midterm study guide

inhibited grief

normal stages of grieving are suppressed

open-ended questions

not simply a yes or no question, requires an in depth response

exaggerated grief

person using dangerous activities to lessen the pain of grieving

what are examples of non-therapeutic communication?

NEVER Offer opinions, advice, or personal experiences NEVER minimize client's feelings NEVER leave the room NEVER give false reassurance -"Everything is going to be alright" -"I'm sure you will do the correct thing" NEVER ask why -"WHY do you feel angry when..." -"WHY do you act this way?" -"WHY did you leave your child alone"

What delegation are CNA, UAP not allowed to do?

NO Teaching NO Assessment NO Meds

What delegation are LVN/LPN not allowed to do?

NO newly admitted NO new post-op NO evaluation (labs, vitals) Initial assessment First teachin

implementation (nursing process)

NURSING ACTIONS -Nursing interventions: Assess, monitor, observe, provide -Procedures, meds, client education

evaluation (nursing process)

OBJECTIVE & MEASURABLE -reassess the client; were the desired outcomes achieved? -adapt plan of care based on new assessment *identify potential errors or problems in plan of care *make adjustments as needed

What evaluation method is used to educate clients?

Teach Back: The client will demonstrate their learning by explaining it back to the nurse.

An RN delegates a routine task to the UAP ... legal consequences for the nurse if there is negligence by the UAP?

The RN may be liable if negligent in supervising the UAP

The client appears angry and demanding following a below-the-knee amputation.

The client is having difficulty accepting the new body image

What is the acronym to remember when to NOT delegate?

U EAT

"I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." ... therapeutic nurse response?

"It must be hard to accept that she has passed away"

What is the most helpful nursing response to a patient who reports thinking of dropping out of college because it is too stressful?

"School is stressful. What do you find most stressful?"

Client who has cancer is scheduled to receive chemotherapy ... she wants to try homeopathic treatments first. What response should the nurse make?

"Tell me more about your concerns about taking chemotherapy."

A man was killed during a robbery 10 days ago. His widow... cries spontaneously when talking to the nurse. What is the nurse's most therapeutic response?

"The sudden death of your husband is hard to accept. Tell me about how you are feeling?"

Client with ... end stage heart failure, says "Why can't this just end? I'm no good to anyone anymore." Which response is best?

"This must be difficult. Please tell me about your feelings?"

A parent who recently lost her child ... states she cries frequently and can't bear the loss ... what therapeutic statement should the nurse make?

"You are feeling great pain at the loss of your child."

The nurse finds the client crying ... & says, "What do you want? Go away, you can't help me. I hate you and I hate myself." Which response by the nurse is best?

"You seem to be in pain; I'll stay with you for a while."

"This condition is just another nail in my coffin." What response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

A client diagnosed with terminal cancer says to the nurse, "I wish my family would stop hoping for a cure! I get so angry when they carry on like this." What response by the nurse is therapeutic?

"You're feeling angry that your family continues to hope for you to be cured?"

Client's spouse has been unemployed for more than six months, and is afraid of not being able to pay the rent. Which response is most appropriate?

"You're worried that you won't be able to pay the rent?"

what are signs of complicated grieving?

- client fails to grieve; refuses to partiipate in his/her normal cultural activities - client becomes recurrently symptomatic of grief on anniversary of loss or on holidays -Persistent guilt -Continued searching for lost person -Small events trigger grief symptoms -Unable to discuss loss without crying or becoming tearful -Relationships with friends and family deteriorate

what are pediatric interventions for grief?

-Play therapy -Honestly answer questions -Therapeutic touch

what are adult interventions for grief?

-Therapeutic communication -Sit with the client -Support Groups -Focus on good memories

passive euthanasia

-withholding life sustaining therapy -withdrawal of extraordinary means of life support -ex. removing a feeding tube or ventilator, allowing the client to die w/o intervention (DNR, no code status)

when do RNs not delegate?

Unstable clients -New admission -Returning to floor after procedure -"Post-Operative" after surgery -Unstable blood sugar, vitals, lab values -Sudden change RR, neuro status. Evaluation -trending/interpreting data (lab values, pain, vital signs) Assessments -initial, first, primary assessments (new admission, post operative) Teaching -inital, first, primary education

what should you do when stating facts to the patient?

Voicing doubt & presenting reality: refutes misconceptions or delusions Suggesting resources or strategies: helps offer guidance

What instructional methods are used to educate clients?

Written Materials: primary language, using simple terms, & appropriate reading level. Demonstration: Showing a client how to perform a skill (Insulin injection) Others: Videos, audio recordings, books, verified websites.

What delegation can CNA, UAP do?

acronym: VAPER Vitals Ambulation Position changes/bathing Eating Recording I & O

active euthanasia

actions that directly bring about the client's death with or without consent

Choose the best discharge teaching strategies for an 82-year-old client with a low literacy level who has been newly diagnosed with COPD? Select all that apply. 1. Print out pictures showing the steps of correct inhaler use. 2. Perform discharge teaching with a family member present. 3. Raise your voice, speak clearly and slowly 4. Strongly discourage internet usage to look up health information. 5. Show the client a professionally produced video from a credible source.

1,2,5

what are the 5 stages of grief?

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

how do you build trust with patients?

1.ask & assess emotions "Tell me when you started noticing ..." "Tell me what concerns you have ..." "What are you feeling right now?" "How are you feeling about your baby?" 2.state facts "We have the vital signs under control" "You must be very upset after experiencing this" "I understand you are worried" "You sound very discouraged & scared." "You sound angry. Anger is a normal feeling associated with loss." COMBO -"This experience has been overwhelming for you. What are you feeling right now?" -"Clients with cancer experience fear of dying, tell me about your concerns."

Elderly client losing their spouse to pancreatic cancer. Choose the most therapeutic response. Select All That Apply 1. Leave the room to allow the client to grieve in private. 2. "I recently lost my grandfather to cancer, so I understand what you are going through." 3. "I know this is a difficult time for you. Tell me how you have been coping with this loss." 4. "What are your feelings & thoughts about attending a support group." 5. "It takes time to deal with & come to terms with a lost spouse, but it will be ok" 6. "Why do you feel sad when you are alone?"

3,4

what is the acronym for the nursing process?

ADPIE

what are sources of loss?

aspect of loss - loss or organs, loss of independence, loss of a limb external objects - money, house, pets familiar environment - leaving a home/losing a home; moving to new place; loved ones, divorce, or death

After being told the feet will need to be amputated, the client states, "I'm sure if I start taking my medication my feet will heal."... example of which behavior?

denial

anticipatory loss

experienced before the loss has actually occurred (a family member that is actively dying but hasn't passed)

perceived loss

experienced by one person but cannot be verified by others (loss of freedom when becoming a stay at home mom)

unresolved grief

extended in length and severity, stages of grief may be the same but the person grieves for an extended period of time

assisted suicide

giving clients the means to kill themselves if they request it

What delegation can LVN/LPN do?

Assess, Teach, Monitor - Secondary, Re-inforce, Follow-up -NOT initial, first, or primary Meds: NO IV push! • Yes: Monitor blood transfusion • Yes: Administer IVPB meds, but NO titrating (changing) rate • Yes: Maintain IVs • Yes: Calc. & monitor IV flow rates Yes - PO, SQ, IM

What are the different types of client education?

Cognitive: thought process & intellect -ex. client learning how to chose low sodium food choices Psychomotor: involves physicality/action -ex. client practicing medication administration like insulin injection Affective: involves emotions/feelings -ex.client's willingness to learn about the disease process

delegating vital signs to an assistive personnel (AP). Which actions should the nurse plan to take?

Communicate the time frame for when the AP should report results

... MOST appropriate way to assess if the plan of care correlates with the client's perceived needs?

Discuss the plan of care with the client

what should you do when asking the patient questions?

Exploring emotions: gather more information Restating: repeating patient words to confirm what you understand Reflecting: return focus on client

assessment (nursing process)

GATHER INFO & REVIEW HISTORY objective data = observed - ex. physical exam, vitals signs, signs & symptoms, labs, etc subjective data = what the client says (reports) -ex.stomachache, chest pain, headache, nausea, etc

planning/plan of care (nursing process)

GOAL, OUTCOMES, & ACTION PLAN acronym: S (specific goals) M (measurable goals) A (attainable goals) R (realistic goals) T (timely goals) *Poorly written outcome: "Client will walk without dizziness." *SMART outcome: "Client will demonstrate improved activity tolerance as evidenced by walking 20 feet without dizziness by day 3 of hospitalization." - Develop an action plan with specific goals & desired OUTCOME of the plan & always discuss this plan with the client to assess that perceived needs are being met. -Don't forget about the patient's opinion here, but make sure patient's desire is realistic, obviously.

Client with Crohn's disease ... feels overwhelmed & has not had any outside support since her recent divorce. Which nursing diagnoses are best for the plan of care? (SATA)

Hopelessness Risk of deficient fluid volume Ineffective coping Imbalanced nutrition

diagnosis (nursing process)

IDENTIFY PROBLEMS (Using the assessment data collected, the goal is to address both actual or potential health problems for the client.) -mainly used to help shape clinical judgment about a client's physical & psychological status -may also include the client's social factors, family, or community experiences. -Physical needs always come before psychological needs, as outlined by the Maslow's hierarchy of needs.

Client with pneumonia ... oxygen sat. 89% ...most appropriate nursing diagnosis?

Impaired gas exchange

complicated grief

grieving period lasts more than 6 months & leads to an inability to perform daily activities

actual loss

loss that can be recognized by others (death, divorce)

What are the 5 rights of delegation?

right task: only delegate tasks allowed by state laws & workplace policies right circumstance: know your client's status - do not delegate a task for an unstable client -key words for unstable client (new admission, sudden change in status, first time doing anything, returning to the floor after a procedure) right person: ensure the assistant has the right skill level, knowledge, & experience -assess the assistant's knowledge & sill to perform the tasks safely before delegating right direction/ communication: communicate goals, timeframe, & when to report back right supervision: RN, LPN/LVN is accountable for evaluation the outcome of the task; always follow up & reassess tasks that you have delegated -negligence - RN, LPN/LVN is may be legally liable if negligent in supervising the UAP or CNA

close ended comments

stating facts used to portray empathy, builds trust & assess further

nursing process

systematic approach used to guide client care

NO Delegating: RN ONLY

• IV PUSH (IV piggy back varies state to state) • Blood transfusion & blood products • Central line drugs: Chemo, TPN