Exam 2 Foundations
When determining priority setting, what is the second thing that takes priority?
Breathing
When determining priority setting, what is the third thing that takes priority?
Comparing
What happens to elderly patients as they age?
Everything slowly starts to decrease (eyes, ears, skin, taste)
What does the "A" stand for in SMART goals?
attainable
Which approach is used to determine the outcome of patient teaching? a. Entrusting b. Teach-back c. Reinforcing d. Telling
b
A nurse is caring for a client who fell at a nursing home. The client is oriented x3 and can follow directions Which of the following actions should the nurse take the decrease risk of another fall. (Select all that apply) a. Place a belt restraint on the client when they are sitting on the bedside commode b. Keep the bed in its lowest position with all the side rails up c. Make sure client's call light is within reach d. Provide the client with nonskid footwear e. Complete a fall risk assessment
c, d, e
What is receptive aphasia?
can't understand written or verbal speech
When we are doing patient teaching, what are the three ways that we teach them?
cognitive (thinking), affective (beliefs), psychomotor (tasks)
Promoting
things that are helping the patient learn
What are the four types of assessment?
1. Primary: from the source 2. Secondary: from someone else 3. Objective: observations 4. Subjective: what the patient says
What are the three categories of critical judgement?
1. Systematic 2. Changing 3. Dynamic
When determining priority setting, what is the first thing that takes priority?
Airway / Respirations
When determining priority setting, what is the fourth thing that takes priority?
Distractions (everything but restrain)
After a patient has had a stroke, what is the first adaptation you must make in their home?
Safe mobility and avoiding falling (go slow, take time to stand up straight before walking to check for dizziness, walk slowly and make sure there is no clutter in the way)
A nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing? a. Evaluation b. Implementation c. Analysis d. Planning
a
A nurse is caring for a client who has a new prescription for a medication. Prior to administering the medication, the nurses uses an electronic database to gather information about the medication. Which of the following components of critical thinking is the nurse using when he reviews this medication information? a. Knowledge b. Experience c. Intuition d. Competence
a
A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning? a. Ensure the room is well lit b. Have soft music playing in the background c. Hand out samples of products during the teaching d. Speak quickly during the teaching
a
A nurse is reviewing information about client education with a newly licensed nurse. Which of the following should the nurse include as the focus of client education? a. Empowering clients to be accountable for self-care b. Providing the client with disease oriented education c. Providing education only to the client to protect confidentiality d. Encouraging clients to let go of previous experiences
a
A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? Select all that apply. a. Find a mentor b. Use a journal to write about the outcomes of clinical judgements c. Review articles about evidence-based practice d. Limit consultations with other professionals involved in client's care e. Make quick decisions when unsure about client's needs
a, b, c
What happens during the implementation phase?
action, care for them
A nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an education session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? a. Cognitive b. Affective c. Psychomotor
b
A nurse is reviewing a client's plan of care. "The client will ambulate 20 feet using a walker" is the desired outcome. Which of the following aspects of the SMART goal should the nurse identify as missing from the outcome? a. Specific b. Timed c. Measurable d. Achievable
b
A charge nurse is planning to discuss factors that can influence the clinical decision making progress in client care with a newly licensed nurse. Which of the following factors should the charge nurse include? (Select all that apply). a. Appropriate delegation b. Cost of client care c. Available resources d. Awareness of client status e. Support from other staff
c, d, e
What are some things that can increase the likely-hood of a patient fall?
clutter, meds, decreased mobility, recent falls, age, elimination habits, decreased cognitive function, miscommunication
A nurse at an urgent care is a clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using? a. Evaluation b. Implementation c. Analysis d. Assessment
d
A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television which in at a loud volume. Which of the following actions should the nurse take? a. Leave a client's room to go check on other clients b. Ask the client why they are ignoring the question c. Repeat the question in a loud voice d. Lower the volume of the television
d
A nurse is teaching a client about how to perform daily blood pressure readings at home. Which of the following statements by the client is an example of the teach back method learning? a. "Show me again how to position the blood pressure cuff on my arm." b. "I have an electronic blood pressure machine at home that I will use." c. "I believe I can take my blood pressure successfully after talking through the steps." d. "Let me show you how I will take my blood pressure at home each day."
d
A nurse is teaching a group of newly licensed nurses about client education. Which of the following information should the nurse include in the teaching? a. Documentation of client education is not required for Joint Commission accreditation b. Client education does not change a client's views c. Client education does not influence the client's pain level d. Client education can improve self care at home
d
What does a black tag on a patient mean?
dead or too far gone
What are the two types of aphasia?
expressive (motor) and receptive (sensory)
What happens during the analysis / diagnosis phase?
figure out the problem, relevant vs. irrelevant, problem vs. potential problem, avoid judgement
Feedback Method
giving them words and description to help them do better next time, or telling them what they did good
Teachback Method
have the patient explain to us in their own words
What does a red tag on a patient mean?
immediate attention or life threatening
What are some examples of things that must be done when we are using critical thinking?
inference, intuition, creative, interpreting data
What does the "M" stand for in SMART goals?
measurable
What does a green tag on a patient mean?
minimal risk of injury
As nurses we are all teachers. What are some things we must think about to be effective teachers?
no distractions, is the information relevant, is the patient motived and ready to learn, is the information task centered
What does the "R" stand for in SMART goals?
realistic
What does a yellow tag on a patient mean?
serious condition but not life threatening
The communication SBAR is an acronym for what?
situation, background, assessment, recommendation
What does the "S" stand for in SMART goals?
specific
Hindering
things that are preventing the patient from learning
What does the "T" stand for in SMART goals?
timely
What is expressive aphasia?
understands written and verbal speech but cannot write or speak appropriately when attempting to communicate
What happens during the planning phase?
you prioritize what must be done first
What happens during the evaluation phase?
you think back on if you met your goal, if your plan worked, and the client's feedback
What are the steps of clinical judgement in a clinical setting?
1. Assessment 2. Diagnosis/Analysis 3. Planning 4. Implementation 5. Evaluation
What is tactile deficit?
The patient will be more sensitive to touch compared to others. Often their skin is more sensitive to every day things clothing textures and hair brushing. They may report that certain touch is painful. Autistic children and adults frequently report tactile defensiveness.
A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? a. "Critical thinking is the foundation for clinical decision making." b. "Critical thinking takes into consideration nursing, scientific, and technological knowledge in client situations." c. "Critical thinking is the visible or observed outcome while using evidence - based practice." d. "Critical thinking is necessary for the nurse to collect objective client data."
a
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all the apply). a. Fall history b. Medical diagnosis c. Use of assistive devices d. Mental Status d. Do not resuscitate status
a, b, c, d
A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing less and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the class? (Select all that apply). a. Move the client to a quiet area or private room b. Speak at a slower pace c. Delay the assessment until the client's family member brings the hearing aid d. Have a sign language interpreter translate the communication with the client e. Avoid using medical terminology
a, b, e
A nurse manager is reviewing with the nurses on the unit in the care of a client who has had a seizure. Which of the following statements by the nurse requires further education? a. I will place the client on their side b. I will go to the nurse's station to get assistance c. I will not the time the seizure begins d. I will prepare to insert airway
b
The nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique b. The client is able to demonstrate the appropriate technique c. The client states that he has an understanding of the process c. The client is able to write the steps on paper
b
A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion? (Select all apply) a. Inspection b. Implementation c. Inference d. Creativity e. Inductive Reasoning
c, d, e
A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client? a. Explain the daily schedule to the client in detail b. Turn the overhead lights on in the client's room when speaking with them c. Speak in a loud voice in the client d. Speak to the client clearly and at a slow pace
d
A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? a. Ask a staff member who speaks the same language as the client to interpret b. Ask a family member of the client to interpret the information c. Search the internet for an electronic application to use for translating d. Request assistance from the facility's interpreter
d
A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicated an understanding of home safety? a. An extension cord is secured under a rug b. The edges of stairs are marked with brightly colored c. A toaster is plugged in when not in use d. The water heater is set to 55 deg C (131 deg F).
b
A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the 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? a. Affirmation b. Open-ended question c. Reflection d. Restating
d
A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process? a. Evaluation b. Implementation c. Analysis d. Planning
d
In what order should an RN perform the steps of the nursing process? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation
