FOUNDATIONS OF NURSING Chapter 4: Communication, FON: Chapter 5 Nursing Process & Critical Thinking, Chapter 3: Documentation Quiz 6

DARE

uses the nursing process; it is not based on a problem list, but a modified list of nursing diagnosis.

personal space

18 in - 4 ft sitting and talking with a patient admission interview taking medical history.

Which statement by the student nurse best demonstrates knowledge of the nursing process when describing defining characteristics?

"Defining characteristics are factors such as signs and symptoms that support the nursing diagnosis"

Following orientation to the facility's computer system, which statement by the new nurse is most accurate?

"I can save on charting time once I am comfortable using this system."

The nursing preceptor is preparing to speak with the new LPN/LVN regarding documentation. Which statement by the preceptor is correct?

"It is important to use only approved medical terms and abbreviations when documenting in the electronic health record (EHR)."

Which phrases are most appropriate to use to connect the parts of a nursing diagnosis?

"Related to" and "as evidence by"

A patient comes to the nurses' station and demands to have his chart because he has decided to leave the hospital and seek care from a different facility. What is the best response?

"Sir, please wait ad I will call the nurse manager right now."

The patient asks the LPN/LVN if he can take his chart with him on discharge from the hospital. Which response by the nurse is most accurate?

"The chart is the property of the hospital, but if you need copies of your records, we can arrange that for you."

Which example includes all appropriate components of a risk for nursing diagnosis?

(Maslow's Hierarchy) 1. Risk for aspiration related to difficulty swallowing 2. Risk for ineffective airway clearance related to accumulation of mucus in trachea

The student nurse is correct in identifying which statement as objective data?

(Observed by the NURSE) 1. 4-cm transverse abdominal incision 2. B/P 178/90

Which statement is correct about formats for documentation?

-Charting by exception documents those conditions, interventions, or outcomes outside the norm -EHR systems allow for patient data to be shared for collaboration of care

VERBAL THERAPEUTIC COMMUNICATION TECHNIQUES

- CLOSED QUESTIONING - specific answer to specific questions (one or few word answers). - OPEN-ENDED QUESTIONING - allows patient to elaborate freely. Useful in assessing feelings, elicits patients thoughts without influencing the response. - RESTATING: repeating to the patient what the nurse believes to be the main point. tone rises slightly a he end of phrase. This lets the patient know whether the nurse heard what was said. - PARAPHRASING: restatement of the patient's message in the nurse's own words. Verifies hat the nurse's interpretation of the message is correct. - CLARIFYING: seek to understand the client's message by asking for more information or for elaborating on a point. expressed as a question or statement followed by a restatement or paraphrasing of part of he patient's message. Allows the patient t verify that the message received was accurate. - FOCUSING: the nurse encourages the patient to select one topic over another as the primary focus of discussion. Allows the nurse to gather more information when the patient 's message is too vague. Focuses on specific data. - REFLECTING: assist the patient to reflect on feelings and thoughts rather than seeking answers and advice from another. Promotes independence, decision making, allows the patient to see that their ideas and thoughts are important. - STATING OBSERVATIONS: sees an observation and communicates it back to the patient. Allows for clarification of the intended message hen verbal cues do not match nonverbal cues - OFFERING INFORMATION: provide patient with relevant data and asks for feedback to determine the patient's level of understanding. Useful in patient teaching. - SUMMARIZING: concise review of main ideas from a discussion. Focuses on key issues and allows for additional information that was perhaps omitted. Useful when interaction was lengthy or covered several topics

Guidelines for communicating with non-English speaking patients

- address question to the patient not the interpreter - avoid using children and relatives as interpreters - be aware that more time will be needed for interactions - give the patient and interpreter time alone together. - select the same age and gender interpreter - be aware of patient's non-verbal communication - determine whether there is a third language that you and the patient speak - pantomime - use picture boards

Nursing interventions for patients experiencing difficult verbally communicating

- determine language spoken, get dictionary, or interpreter - listen carefully and listen to verbal and nonverbal expression, particularly when dealing with pain - anticipate patients needs until effective - use simple communication, speak in well modulated voice., smile and show concern for the patient. - maintain eye contact at patient's level if culturally appropriate. - use touch as appropriate and if culturally appropriate. - spend time with the patient, allow time for responses, have call light available - explain all health care procedures - determine literary status - obtain communication equipment, electronic devices, paper pen, communication board - establish an alternative method of communication -

factors that affect communication

-Posturing and Positioning -Space and Territoriality -Environment -Level of Trust -Language Barriers -Culture -Age and Gender -Physiologic Factors -Psychosocial Factors

The nurse is preparing to document patient care. What data is most important for the nurse to include?

-Time of care -Type of procedure performed -Patient's pain level

Problem list

-active, inactive, potential, and resolved problems - care place with nursing diagnosis is developed for each problem by disciplined involved in care.

The nurse is being advised by an auditor about possible inadequate or inappropriate documentation that could be involved in a malpractice suit. What type(s) of documentation is/are likely to cause problems in malpractice cases?

-failed to document latex allergy -documented patient's complaint about care by using patient's remarks in quotes -charted medication that patient claims he did not receive -documented amount of IV fluid, but no assessment of IV site

Examples of inappropriate documentation

-not charting the correct time that events occurred or that an event occurred at all - failing to record verbal orders - charting nursing care in advance - documenting incorrect data

Which statement is correct about abbreviations?

-the nurse should be aware of any abbreviations on the "do not use" list -When in doubt, the nurse should use the complete word and not the abbreviation

intimate space

0-18 inches bathing inserting catheter changing dressing

The five basic purposes for patient records

1) documented communication 2) permanent record for accountability 3) legal record of care 4) teaching 5) research and data collection

Rank the nursing diagnosis in order of priority. 1. Risk for ineffective airway clearance 2. Functional urinary incontinence 3. Alteration in nutrition: less then body requirements 4. Risk for constipation

1,3,2,4

the nurse is working with a patient forma different culture. Which action by the nurse is most likely to cause offense if the patient's sense of intimate space differs from the nurse's?

1. Assist the patient to transfer from bed to chair

The five basic purposes of written patient records are:

1. Communication 2. Permanent 3. Record of accountability 4. Legal record of care 5. Information for teaching & source for research & data collection

A patient is grimacing while trying to change his position in bed. He tells the nurse that he is feeling great and is ready to get up and go home. Which response best indicated that the nurse recognizes that the patient's communication is incongruent?

1. Going home is the goal, but let me help you ge tup and you can walk around for a while.

the patient is fearful concerning his upcoming surgery. Which statement by the nurse is most therapeutic?

1. Sometimes anxiety is not easy to deal with. Can you tell me what tis bothering you the most about your upcoming surgery?

The nurse is completing the patients history. Which question encourages the patient to provide a specific answer with relevant detail?

1. What type of surgeries have you had in the past?

the nurse is admitting a patient with long-standing type 1 diabetes. Which communication technique is most efficient in ascertaining the number of units of insulin the patient usually takes?

1. closed question

a nursing student goes to an instructor's office to discuss an uncomfortable interaction that occurred with a patient during the last clinical experience. Which behaviors suggest that the student does not have the instructor's full attention? select all that apply

1. instructor smiles and waves at others who walk past the office. 3. instructor offers advice before the student explains the details of the incident 5. instructor frequently handles her cell phone 6. instructor shuffles and rearranged papers on the desk.

which statement by the student nurse is an example of assertive communication? (select all that apply).

1. it's time for your morning care. Do you prefer to use the shower chair, or do you think you are strong enough to stand during oyur shower today? 5. since you will be going to physical therapy soon, its important we get your morning care completed. Do you want to take a sponge bath or a shower now?

which communication technique is considered appropriate in all interactions?

1. listening

the patient is in a coma after a motor vehicle accident. Which statement regarding communication with the patient is most appropriate? (select all that apply).

1. speak to the patient as is he can hear what is being said. 5. encourage the family members to read a book or newspaper to the patient.

When communicating with the patient of an unfamiliar culture, what should the nurse do? select all that apply

1. use formal names until preference is assessed. 2. realize that interpretation of social time versus clock time can differ 3. be aware that touch varies according to gender and relationship. 6. understand that eye contact has different meaning among cultures

eye contact

2-6 seconds is appropriate and represents confidence. consider the cultural implications of eye contact absence of eye contact (less than 2 seconds) can mean shyness, lack of confidence, disinterest, embarrassment excessive eye contact (longer than 6 seconds) can be inappropriate and intimidating

The patient says "I trust you, soI am going to tell you a secret. I am going to end it all by going for a swim in the ocean." What should the nurse do?

2. Ask the patient to elaborate on the meaning of "end it all" and "long swim".

in which circumstance would it be most appropriate to incorporate the phrase "nursing diagnosis: into the verbal communication?

2. The nursing student and the nursing instructor discuss the patient's care plan.

The patient tells the nurse that the unlicensed assistive personnel is always making jokes. What is the best response?

2. What do you think about the UAP's jokes?

when communicating with an older adult, what should the nurse do?

2. allwo time for processing information

social isolation is one of the identifiable problems on the care plan for a resident with hearing impairment in a long-term care facility. The nurse goes to the patient's room and finds that he is cheerful, conversant and happy to engage. What should the nurse do first?

2. assess the patient to determine his social skills and the extent of his social network

which method is most appropriate for communicating with an alert a patient on a ventilator with and endotracheal tube in place?

2. communication board

the night nurse is giving report during shift change. A visitor passing by is an unintended receiver of the nurse's communication. What is the best method to prevent this type of occurrence

2. give the report in a private room with the door closed

the patient will be discharged from the hospital tomorrow. During the discharge teaching, the patient states, "I don't know how I will be able to care for myself after I leave the hospital." What is the most therapeutic response?

2. it sounds like you have some concerns

the patient is being seen in the clinic for a follow-up visit after fracturing her ankle. The nurse notes that she is not using her crutches correctly. Which statement by the nurse is most appropriate?

2. let me show you some ways to make crutch walking easier for you.

The nurse is present when the obstetrician informs a 17 year old that she is pregnant. The adolescent shrugs, appears bored and says, "That's no big deal to me." The nurse who has been trying to get pregnant for several years, feels angry and hostile toward the patient. What should the nurse do first?

2. perform a self-assessment of ability to convey acceptance.

The nurse is talking with the patient about her husband's death 2 years ago. Tears form in the patient's eyes, and she stops talking. What is the most appropriate therapeutic response by the nurse?

2. remain silent and hold the patient's hand

the newly admitted vietnamese patient speak almost no English. The nurse needs to obtain from the patient a urine specimen for culture and sensitivity. An interpreter is not readily available. What is the best nursing action to assist in obtaining the specimen?

2. show the patient the equipment and illustrations of the process.

which statement about communication is most accurate?

2. some form of communication takes place each time there is an interaction between individuals.

The patient tells the nurse that he is frightened about having cancer. Which response by the nurse is most effective in getting the patient to vent his concerns?

2. tell me more about being frightened by having cancer

When communicating with a patient who has expressive aphasia, which communication strategy is the nurse most likely to use?

2. use eye blinks, one for "yes" and two for "no"

the patient has a long history of smoking and has just been diagnosed with lung caner. He states to the nurse, "there's no point in trying to stop now. I might as well enjoy the time I have left." Which statement is the best response by the nurse?

2. you feel that there is no reason to stop smoking now?

The patient states, "Im so nervous about being hospitalized." Which statement is the nurse's best response to get the patient to elaborate?

2. you're feeling especially nervous?

the patient states, "I'm worries and don't know what to expect after my biopsy." which question best encourages the patient to explain the problem to the nurse?

3. What are you worried about

which nurse-patient interaction usually occurs in the "personal zone" of space surrounding the patient? (select all that apply).

3. discharge instruction 5. admission interview

which question is an example of clarification? (select all that apply)

3. in other words, you feel that your stomach aches are associated with stress at work? 5. Do I understand you correctly that you are saying that you don't understand why the doctor prescribed this medication to you?

what type of eye contact would be best to use if the nurse is trying to involve the patient in a discussion about sexuality without being threatening or intimidating?

3. maintain eye contact for 2-6 seconds during the discussion

the nurse is explaining a change in a patient's condition to a provider. The provider rudely and sarcastically replies, " well what do you want me to do about that?" What is the best response?

3. please come and examine the patient, because the condition has changed.

which approach is most appropriate for effective communication with a patient with cognitive impairment?

3. using simple sentences and avoid detailed explanations

social space

4-12 feet lecture teaching a diabetes class giving a presentation

The nurse is trying to take a patient;s history, but the patient makes frequent references to her aunt's health, a neighbor's illness, and events that happened many years ago to him or others. Which therapeutic communication technique is the nurse most likely to use with this patient?

4. Closed questioning

During an admission interview, the patient refers several times to "all the problems I has last time." What is the most appropriate communication?

4. Focusing

an experienced UAP gives excellent care and is well-liked by all of the residents in the long-term care facility. She calls the female residents " sweetie" and the males residents "honey-bunch" the nurse is newly graduated but realizes the UAP is using "elder-speak." What should the nurse do?

4. Praise the UAP for excellent giving excellent care and role-model use of "mr.," "mrs.," or "ms."

The nurse is about to begin teaching a small group of adolescents about healthy eating habits. Which nonverbal behavior best indicates potential interest in listening to the nurse?

4. Removing a notebook and pen from backpack

The patient has just died. The wife and daughter are holding each other and crying at the bedside, while the little boy is standing apart staring out the window. Which communication approach would be best to support everyone in the family?

4. Stand beside the little boy and keep open body position toward the mother and daughter

the nurse is attempting to elicit the patient's state of mind about an upcoming surgery. Which approach is likely to be most effective?

4. What do you understand about the procedure?

the nurse is providing discharge instruction to a patient. Which action provides the most accurate assessment of understanding by the patient?

4. asking the patient to repeat the instructions.

During his admission interview, an older patient states, "I can't hear you very well." After determining that the patient does not have a hearing aid, which action assists with communicating with this patient? (select all that apply).

4. face the patient and speak slowly and distinctly 5. be sure to get the patient's attention before speaking

The patient tells the nurse "I'm supposed to check my blood sugar at least three times each day, but I can't always find the test sticks and they're very expensive." which response by the nurse is the best example of effective clarification?

4. let me make sure I understood what your concern is with the blood sugar testing.

the nurse is trying to interview a patient who is very hard of hearing. What strategy should the nurse try first?

4. use normal volume and lower tone of voice.

abdominal surgery has revealed that the patient, a young mother, has advanced metastatic colon cancer. While the nurse is changing her dressing the patient begins to cry and states, "If I had just gone to the doctor sooner, my kids wouldn't have to grow up without a mother." Which response by the nurse is most therapeutic?

4. you feel that if you had been diagnosed earlier, the situation might be different?

Which date would be included in a cluster relevant to the nursing diagnosis of constipation?

Abdomen firm and contender to touch; Decreased bowel sounds; Takes opioid pain medications as needed; Passed a small, hard stool yesterday; Prefers to eat meat and potatoes, but lacks appetite.

NONVERBAL THERAPEUTIC COMMUNICATION TECHNIQUES

Active listening - full attention, allows feedback to verify understanding of the message Maintaining silence - allows time to organize thoughts, and formulate appropriate response. conveys respect, understanding, caring, and support. A;lows observation of patient's nonverbal responses. Minimal encouragement - (nodding occasionally, eye contact, brief verbal comments "yes" "go on" "then what happened?" Communicates to the patient that the nurse is interested and wants to hear more Touch - conveys warmth, caring, comfort support and understanding when used appropriately. conveying acceptance (usually involves a verbal component. shows acceptance of patients rights to current beliefs and practices without condoning them. nonjudgemental, therefore encourages honesty and openness.

What is the major advantage of using the nursing process to identify nursing diagnoses?

Allows nurses to use clinical judgment about actual or potential health problems.

Quality assurance, assessment and improvement

An audit in health care that evaluates services provided and the results achieved compared with accepted standards

The nurse is organizing the tasks and care that are required throughout the work shift. What is the best time to plan on documenting patient care?

As soon as possible after completion of care

The nurse observes that the patient is pale, diaphoretic; slightly hunched over; and demonstrates deep, rapid breathing. Based on this objective data, which question will the nurse use to elicit the most relevant subjective data?

Are you having any pain?

The nurse is working on a medical-surgical unit in a large hospital and observes an unfamiliar person looking at a patient's chart. What should the nurse do?

As for identification and determine if the person can look at the chart

The LPN/LVN in reading the documentation that was written by a newly graduated RN. There are numerous spelling mistakes and the grammar is terrible. What should the nurse do?

Ask the charge nurse to review the documentation

Styles of communication

Assertive Aggressive Unassertive Passive-aggresive

arguing

Challenging or arguing against the patient's statements or perceptions.. Denies the patient's perceptions are real and valid. implies that the patient is not being truthful

The student nurse is correct when identifying which concept regarding documentation as being correct?

Chart as soon and as often as necessary

The post surgical patient reports that he is having lower abdominal pain. What would the nurse include in the focused physical assessment?

Check for rigidity and rebound tenderness.

It is 10:00 am, and the nurse needs to give a patient a blood pressure medication, but would like to know what the morning vital signs were before administering the medication. The nurse looks at the flow sheet, but the vital signs are not there. Which action should the nurse take first?

Check the blood pressure, give the medication as appropriate, and then document both.

As a newly hired nurse, what is the best way to chart using correct abbreviations?

Check to see if the facility has a published list of abbreviations

D.A.R.E stands for

Data,Action, Response and evaluation, Education and patient teaching. associated with focus charting

The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on what prospective payment system?

Diagnosis-related groups (DRGs)

gestures

Distinct movements of hands, head, body. Emphasis, clarification, pleasure, helpfulness, anger, threat, disrespect.

Which statement is a safe principle of computerized charting?

Do not leave patient information displayed on the moior

The student nurse sees that it is time to give medication to a patient, but the patient is currently in x-ray. The student is aware that there is a 30-minute time window to administer the medication, otherwise it will be considered late. What should the student do?

Document that the patient is in x-ray, advise the charge nurse, and administer the medication when the patient returns to the unit.

Which statement best describes narrative documentation?

Documentation that describes occurrences in descriptive form

The nurse demonstrates knowledge of correctly completing an incident report with which action?

Documenting facts regarding the incidient

The nurse is documenting with a black pen on the hard copy nurses' notes about a patient's response to pain medication. The nurse suddenly realizes that she is writing the note in the wrong chart. What is the best action to take?

Draw a line through the error and initial it.

Based on the definition, which would be an example of a collaborative problem?

Edema

The home health nurse has been visiting a pt for several months. One of the nursing dx is "social isolation r/t reluctance to leave the house. The goal of "patient will attend a social function two times per month" has not been met. What should the nurse do first?

Evaluate the factors that are affecting or interfering with the patients response.

Which of the following are examples of a nurse using non therapeutic communication techniques? (select all that apply).

Focusing on the nurse rather than the client changing the subject making value judgements giving advice

The nurse will perform a focused assessment on which patient(s)?

Has a head injury that was sustained during a fall; Suddenly becomes confused and does not recognize family; Reports pain in the left leg that worsens with walking; Reports back pain, painful urination, and low-grade fever.

collaborative problems

Health related problems that the nurse anticipates based on the condition or diagnosis of a patient

What is the best rationale for collecting a patients biographical data, such as age, weight, and place of employment?

Helps the health care tim identity potential risk factor for health problems.

The nursing student attempts to document AM hygienic care, but several computers are broken and the remaining functional computers are being used. What should the student do?

Jot down the time that care was given and document when a compute is available.

What is the primary purpose of Title II of the Health Insurance Portability and Accountability Act (HIPAA)?

Maintain privacy and confidentiality of patient's health information

Giving Advice or Personal Opinions

Making a decision for a client; offering personal opinions; telling a patient what to do with phrases such as "should do," "ought to".. This takes the decision making away from the client, impair decision making, creates doubt, encourages blaming the nurse if decision has unwanted outcomes.

false assumptions

Making an assumption without validation; jumping to conclusions.

The home health nurse needs the patient's complete medication history, but the patient tells the nurse that many changes were made in the hospital and at discharge, so he is not really sure what to tell her. What would be the best secondary source for this information?

Medication reconciliation form.

The nursing student has diligently read all assignments, attended all lectures and skills practice sessions, but lacks clinical experience to improve critical thinking skills. What should the student do to improve critical thinking as it applies to patient care?

Mentally rehearse clinical scenarios:"What would I do if..."; Develop the habit of formulating relevant questions when listening or reading; Ask the instructor or nurse preceptor to "think out loud"; Discuss with classmates how they reached a certain decision.

In using the hospital's computer information system, where would the nurse most likely find documentation about the patient's response to the last dose of pain medication?

Narrative notes

NANDA-I

North American Nursing Diagnosis Association International; a professional nursing organization that provides standardized language to identify patient problems and plan customized care

What form on the patient's chart do nurses record their observations, care given, and the patient's responses?

Nurses' notes

The nurse is performing the assessment phase of the nursing process. Which nursing action would be done during this phase?

Observe a patients ability to independently perform AM hygienic care.

The nurse sees on the care plan that there is a nursing diagnosis of ineffective breathing pattern r/t narrowing of airways,with an intervention of "use inhaler PRN for asthma attacks." How does the nurse implement this intervention?

Observe baseline respiratory effort and repeat at least every l4 hours or as needed.

When charting by exception, which acronym is generally used?

PIE

A patient comes to the clinic for a broken toe. The nurse check the pt's pulse and then attaches him to the cardiac monitor, which reveals an irregular heat rhythm. What is the best rationale for the nurse's action?

Palpation of the pulse revealed irregularities, the nurse considered pathophysiology.

A newborn has the nursing diagnosis of risk for ineffective thermoregulation. What is the most accurate outcome for this diagnosis?

Parents state they will keep their infant's temperature between 97.5 F and 98.6 F

The LPN/LVN is using the SOAPE method to chart. When documenting the S portion, which entry demonstrates correct documentation?

Patient ambulated 20 ft unassisted with steady gait

The nurse has completed the assessment and reviewed the patient's record. The nursing dx risk for impaired skin integrity is identified of this patient. Which data would support the choice of his diagnosis?

Patient is underweight and has trouble changing position.

What is considered an appraisal by a professional co-worker of the manner in which an individual nurse conducts practice, education, or research?

Peer review

An elderly patient is wetting the bed because he is unable to independently get up and go to the bathroom, for this particular pt, which phase of the nursing process is most critical to address the pt's needs?

Planning

The nurse has identified six relevant nursing dx that would apply to the patients care. Which nursing action is the most important?

Prioritize the nursing diagnoses from most urgent to least urgent

A patient has been admitted to the medical floor. Whose responsibility is it to complete the patient's initial admission nursing history, physical assessment, and development of the care plan?

RN

A patient has been admitted to the floor. Whose responsibility is it to complete the patient's initial admission nursing history, physical assessment, and development of the care plan?

RN

Understanding the health care personnel must respect the confidentiality of patient records, which action by the nurse is appropriate?

Reading charts only for a professional reason

defensiveness

Responding negatively to criticism; often in response to feelings of anger or hurt on your part; usually involves making excuses. implies that the patient has no right to an opinion

The nursing student leaves a copy of a patient's Kardex on a bedside table. A visitor finds the copy and reads it. What should the student do?

Retrieve the Kardex, contact instructor, and complete an incident report.

Unassertive Communication

Sacrificing your legitimate personal rights to the needs of the patient causing resentment. nontherapeutic

Which nurse behavior / response best indicates to the patient that the nurse was actively listening to what he or he is trying to say?

Says, "so in other words, you are..."

The caregiver of a patient with Alzheimer's disease reports that the patient is unsteady and easily loses his balance, peaces the house, and needs couching to accomplish tasks, Which nursing dx will apply to this patient?

Self-care deficit for activities of daily living; Wandering; Risk for caregiver role strain; Risk for falls.

SBAR stands for

Situation, Background, Assessment, and Recommendation

physical appearance

Size, color of skin, dress grooming, body carriage, age, sex. Professional or nonprofessional, trust or distrust, respect or disrespect, comfort or intimidation, interest or disinterest, competence or incompetence.

Which statement best describes the nursing diagnosis?

Statement of the patients needs according to Maslow's Hierarchy.

automatic responses

Stereotyped or superficial comments that do not focus on what the client is feeling or trying to say. tends to belittle the individual's feelings and minimize the importance of the message. Communicates the message that you are not taking the patient's concerns seriously

ATI

THERAPEUTIC COMMUNICATION

Which accreditation agency specifies guidelines for documentation?

The Joint Commission (TJC)

When reviewing information regarding the problem-oriented medical record (POMR, the LPN/LVN correctly identifies which guideline?

The charting format is SOAPE or SOAPIER

The nurse notes skin breakdown on a patients coccyx during a bath. What part of the nursing diagnosis statement is this observation?

The defining characteristic

Nursing Notes

The form on the patient's chart on which nurses record their observations, care given, and the patient's responses

What occurs during the last phase of the nursing process?

The nurse compare the desired outcomes with the actual outcomes.

A 14-year-old patient is admitted to the emergency department with a possible medical diagnosis of acute appendicitis. Who should the nurse interview first when performing the assessment?

The patient

The patient is experiencing severe respiratory distress that is related to his chronic obstructive pulmonary disease. Which source of information does the nurse use when performing a nursing history during the admission assessment?

The patient and his wife

A woman who has had four children comes to the clinic. She tells the nurse that when she laughs or coughs she wets her underwear. Which nursing intervention is properly written?

The patient will perform kegel exercises 10 times a day with four to six repetitions.

Which statement is a recommended guideline for charting?

The patient's name and identification number should be on all documents

Informatics

The study of information processing

A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life." Which of the following responses is appropriate?

This must be a difficult time for you.

False reassurance

Using falsely comforting phrases in an attempt to offer reassurance. You promise something that will not occur or is unrealistic

Which of the following is an example of the nurse using clarification to facilitate communication? (select all that apply).

What would you say is the main point of what you are saying I am not sure I am following you.

Which nursing action demonstrates that the nurse believes that evidence-based practice is important for quality patient care?

Works on a committee to update policy and procedure manuals.

planning

a category of nursing behavior in which a strategy is designed for the achievement of the goals of care for an individual patient, as established in assessing & analyzing; includes developing & modifying a care plan for the patient, cooperating with other personnel, & recording relevant information

Nomenclature

a classified system of technical or scientific names and terminology. must be considered when choosing computer based documentation.

actual nursing diagnosis

a clinical judgement about human experience/responses to health conditions/life processes that exist in an individual, family, or community

wellness nursing diagnosis

a clinical judgment about a person's, family's or community's motivation & desire to increase wellbeing & actualize human health potential as expressed ion the readiness to enhance specific health behaviors, & can be used in any health state

nursing diagnosis

a clinical judgment about actual or potential individual, family, or community responses to health problems/life processes; a type of health problem that can be identified

syndrome nursing diagnosis

a clinical judgment describing a specific cluster of nursing diagnoses that occur together, & are best addressed together & through similar interventions

database

a collection of data or information

reflecting

a communication technique that assists the patient to "reflect" on inner feelings & thoughts rather than seeking answers or advice from someone else

focusing

a communication technique used when more specific information is needed to accurately understand the patient's message

Patients charts provide

a concise, accurate, and permanent record of past and current medical and nursing problems, plans for care, care given, and the patients responses to various treatments.

altered cognition

a decrease or lack of cognitive ability to receive, process, and send information

evaluation

a determination made about the extent to which the established outcomes have been achieved

two-way communication

a form of communication that requires that both the sender & the receiver participate equally in the interaction

managed care

a health care system that involves administrative control over primary health care services in a medical group practice. Redundant facilities & services are eliminated, & costs are reduced. Health education & preventive medicine are emphasized.

database

a large store or bank of information for the patient, which leads to a nursing diagnosis

SBAR is

a method of communication among health care workers and a part of documentation. Safety measure in preventing errors from poor communication during "hand off" or "handover" that occurs when changing shifts. Joint commission states "it meets the national patient safety goals".

clinical pathway

a multidisciplinary plan that incorporates evidence-based practice guidelines for high-risk, high-volume, high-cost types of cases while providing for optimal patient outcomes and maximized clinical efficiency

Electronic Health Record (EHR) / Electronic Medical Records (EMR)

a patients chart in electronic form

expressive aphasia

a physiologic condition in which an individual is unable to communicate a desired message

cue

a piece or pieces of data that often indicates that an actual or potential problem has occurred or will occur

open-ended question

a question that does not require a specific response & allows the individual to elaborate freely on a subject

open posture

a relaxed stance with uncrossed arms & legs while facing another individual

one-way communication

a structured form of communication in which the sender is in control

minimal encouragement

a subtle therapeutic technique that communicates to the patient that the nurse is interested & wants to hear more

Abbreviations can be used when documenting care for the patient as long as the

abbreviations are approved by the facility

A nurse is using a health related internet blog. Which of the following is an acceptable use of this form of communication>

access information

nursing interventions

activities that promote the achievement of the desired patient outcome

communicating with patients who are cognitively impaired

allow time for patient to respond ask one question at a time be attentive when listening to the patient speak get patient's attentions before speaking include family and friends in conversations reduce environmental distractions use simple sentences and avoid long explanations

Constipation related to the effecgts of analgesic medications on the bowel manifested by statements of straining to have a bowel movement and no bowel movement in 5 days" is an example of:

an actual nursing diagnosis

Problem, intervention, and evaluation (PIE)

arose from the nursing process and often is used when charting by exception

Peer review

an appraisal by professional coworker of equal status.

therapeutic communication

an exchange of information that facilitates the formation of a positive nurse-patient relationship & actively involves the patient in all areas of care

aggressive communication

an individual interacts with another in an overpowering & forceful manner to meet one's own personal needs act the expense of the other

Electronic health record

are used in various settings, including hospitals, long-term care settings, health care providers offices, clinics, and home care agencies.

which of the following is an example of closed-ended questioning? (select all that apply.)

are you going to group therapy tomorrow? how long have you been depressed? do you not want to take your medication? Do you have a family history of depression?

Guidelines for communicating with patients who are partially fluent in English

ask for feedback assess nonverbal and verbal communication avoid using medical terms remain at eye level with patient. patient can usually understand more than they can speak. stress interferes with patient's ability to think and speak in English Speak slowly and never loudly use pictures when possible

asking for explanations

asks the patient to explain her or his actions, belied. or feelings with "why" questions accusatory.

communicating with patients who have hearing impairment

be sure to get patients attention when entering the room before speaking ensure the patient is wearing hearing aids and/or glasses if they have them ensure the patient can see your lips because man lip-read. face the patient if the patient hears better from one side, use that side. reduce environmental noise (TV) rephrase comments rather than repeating the same phrase speak at a normal volume rather than shouting. try to lower the town of voice and avoid high pitch voice use sign language or provide a sign language interpreter if needed.

public space

beyond 12 ft from a person.

non therapeutic communication

blocks the development of a trusting & therapeutic relationship

Therapeutic relationship

builds a trusting nurse-patient relationship ensure that the patient is the main focus of each interaction has boundaries

Communication techniques

can be categorized as therapeutic (facilitates positive nurse-patient relationship) and nontherapeutic (blocks the development of a trusting relationship).

Narrative charting

care given is descriptive. written in abbreviated story form. Includes: patient need or problem data, whether someone was contacted, care and treatments provided and response to treatment.,

The nurse phones the health care provider to report a change in the patient's condition and uses the SBARR method of communication; however, the healthcare provider declines to listen to the "read back" and then hangs up. What should the nurse do first?

carry out the orders if they are clear

The LPN must ensure the information recorded in the chart is

clear, concise, complete, and accurate

a nurse is planning to document a conversation with a client who is preparing for a surgical procedure. which of the following client information is an accurate and factual form of written communication? (select all that apply.)

client state, "I have a throbbing pain on my left foot." client states, "i feel nervous about having my foot removed."

jargon

common place "language" or terminology unique to people in a particular wok setting such as hte hospital

denotative meaning

commonly accepted definition of a symbol.

Environment

consider the environment of where communication takes place comfortable temperature noise privacy

electronic health records capture data for which of the following? (select all that apply).

continuous quality improvement utilization review resource planning risk management

risk nursing diagnosis

describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community; supported by risk factors that contribute to increased vulnerability

outcome

description of the specific measurable behavior (outcome criteria) that the patient will be able to exhibit after the nursing interventions

Focus charting

developed by nurses, a modified list of nursing diagnoses is used as an index for nursing documentation instead of problem lists. uses the nursing process. Positive concept of the patients needs.

An auditor is randomly reviewing the nurses' charts and the nurse manager has agreed that the auditor can ask questions and give feedback as necessary. Which documentation is the auditor mostly likely to query(question)?

discharged to home accompanied by spouse

charting/ recording

documenting and recording. recording of interventions carried out to meet client needs

communicating with patients from different cultures from your own

dominant language and dialects cultural communication patterns attitudes towards time format for names

case management

encompasses planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for the patient

assessment

evaluation or appraisal of a condition; includes observing, gathering, verifying, & communicating pertinent data, usually information about the patient

communication

exchange of information. verbal and nonverbal forms that convey a variety of messages

Assertive communication

expressing needs while being aware of others needs being confident in communicating directly and honestly feeling comfortable and in control of anxiety honoring the fact that you and the other person have rights

which of the following care characteristics of effective written communication? (select all that apply)

factual objective accurate concise

Which diagnosis includes all appropriate components of an actual nursing diagnosis?

fear related to separation from support system manifested by statements of being scared, pallor, and increased respiration

closed questioning

focused & seeks a particular answer, such as yes or no

Incident report

form used to document any event not consistent with the routine operation of a health care unit or the routine care of a patient.

closed posture

formal, distant stance, with arms & legs tightly crossed

active listening

giving full attention & a effort to understand the message being sent

A nurse is admitting a client who has schizophrenia. The client states, "The FBI has bugged the phone and is monitoring my calls." which os the following responses by the nurse is appropriate?

i understand that you believe this is true, and it must be very frightening for you.

receptive aphasia

inability to recognize or interpret the verbal message being received

changing the subject

inappropriately focusing the discussion on something other than the patient's concern rude and shows lack of empathy, blocks further communication

A nurse is caring for a client who state, "I would like to go out on a date with you. Which of the following is an appropriate response by the nurse?

inform the client that this is an inappropriate statement.

subjective data

information provided by the patient

The RN has primary responsibility for each patients

initial admission nursing history, physical assessment, and development of care plan based on the nursing diagnosis identified.

Aggressive communication

interacting with another in an overpowering and forceful manner to meet one's own needs at the expense of others. destructive an nontherapeutic

assertive communication

interaction that takes into account the feelings & needs of the patient, yet honors the nurse's rights as an individual

Documenting

involves recording the interventions carried out to meet the patients needs.

restating

involves the nurse repeating to the patient what the nurse believes to be the main point that the patient is trying to convey

verbal communication

involves the use of spoken or written words or symbols

Chart (health care record)

is a legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems.

SBAR (situation, assessment, recommendation)

is a method of communication among health care workers and a part of documentation. Known as a safety measure in preventing errors from poor communication during"hand off" or "handover" interactions. (When your changing shifts)

Kardex (or Rand)

is a system used by some facilities to consolidate patient orders and care needs in a centralized concise way. It's kept at the nursing station.

Quality assurance, assessment, and improvement

is an audit in health care that evaluates services provided and the results achieved compared with accepted standards.

Personal health record

is an extension of the EHR that allows patients to input their own information into an electronic database. is how the information is going to be stored, an what economic costs are involved.

Traditional (block) chart

is divided into sections or blocks. emphasis is placed on specific sections. the sections include admission information, physicians orders, progress notes, history, and physical examination data.

Charting, recording, or documenting

is the process of adding information to the chart.

posture and position

it is ideal to be at the same level of the patient.

passive listening

it is not possible for the patient to be sure that the nurse has received or understood he message accurately. passive listening lets the patient know that the nurse is interested and being attentive to what is being said by the patient. Do not think ahead to formulate a response. You ill miss out on what the patient is trying to communicate.

A nurse is caring for a client who has depression. the client states, "Things are always going to be bad for me. I wish I could just go to sleep and forget about all my problems." Which of the following is an appropriate response by the nurse?

it seems as though you're expressing feelings of hopelessness.

nonverbal communication

messages transmitted without the use of words (oral or written); include tone & rate of voice, volume of speech, eye contact, physical appearance, & use of touch

Point of care

lab test or care being given to patient at their bedside.

jargon

language or terminology unique to people in a particular work setting, such as a hospital, or to specific type of work, such as nursing

Which nursing action/behavior would be considered a potential HIPAA violation?

leaves the computer monitor display open for easy access

A patient is admitted to the hospital for a total hip replacement. Care and documentation are performed according to the facility's clinical (critical) pathway for this condition. What information is likely to appear in this documentation tool?

level of activity on a day-to-day basis following surgery

passive listening

listening to the speaker is indicated by nonverbally through eye contact & nodding or verbally through encouraging phrases such as "Uh-huh" & "I see"

Standards and policies regarding documentation in long-term care facilities are guided by:

minimum data sets (MDS)

gestures

movements people use to emphasize the idea they are attempting to communicate

objective data

observable & measurable signs

nonverbal communication

tone rate of voice volume of speech eye contact physical appearance use of touch

sender

one who conveys the message

assertiveness

one's ability to confidently & comfortably express thoughts & feelings while still respecting the legitimate rights of the patient

posture

open: relaxed stance, facing receiver, uncrossed arms and legs, slight shift towards receiver. smiling closed: formal, distant, arms and legs possibly crossed

Auditors

people appointed to examine patient charts and health records to assess quality of care. Check to see whether all ordered care was charged as given whether responses to specific care plan items and treatments are noted.

a nurse engages in verbal communication with a client. Which of the following is reflective of the nurse's word selection?

personal values

implementation

phase of the nursing process in which the nurse & other members of the team put the established plan into action to promote outcome achievement

Nursing care plan

plan that outlines the proposed nursing care based on the nursing assessment and nursing diagnoses to provide continuity of care.

which of the following should not be included when discussing components of the communication process?

tone of voice

connotative meaning

reflects the individual's perception or interpretation of a given word

paraphrasing

restatement of the patient's message in the nurse's own words in an attempt to verify that the nurse has correctly interpreted the patient's message

clarifying

restating the patient's message in a manner that asks the patient to verify that the message received is accurate

Based on Maslow's hierarchy of needs, which nursing diagnosis label has the highest priority?

risk for aspiration

voice

tone volume and rate of speech. can indicate fear excitement, enthusiasm, stress anger, comfort concern

Problem-oriented medical record

scientific problem-solving system or method.

assertive nurse

self confident and composed ensures that verbal and nonverbal communication is congruent unapologetic maintains eye contact speaks firmly and with positive attitudes speaks genuinely without sarcasm takes initiative to guide situations uses clear concise speech

when communicating with a health care provider with an oncoming nurse, it is important to use a format such as SBAR, which stands for?

situation, background, assessment, and recommendation.

connotative meaning

subjective and is reflective of individuals interpretation. There is a potential for miscommunication.

SOAPE

subjective, objective, assessment, plan, evaluation

SOAPIER

subjective, objective, assessment, plan, intervention, evaluation, revision

In most states, patients can gain access to their medical records by which means?

submitting a written request to the facility to view the record

nursing process

systematic method by which nurses plan and provide care for patients

Which of the following statements is an example of a therapeutic communication technique?

tell me about your relationship with your wife.

standardized language

terms that a have the same definition & meaning regardless of who uses them in regards to patient care

defining characteristics

the clinical cues, signs, and symptoms that furnish evidence that the problem exists

denotative meaning

the commonly accepted definition of a particular word

The nurse documents in the patient record, "0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated, physician notified, and analgesic administered as ordered with adequate relief. J. Doe RN." Which statement about the documentation is most accurate?

the documentation is unacceptable because it is vague non-descriptive data without supportive data

biographic data

the facts & events of a person's life

medical diagnosis

the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review of medical records, and patient history

unassertive communication

the nurse agrees to do what the patient requests, even though doing so creates additional problems for the nurse

send, sender

the one who conveys the message

Which patient outcome statement meets the necessary criteria?

the patient will have a soft, formed bowel movement on the third day after nursing interventions

The patient is admitted to the hospital with an upper respiratory infection. The nurse writes the following nursing diagnosis: Risk for deficient fluid volume related to refusal to drink fluids secondary to a sore throat. Which is the best outcome statement for the patient?

the patient will maintain adequate hydration as evidenced by moist mucous membranes; elastic skin turgor; and voiding of clear, dilute urine

receive, receiver

the person or people to whom the message is conveyed

goal

the purpose to which an effort is directed

nursing-sensitive patient outcomes

the results or outcomes of nursing interventions; these outcomes or indicators are influenced by nursing & can be used to judge effectiveness of care & determine best practices

variance

the unexpected event that occurs during the use of a clinical pathway; can be positive or negative

verbal communication

the use of spoken or written words or symbols. it may seem that. can have potential for misunderstanding.

posture

the way an individual sits, stands, & moves

diagnose

to identify the type & cause of a health condition

receiver

to whom the message is conveyed can be intended receiver or unintended receiver

Considerable time needs to be invested in

training personnel, both in charting procedures and the terminology the system uses and in conducting ongoing refresher training.

approval or dissapproval

trying to impose the nurses own attitudes, values, beliefs and moral standards on a patient about what is right and wrong. easily leads the patient to doubt persona values, crates feelings of guilt and resentment, causes friction between you and the patient.

a nurse manager is discussing the topic of personal space as it related to nonverbal behavior with a staff nurse. Which of the following statements by the staff nurse indicated a need for further teaching?

use of personal space will crease the client's self-esteem.

A nurse is implementing therapeutic communcation techniques with a client in an outpatient mental health facility. Which of the following actions allows the client an opportunity to organize thoughts, consider the topic, or to think through a point?

use of silence

communication

use of words & behaviors to construct, send, & interpret messages

Computer on Wheels (COW)

used for charting at bedside

a charge nurse is discussing with a staff nurse the establishment of credibility when providing nursing care. Which of the following statements made by the staff nurse indicates a need for further teaching?

using sympathy will help build credibility.

a nurse is counseling a client who recently received a diagnosis of type 1 diabetes mellitus. Which of the following is a component of nonverbal communication the nurse may display? (select all that apply).

vocal inflection volume posture gestures

which of the following should not be included when discussing mode of computer-mediated communication?

voice mail

SBARR

when a nurse and a healthcare provider over the phone and an order is received from the health care provider, an additional "R" is added, it represents "read back".

Ac client presents at a community shelter after surviving the destruction of her home by a fire. Which of the following questions should the nurse ask to determine the client's ability to cope?

who do you talk to when you have the feeling of being overwhelmed?