Comfort / Rest

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

Respect for client Competence Professionalism Caring

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client.

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data?

Safety and security

ANA standards for patient education

Scope and Standards of Practice includes a standard of practice for nurses focused on educating patients about their illness, treatment, health promotion, or self-care activities

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source?

The client

Who or what is the primary source of information for a nursing history?

The client

Following a client interview, the nurse is organizing data obtained according to Gordon's functional health patterns model. Which statements reflect the focus of this model? Select all that apply.

The nurse collects data regarding the client's health perception and health management. The nurse explores the client's perception of the client's major roles and responsibilities in life. The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training?

The nurse introduces oneself to the client by pointing to the nurse's name badge.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

what is included in writing a goal or outcome

WHO DOES WHAT HOW and WHEN = TO ACHIEVE GOAL WHO, the patient DOES, will demonstrat WHAT, dressing change HOW, without cueing WHEN, before discharge = to achieve goal

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize.

the most accurate way to assess if the client education has been effective

ask an open ended question. Dont ask yes no questions

Joint commission

has established standards for patient education that healthcare agencies must meet to receive accreditation.

The purpose of obtaining a nursing history is to:

identify actual and potential health problems.

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

difference between literacy and health literacy

literacy, can they read health literacy, can they understand healthcare information, can patient obtain, understand, process health info to make health decisions. the new 6th vital sign

what teaching aids

pamphlets, audiovisual aids, internet, equipment and models

how do I document patient education

•It communicates the plan and progress to other healthcare professionals. •It fulfills the nursing job description as delineated by local, state, and national licensing agencies. •It provides a legal record. Documentation must contain the subject matter, the patient's response to teaching, and any necessary break in the process (e.g., if, after evaluation, the nurse found it necessary to return to the planning stage). Well-documented patient education is a record of methods that did or did not work, and it can give some indication of patient accomplishments and adherence to healthcare regimens over time.

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply.

"My leg hurts when I move." "I am so afraid of what my diagnosis is." "I am always anxious."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply.

38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg)

Which are examples of subjective data? Select all that apply.

A client describes pain as an 8 on the pain assessment scale. A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket.

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

Which assessment data cue does the nurse recognize as subjective data?

A pain rating of 7

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview.

Affective learning

Affective learning includes changes in attitudes, values, and feelings (e.g., desire to lose weight)

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

cognitive domain

As the client enjoys reading books and magazines, the client's learning style would fall in the cognitive domain, where information is processed by listening or reading facts and descriptions

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure.

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection

Which is the best source of information for the nurse when collecting data for an assessment?

Client

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?

Consult with another nurse for that colleague's description of the assessment or observations.

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrintestinal symptoms or should be reported to the physician. Which action should the nurse perform next?

Consult with another nurse.

The nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?

Continue the health history with questions focusing on respiratory function.

psychomotor learning

Demonstrating a skill, such as insulin injection, is an example of psychomotor learning

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

Disturbed sleep pattern

A client comes to the emergency department with a stab wound and is bleeding profusely. Which type of assessment should the nurse perform on this client immediately?

Emergency

A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using?

Gordon's functional health patterns

As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?

Have client rate pain level and reschedule the teaching session. The client is not ready or able to learn and is reporting a need that first must be met. Assessing the client's knowledge of self-care or redirecting the subject only delays the care that must be done before the client is able to learn.

Which nursing skill uses all five senses?

Observation

qualities of the teaching-learning relationship

PATIENT FOCUSED HOLISM, the whole person NEGOTIATION, patient and nurse determine what is known and what needs to be learned. can be a written contract INTERACTIVE, dynamic and nurse can also learn from patient. they discuss, clarrify and revisit specific points

the stages of change with patient teaching

PRECONTEMPLATION - denial/demoralized not making a change within 6 months (not thinking about quitting smoking) CONTEMPLATION - stuck, stalling. seriously thinking about change in the next 6 months, (thinking about quitting smoking in the next 6 months PREPARATION - actively planning change, telling family and friends, (thinking about quitting in the next 30 days) ACTION - begin to modify behavior, overtly making change, (in the process of quitting) MAINTENANCE - struggling to prevent lapse, work to consolidate gains, taking steps to sustain change and resist temptation to relapse, (abstaining from smoking for over 6 months)

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?

Palpation

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time-lapse

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

if a patient cannot read or write the most important tools are to

Using verbal and visual modes of instruction is most appropriate for a client who is unable to read or write. This meets the special needs of the patient

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?

Validate the data.

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first?

Validate the questionable data.

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician.

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:

body systems.

A nurse is asking questions about a client's sexual history. It is important for the nurse to:

collect data in a quiet, private environment.

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to:

complete an exam of all body systems.

American Hospital Association standards for patient education

defining a Patients' Bill of Rights In 2003, the American Hospital Association replaced this document with a plain language brochure for patients, The Patient Care Partnership, Understanding Expectations, Rights and Responsibilities (2006). This brochure emphasizes that patients have not only the right to high-quality hospital care but also the right of involvement in care decisions about diagnosis, treatment, and prognosis

The affective domain

is a style of processing that appeals to a person's feelings, beliefs, or values.

The psychomotor domain

is a style of processing that focuses on learning by doing.

The interpersonal domain

is a style of processing that focuses on learning through social relationships.

what is learning

is the acquisition of a skill or knowledge by practice, study, or instruction. It can be: cognitive, thinking critically etc affective, emotions or feelings, difficult to measure. I want to lose weight psychomotor, easiest to measure, they demonstrate a skill. Return demonstration.

what would be the most important thing to teach a patient that you are caring for prior to them going home

self administer of meds

cognitive learning

storing and recalling of new knowledge in the brain eg, The patient's ability to describe the signs and symptoms of hypoglycemia demonstrates cognitive learning

what is teaching

the core of effective teaching is to produce capable self-learners, who continue their learning well past the teaching-learning encounters

effective teaching-learning

the teaching-learning relationship between the nurse and client is special, characterized by mutual sharing, advocacy, and negotiation. Effective learning occurs when clients and health care professionals are equal participants in the teaching-learning process

how do I evaluate learning

written test or questionaire oral test teach back, "can you explain to me how you will take your meds" return demonstration- psychomotor showing how to give insulin shot check off lists simulation-offer a senario and ask best choice

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?"

reinforce learning when a patient is able to say walk, or ambulate or is working towards a goal say

"You have made an amazing recovery." dont talk about how good the pt staff are etc.

implementation of patient teaching

*should be limitied 20-30 min *best time is outpatient better than inpatient, not in the hospital *Include family and friends with patients permission, support *ideal learning environment is patient has eaten, pain free, quiet environment. *teaching methods are cognitive, affective, psychomotor,

Which is the purpose of a focused assessment?

Adds depth to existing information

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

Avoid the impulse to interrupt.

how do i assess for learning

BASELINE KNOWLEDGE CULTURAL AND LANGUAGE NEEDS PRIORITIES, use ask me 3 (ASK ME 3): what is my main problem what do i need to know why is it important for me to do this? REALISTIC APPROACH

motivational interview

ELICIT-PROVIDE-ELICIT (E-P-E) elicit, find out what they already know by asking questions. provide, fill in missing info and correct errors elicit, find out what this info means to the patient ASSESSING IMPORTANCE patient rate importance 0-10 ask why they chose the rating find out what would increase the score summarize the discussion EVOKING CHANGE TALK ask open ended questions to elicit desire, ability, or reason, or need to change.

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

individualized teaching plans

Gaining insight into the client's own perceptions of health and aging will allow the nurse to tailor the plan of care to the client's personal needs. Knowing his religion etc is important but not individualized. The patients personal perception of health and aging matters when creating an individualized teaching plan, it also gives the nurse a chance to assess and note inadequate knowledge for the plan

What must the nurse do to identify actual or potential health problems?

Gather data from sources

Which piece of client information is subjective?

Generalized myalgia or muscle pain

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs

The nurse notices during an assessment interview that the client cannot stay focused and jumps from one topic to another. The client also is speaking very rapidly and at times incoherently. What should the nurse suspect is the main cause of this behavior?

High anxiety

Which are models used in nursing to assist in clustering data? Select all that apply.

Human Needs Functional Health Patterns Human Response Body Systems

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding

Which is the most appropriate reason for a nurse to ask a client what the client would like to be called?

It communicates respect for the client.

what teaching strategies can the nurse use to individualize the teaching session

LECTURE, to a group using cognitive and sometime phsycomotor skills, can be combined with discussion DISCUSSION, exchange ideas, individual or group, I am the facilitator DEMONSTRATION, psychomotor, video tapes, repeat practive ROLE PLAY

Which are examples of objective data? Select all that apply.

Laboratory test results Breath sounds on auscultation A client's temperature

6 barriers to teaching and learning

MOTIVATION, use motivational interview COMPLIANCE, are they following the plan, can be too authoratative, (non compliant) ADHERENCE, alternative to compliance, agreed on by patient as a partner SENSORY AND PHYSICAL STATE, patient may have poor vision, motor skills, pain LITERACY LEVEL, education can give an estimate, tools to determine literacy are most accurate but not practicle WRAT, (Wide Range Achievement Test) REALM, (Rapid Estimate at Adult Literacy in Medicine) HEALTH LITERACY LEVEL. can they obtain understand info to make a decision.

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data?

Objective

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?

Objective

3 levels of teaching disease prevention

PRIMARY PREVENTION, stop disease from happening, shots, fluride treatment, car seat, oral contraception, education about drugs. SECONDARY PREVENTION, seek to identify illness at early stage with prompt attention. physical assessment, screening, breast exam, pregnancy test TERTIARY PREVENTION, after disease, halt the disease, rehab, support groups, AA, health education for a new diagnosis

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

Pain

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse

The nurse is admitting a client to a medical unit. The nurse delegates the measurement of the vital signs to an unlicensed assistive person (UAP) while the nurse collects data. After completing the admission process, the client reports a severe headache, so the nurse reassesses the vital signs and find the client's blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?

The nurse

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly.

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting

A client is admitted for removal of a cancerous tumor of the lung. The client expresses concern to the nurse about how the cancer and the treatment will affect the client's family. The client explains that the client's spouse has never worked outside the home and that the client is concerned that their financial situation will be compromised by this illness. Which would be the best nursing diagnosis for this client?

Risk for Interrupted Family Processes

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

The client tells the nurse that there is a burning sensation when voiding.