PVA FINAL TEST REVIEW.

Touch

Nonverbal

Which notations made by the nurse indicate accurate nursing documentation?

1-Abdominal wound dressing is dry and intact without drainage. 2-The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Submit 3-The client appears to become anxious when it is time for respiratory treatments.

Recognize cues

Assessment

Layer 1

Clinical judgement

Layer 4

Contextual factors

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?

Data clustering

Prioritize Hypothesis

Diagnosis

Layer 2

Evaluate patient outcomes

Closed posture

Nonverbal

Eye contact

Nonverbal

Open ended questions

Verbal

The nurse knows that litigation involving nurses is common because of which reasons?

1-Clients are better informed about their rights. 2-Clients are better educated about health care. 3-Clients are aware that lawsuits result in payment of large sums of money.

Which of the following are objective data? (Select all that apply)

1-Cyanotic (blue) lips 2-Oozing left hip ulceration 3-Edematous (swollen) left ankle

During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply)

1-HIPAA Violation 2-Invasion of privacy

Which are true regarding communicating while using eye contact? (there is more than one correct answer)

1-Making eye contact generally indicates an intention to interact. 2-Extended eye contact can lead to heightened anxiety. 3-Extended eye contact can imply aggression.

Which are the best ways for the nurse to avoid malpractice?

1-Perform interventions in a timely manner. 2-Document assessments and procedures completed. 3-Provide the same standard of care to each and every client. 4-Know current nursing literature in their area of practice.

What is the use of touch in therapeutic communication? (Select all that apply)

1-Touch can convey warmth and caring 2-Touch can convey support and understanding 3-Touch is a form of nonverbal communication 4-Touch should be used sincerely and genuinely

The nurse is sitting in a chair near the patient's be, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating?

Active listening

The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility?

Document the child's physical assessment findings accurately and thoroughly.

Generate solutions

Outcome identification

Layer 0

Patient needs

What is the basis for designing and selecting nursing interventions to meet patient needs?

Patient problems

Analyze cues

Planning

What therapeutic communication technique requires a great deal of skill and is not used as frequently as other communication techniques?

Silence

Restating

Verbal

Summarizing

Verbal

Two way communiation

Verbal

What is the last step for the first time you are caught using your cell phone in class?

You receive a behavioral counseling slip

A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of:

malpractice.

Recognizing that a patient experiencing stress most likely feels vulnerable, the nurse intervenes by:

using multiple communication methods.

Evaluate outcome

Evaluation

What objective data should the nurse include after a patient assessment?

Flatulence

Layer 3

Hypothesis

Considering Maslow's hierarchy of needs, what would be the highest priority patient problem?

Imbalanced nutrition

A patient is admitted to the hospital with a sacral wound that has a foul odor and thick drainage and necrotic (dead) tissue in the center. It measures 4cm in circumference and 2 cm deep. What is the most appropriate patient problem?

Impaired skin integrity

Take Action

Implementation

A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary infection. What do the nurse's actions exemplify?

Malpractice

The nurse caring for a patient in the acute care setting assumes responsibility for a patient's care? What is this legally binding situation?

Nurse-patient relationship