive personnel (AP) how to use a bedside glucose monitor. The nurse will include a 30-minute face to face lecture and a written copy of the step by step procedure. Which of the following is the nurse teaching plan?(select all that apply) 1. verbal 2.written 3.electronic 4.nonbervak 5.assertive

2. "respect the client during the conversation"' 4. "allow time for reflection during the conversation with the client" 5." show empathy during the conversation with client"

A nurse is preparing to reinforce education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply) 1." interrupt the client occasionally during the conversation' 2. "respect the client during the conversation" 3. "Use complex terms when explaining with the client" 4. "allow time for reflection during the conversation with the client" 5." show empathy during the conversation with client"

Channel

A nurse is reinforcing discharge instructions with a client during a follow-up telephone call. Based on Shanon-Weaver communication model, which of the following component of the model is the nurse demonstrating? 1. Reciever 2. Sender 3. Channel 4. Decoder

2. Schedule a face to face unit staff meeting

A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use? 1. Send an email to staff via the facility's email system 2. Schedule a face to face unit staff meeting 3. Place a copy of the policy on the bulletin board in the hallway 4. Leave a voicemail on each staff's member's phone

Palpation

A nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse?

I am unable to send the instructions due to HIPPA privacy

A nurse recieves a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make? 1. The nurse manager will need to email the discharge instructions to you' 2. I am unable to send the instructions due to HIPPA privacy 3. You will need to ask your provider to email discharge instructions 4. Sending instructions is a violation of affordable Care Act

D. A familiar object the nurses places in the hand

A nurse, who is assessing a client's neurologic system, should ask the client to close their eyes and identify which of the following items? A. A word the nurse whispers 30 cm from the ear B.A number the nurse traces on the palm of the hand C. The vibration of a tuning fork the nurse places on the foot D. A familiar object the nurses places in the hand

4. • Poor skin turgor

A patient complains of thirst and headache. The patient appears emaciated. On initial examination, you find that the skin does not return to normal shape. This finding is consistent with] 1• Pallor. 2• Edema. 3• Erythema 4. • Poor skin turgor

4.Be unable to speak or write

A patient in a rehabilitation facility has experienced a cerebrovascular accident (CVA/stroke) that has left the patient with an expressive aphasia. The nurse anticipates that this patient will: 1.Respond inappropriately to questions 2.Be unable to follow directions 3.Have difficulty interpreting words and phrases 4.Be unable to speak or write

4.Marked edema

A patient is admitted to a medical center with a peripheral vascular problem. A nurse is performing the initial assessment of the patient. While assessing the lower extremities, the nurse is alert to venous insufficiency as indicated by: 1.Coolness to touchThin' 2. shiny skin 3.Dusky red coloration 4.Marked edema

B. Rhonchi.

A patient is admitted with pneumonia. When auscultating the patient's chest, you hear low-pitched, continuous sounds over the bronchi. These sounds are labeled as A. Crackles. B. Rhonchi. C. Wheezes. D. Pleural rub.

1.spider angiomas 3.red, dry areas- 5.burns on the fingers

A patient is suspected of substance abuse. What physical findings would be found on the skin? Select all that apply. 1.spider angiomasir 2.regularly shaped moles 3.red, dry areas 4.hematomas 5.burns on the fingers 6.loss of pigment

Clarifying

A patient says to the nurse, "I was hurting so bad that I called my husband at work. He works at a school as a teacher, so it was hard to get a hold of him. The pain is just so overwhelming." The nurse responds by saying, "Are you saying the pain is unbearable?" Which therapeutic technique did the nurse use? 1. Summarizing 2. Reflecting 3. Clarifying 4. Using open-ended question

Availability

A patient tells a nurse that he feels anxious and afraid. The nurse responds by saying, "I will stay here with you." The nurse is using the principle of effective communication known as: 1. Encouragement 2. Empathy 3. Courtesy 4. Availability

Identifies that there are no people under the bed

A patient tells a nurse that there are other people in the room that are watching her from under the bed. The nurse employs therapeutic communication when he or she: 1. Tells the patient that he or she will help look for the other people 2. Asks the patient why other people are watching her 3. Reassures the patient that he or she will tell the people to go away 4. Identifies that there are no people under the bed

A. some basic knowledge about the illness.

A patient who is ready for enhanced knowledge will have: A. some basic knowledge about the illness. B. little to no knowledge about the disease process. C. just received their diagnosis. D. advanced knowledge of their illness.

C. Assess the oxygen saturation.

A postoperative patient is breathing rapidly. You should immediately A. Call the physician. B. Count the respirations. C. Assess the oxygen saturation. D. Ask the patient if he feels uncomfortable.

assertive

Acting with confidence and force; sure of one's self

Patient

As the nurse walks into a patient's room, the patient states, "Where is my medication?" The nurse replies, "It is not time for your medications." According to the communication process, which component of this scenario is the sender? 1. Patient 2. Nurse 3. "Where is my medication?" 4. "It is not time for your medications."

Aorta, Pulmonic, Erb's, Tricuspid and Mitral

Cardiac Auscultation sites

Phantom Pain

Define the type of pain perceived in a missing limb or a paralyzed body part.

Therapeutic communication

Development of a working, functional relationship by the nurse with the patient, fulfilling the purposes of the nursing process

B.Closure of mitral valve D. apical heat rate

During a cardiovascular examination, a nurse in a provider's office places the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate?(Select all that apply) A.Ventricular gallop B.Closure of mitral valve C.closure of the pulmonic valve D. apical heat rate

C. Flatus

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at the midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

Cultural or religious beliefs or practices

Factors That Affect Learning, Environment, Comfort, Readiness, Language, Senses, _____________

Feedback

Indicates whether the meaning of the sender's message was received

message

Information sent or expressed by the sender

channel

Means of conveying messages

Reciever

Person to whom the message is sent

Sender

Person who initiates interpersonal communication

Sebder, Information, Receiver, Feedback

Place the sequence of the communication process in the correct order. 1 Receiver 2 Information 3 Sender 4 Feedback

Avoiding Bias

Remain open and relaxed Be sensitive while still obtaining factual information that you need

Must remain confidential

Shift report should be __________________________

appropriate data

Shift reports also should include Basic patient data, Special safety issues, Sensory deficits, Scheduled procedures, Pertinent diagnostic results, Assistive equipment, Prosthetic devices, these are cosider to be __________________

d. touching

Someone who has a kinesthetic learning preference would likely prefer to learn by: A. seeing. B. hearing. C. watching. D. touching.

1. Downward 3. Job instructions

The LPN/LVN tells the unlicensed assistive personnel to have a patient's complete bed bath done by 0900 and to report any skin problems. Which types of communication did the nurse use? Select all that apply. 1. Downward 2. Upward 3. Job instructions 4. Aggressive 5. Job rationale

B. False

The normal pulse rate for adolescents and adults ranges from 60 to 110 beats/min. • A. True • B False

Trust

The nurse is beginning care with a patient who was just admitted with a stroke. What is essential for the nurse to develop in the nurse-patient relationship? 1. Humor 2. Trust 3. Encouragement 4. Intellect

Announce when entering the room.

The nurse is caring for a patient who had eye surgery and has patches over both eyes. Which action should the nurse take? 1. Avoid body language. 2. Speak in a loud voice. 3. Quietly slip out the door. 4. Announce when entering the room.

4. The patient will not look at the surgery site.

The nurse is caring for a patient who had surgery for the placement of a colostomy. The nurse is planning to review colostomy care with a patient. Which situation is most likely to interfere with learning? 1. The patient voices the need for a nap. 2. The patient's pain is a level 5 on a 0 to 10 scale. 3. The patient's roommate has visitors. 4. The patient will not look at the surgery site.

closed-ended

The nurse is collecting data from a patient about specific information to contribute to the health history. Which type of questions should the nurse use to obtain this data? 1. Closed-ended 2. Open-ended 3. Nondirective 4. Health literacy

She has stable vital signs.

The nurse is giving report about a transgender patient. On the chart, the patient's legal name is shown as Shawn, but the patient prefers the name Lisa. Which information should the nurse share in a report to the oncoming shift? 1. He was admitted with chest pain. 2. Shawn does not like orange juice. 3. She has stable vital signs. 4. His mother is in the room.

"Patient care is not getting completed for your assigned patients. What is happening?"

The nurse is having problems getting the unlicensed assistive personnel to complete assigned tasks. Which communication technique would the nurse use? 1. "Tasks are not getting completed. Why are you so lazy?" 2. "You have been working here for over 6 months. I don't understand your lack of organizational skills." 3. "Patient care is not getting completed for your assigned patients. What is happening?" 4. "Stop wasting time. Try to get the rest of your work done on time."

Opening

The nurse is interviewing a patient and states, "I will be asking you questions about nausea and vomiting you have been having." This represents which stage of the interview process? 1. Opening 2. Closing 3. Body 4. Structure

Explaining the care plan for a family member who is in the hospital to the patient

The nurse is observing an unlicensed assistive personnel (UAP) who is caring for a comatose patient. Which action by the UAP would require the nurse to intervene? 1. Talking to the patient about the weather 2. Telling the patient that laboratory personnel is here to draw blood 3. Informing the visitors in the room that they can talk to the patient 4. Explaining the care plan for a family member who is in the hospital to the patient

2. Current pain assessment 3. Recent vital signs 4. Patient allergies

The nurse is preparing to notify the healthcare provider that a patient's pain is not relieved by the current pain medication. Which information should the nurse have available? Select all that apply. 1. Number of visitors in the room 2. Current pain assessment 3. Recent vital signs 4. Patient allergies 5. Type of insurance

2. Kinesthetic

The nurse is preparing to reinforce previous teaching activities. The patient states, "Just show me what I need to know. I get bored watching videos and reading pamphlets." Which learning style does the nurse recognize for this patient? 1. Auditory 2. Kinesthetic 3. Passive 4. Visual

1. Patient compliance will increase with a greater understanding of and reasons for the treatment.

The nurse is preparing to reinforce teaching about the patient's diagnosis of obesity. In this session, the nurse will cover dietary restrictions and the effects of obesity on the body. For which reason will the nurse provide this reinforcement? 1. Patient compliance will increase with a greater understanding of and reasons for the treatment. 2. The patient is likely to be resistant to change, and reinforcement is necessary. 3. Most patients with this diagnosis feel helpless to change behaviors. 4. Reinforcement will prevent the patient from making excuses for their diagnosis.

1. A patient has a hearing deficit.

The nurse is preparing to review patient teaching with a patient. Which assessment finding is most likely to cause the nurse to modify the review process? 1. A patient has a hearing deficit 2. A patient is watching television. 3. A patient has visitors at their bedside. 4. A patient is preparing to take a shower.

Mr. Allan is having chest pain that is not relieved by medication.

The nurse is using the ISBARR to report a patient problem to the healthcare provider. Which information should the nurse include for the B? 1. Dr. Smith, this is Mary Jones, LPN, at Lakeview Hospital. 2. Mr. Allan is having chest pain that is not relieved by medication. 3. The patient's O2 sats are 86% and pulse is 54 and irregular. Skin is clammy. 4. Would you like an ECG done and cardiac enzymes drawn?

2. "The key to understanding and remembering information is repetition."

The nurse states, "I guess I will start reinforcing patient teaching now. I feel like I just say the same things over and over." Which reply by the nurse manager will promote correct patient teaching? 1. "The patient will become more interested if you keep saying something over and over." 2. "The key to understanding and remembering information is repetition." 3. "I understand, maybe you could switch information around to sound more interesting." 4. "Maybe it is time to give the patient printed material to be reviewed as desired."

4.Orthopnea

The patient needs to sit upright in order to breathe easier. This is recorded by the nurse as: 1.Tachypnea 2.Apnea 3.Dyspnea 4.Orthopnea

Innotation

The tone of the speaker's voice that may affect a message's meaning

Barriers

Therapeutic Communication techniques _________ are asking questions that would be answered with a " yes " or "no", Giving false reassurance, Asking too many personal questions, and Expressing disapproval.

written communication

These are consider to be _____________ Know your audience Identify the purpose K I S S: Keep It Short and Simple!

Therapeutic Communication Techniques

These are considerd _____________________ 1) ACTIVE LISTENING - Shows clients that they have your undivided attention 2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in their own way. Ask questions in a language that a client can understand 3) CLARIFYING - Questioning clients about specific details in greater depth or directing them toward relevant parts of the history. 4) SUMMARIZING - Validates the accuracy of the story.

Patient teaching

These are cosiderd to be _______________ To instruct patients on health promotion and wellness strategies To explain disease processes, treatments, and care

active listening

Uses all sense, Interprets verbal and nonverbal messages, Demonstrates you are interested in patient's feelings, concerns and needs. These are considerd _____________

lerning style

Visual, auditory, Kinesthetic

(barrel chest), breathe sounds, respiratory rate, color of skin

What are objective signs observed during a physical examination for lung assessment?

B. Direct percussion and indirect percussion

What are the two types of percussion? A. Temperature and pulse B. Direct percussion and indirect percussion C. Physical and visual D. Light percussion and deep percussion

-Speaking privately with adolescents about their concerns -providing time for children to play -performing the examination for an older adult to finish is as quickly as possible

What techniques are appropriate when assessing patients of different ages?

Reflection

When communicating with a patient, the patient says, "I don't think I can go through with this surgery." The nurse replies by stating, "You don't think you can go through with the surgery?"Which therapeutic communication technique did the nurse use? 1. Validation 2. Summarizing 3. Clarification 4. Reflection

2) 4 a.m. to 6 a.m.

When evaluating the vital signs of a group of patients the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at its lowest? 1) 4 p.m. to 6 p.m. 2) 4 a.m. to 6 a.m. 3) 8 p.m. to 10 p.m. 4) 8 a.m. to 10 a.m.

B. Consensual reflex

When pupils rapidly constrict simultaneously and equally, it is known as: A. Ptosis B. Consensual reflex C. Accommodation response D. Cheilitis

3.Annual mammograms

When teaching a 45-year-old patient in the gynecologist's office about breast cancer, a nurse includes information on recommendations for screening. The patient is informed that a woman her age should have: 1.Physical examinations every 3 years 2.Breast self-examinations every 3 months 3.Annual mammograms 4.Biannual CT scans

Turn off the television.

Which action should the nurse take to facilitate communication with a patient who wears a hearing aid?1. Use an interpreter. 2. Speak loudly into the good ear. 3. Turn off the television. 4. Leave the door open.

3) 65-year-old man with a respiratory rate of 10

Which assessment requires the nurse to assess the patient further? 1)18-year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike 2) 50-year-old man with a BP of 112/60 mm Hg on awakening in the morning 3) 65-year-old man with a respiratory rate of 10 4) 40-year-old woman with a pulse of 88

1.Lungs clear bilaterally with no cough. 2. Oh, I forgot, the blood pressure is continuing to rise. 4. Chest x-ray indicates tuberculosis. 5. The patient uses a walker.

Which information should the nurse include in a change-of-shift report? Select all that apply. 1. Lungs clear bilaterally with no cough. 2. Oh, I forgot, the blood pressure is continuing to rise. 3. You should see what the patient's mother is wearing. 4. Chest x-ray indicates tuberculosis. 5. The patient uses a walker.

A. Questions are open-ended

Which is characteristic of a nondirective interview? A. Questions are open-ended B. Structured to elicit specific data C. Time is limited D. Conducted to gain factual information

B. Assigns the aide to measure the VS for all the clients on the unit.

Which is the correct action when a busy nurse delegates tasks to a nursing aide? A. Asks the aide to watch/monitor a client because the client has been ill. B. Assigns the aide to measure the VS for all the clients on the unit. C. Requests that the aide take & document all of the VS for a the shift. D. Tells the aide to take VS & report any that seemunusual.

a. Use an open posture c. Establish and maintain eye contact e. Sit facing the client

Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (select all that apply) a. Use an open posture b. Write down what the client says to avoid forgetting details c. Establish and maintain eye contact d. Nod in agreement with the client throughout the conversation e. Sit facing the client

Encourage the client to communicate their thoughts and feelings

Which of the following strategies should a nurse use to establish a helping relationship with a client? a. Make sure the communication is equally distributed between the nurse's and client's desires b. Encourage the client to communicate their thoughts and feelings c. Give the nurse-client communication no time limits d. Allow communication to occur spontaneously throughout the nurse-client relationship

C. Connotative meaning

Which of the following terms refer to words that can elicit emotional responses, resulting in a message that is distorted and altered? A. Nonverbal communication B. Therapeutic communication C. Connotative meaning D. Shared meaning

Antipyretics

Which one of the following medications has the greatest potential to influence patient communication? 1. Diuretics 2. Antipsychotics 3. Anticholinergics 4. Antipyretics

1. "What is causing you the greatest concern at this time?" 2. "Tell me more about this pain you are having."

Which responses by the nurse would facilitate communication? Select all that apply. 1. "What is causing you the greatest concern at this time?" 2. "Tell me more about this pain you are having." 3. "Why did you do that?" 4. "I don't think you should divorce your spouse." 5. "It will be OK; my father had this surgery and did fine."

"I do not appreciate that kind of behavior."

Which statement would an assertive nurse use during patient care? 1."I do not appreciate that kind of behavior." 2."Do you think you could walk for me today?" 3."It doesn't matter what I do." 4." Who do you think you are talking to?"

Ask "Are you in pain?"

Which technique can the nurse use to facilitate communication with a patient on a ventilator? 1. Place the patient in a side-lying position. 2. Ask "Are you in pain?" 3. Speak softly into the good ear. 4. Stand in front of the patient.

2.Pin-point size, flat, red spots

While completing a physical examination, a nurse assesses and reports that a patient has petechiae. The nurse has found: 1.Thickness on the soles of the feet 2.Pin-point size, flat, red spots 3.Moles with regular edges 4.Light perspiration on the skin

Connotative

Words such as "love," "death," and "cancer" are emotionally charged; they can elicit emotional responses

D. Wait 30 minutes and take an oral temperature.

You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to A. Take a rectal temperature. B. Take the oral temperature as planned. C. Advise the patient to drink a glass of cold water. D. Wait 30 minutes and take an oral temperature.

2. Assessing the apical pulse rate for 1 full minute.

You notice that a teenager has an irregular pulse. The best action you should take includes 1. Reading the history and physical 2. Assessing the apical pulse rate for 1 full minute. 3. Auscultating for strength and depth of pulse 4. Asking whether the patient feels any palpitations or faintness of breath

petechiae

a small red or purple spot caused by bleeding into the skin.

orthopnea

ability to breathe only in an upright position

induration

abnormal hard spots

Rales, Ronchi and Wheezes

adventitious breath sounds

melena

black, tarry stools; feces containing digested blood

bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

Passive or avoidant

communication that avoids confrontation - unable to share feelings or needs with others

downward communication

communication that flows from higher to lower levels in an organization. Examples are • Job instruction' • Job rationale • Practices and procedures • Feedback • Role modeling

nonverbal communication

communication using body movements, gestures, and facial expressions rather than speech

hypoventilation

decreased rate or depth of air movement into the lungs

Dyspnea

difficult or labored breathing

-ptosis

drooping or falling of the upper eyelid

Factors that affect communication

environment, developmental variations, gender, personal space, territoriality, sociocultural factors, roles and relationships are _______________

kyphosis

excessive outward curvature of the spine, causing hunching of the back.

aggressive

hostile and unfriendly in the way one expresses oneself

Hyperventilation

increased rate and depth of breathing

upward communication

interaction with those in authority over you and is formal by nature • Written • Over the phone

I-SBARR

introduction, situation, background, assessment, recommendation, read back.

hypernea

labored, in depth and rate(greater than 20 and can occur normally during exercise)

alopecia

loss of hair

edema

puffy swelling of tissue from the accumulation of fluid

erythema

redness of the skin due to capillary dilation

Tachypnea

regular but abnormally rapid (greater than 20/min)

bradypnea

regular but abnormally slow (less than 12 breaths/min)

Verbal

spoken, using words

apnea

temporary cessation of breathing

denotative meaning

the literal meaning of a word. (Ex: The girl face is blue)

-smoking -a history of falls -a history of Cushing disease -a thin, light body frame

what are the risk factors associated with osteoporosis:

( Inspection- Palpation-Percussion-Auscultation)

what is the order of assessment technique