Basic Nursing Skills Chapters 18-22 SG

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Aphasia

(BEGINNING OF CH 21) Patient knows what they want to say but cannot say the words

communication process

(BEGINNING OF CH 6) An exchange of information, feelings, needs, and preferences between two people

Discrimination

(BEGINNING OF CH 8) Type of unfair treatment of one or more persons because of misguided beliefs about the person's race, gender, ethnicity, or religious beliefs

public (proxemics)

12 ft if possible

casual-personal (proxemics)

18 inches to 4 ft

social-consultative (proxemics)

4 to 12 ft

SI & S2

44. What is the medical abbreviation for each of the "lubb dupp" heart sounds? _______________________________________.

A 5-year-old child has a fever of 104.4°F (40.2°C) axillary. When should you reassess the child's temperature? a. Within 1 hour b. Within 1.5 hours c. Within 2 hours d. Within 4 hours

Prejudice

A determination or judgment about a person or group based on irrational suspicion or hatred of a particular group, race, or religion

a, c

A patient expresses fears about her upcoming surgery. The nurse responds, "You really don't have to worry. You have a great doctor. Everything will turn out fine." Why is this statement a barrier to communication? (Select all that apply.) a. It diminishes the patient's concerns. b. It is not a complete answer; the nurse should provide more information. c. It is equivalent to telling the patient to not talk about her fears. d. It provides reassurance but is not therapeutic. e. It takes away her worries, so she has nothing more to say.

guarding

A patient flinches and tightens the abdominal muscles while you are palpating their abdomen. This tightening of abdominal muscles is known as __________________________________.

A patient on your unit is very angry and hard to care for. She frequently belittles her caretakers. You have taken care of her for 2 days and ask the nurse manager to assign the patient to someone else. The nurse manager does as you ask, but the nurse she chooses comes to you and says, "This isn't fair at all! She is your patient, and you are dumping her on me!" Which of the following alternatives is the best way to begin to resolve this conflict? a. Go back to the nurse manager and ask her to smooth things out. b. Tell the nurse privately that you needed an emotional break from the patient. c. Apologize to the nurse, take the patient back, and give the nurse one of the patients that had been assigned to you. d. Suggest that the nurse has not had to care for the patient recently and that it is her turn.

A patient was admitted yesterday with pneumonia. During your assessment, you notice that the patient has a frequent cough that is sometimes productive. How quickly should you reassess this abnormal finding? a. Within 15 minutes b. Within 60 minutes c. In less than 2 hours d. In 4 hours or less

eye response - 2 points motor response - 4 points verbal response - 2 points total is 8 out 15 This indicates moderate to severe neurological impairment.

A patient with a head injury responds as follows: Opens eyes to pain stimulus. Withdraws from pain. Makes incomprehensible sounds. Score the patient responses on the Glasgow Coma Scale. Calculate the patient's total score. Does this patient have any neurological impairment?

Culture

A way of life that distinguishes a particular group of people from other groups

adventitious breath sounds

Abnormal sounds that can be auscultated over the lung fields are called _______________________________.

b, c, d

Acceptable, polite communication styles between professionals and their patients vary greatly among different cultures. Acceptable styles also vary within cultures. When approaching a patient from a cultural background other than your own, you should (select all that apply) a. Maintain distance and avoid direct eye contact to be on the safe side. b. Observe how the family interacts and take your cues from that. c. Ask another professional from that cultural background for advice, if possible. d. Find out information about that culture from a different source, such as a pertinent website or text. e. Communicate in the way that makes you feel most comfortable.

According to The Joint Commission, all patients have the right to a. Receive medical care considerate of their culture, religion, and spiritual being. b. Have a service performed in the hospital chapel of their religion. c. Have meals prepared according to their cultural preferences. d. Receive care from nurses of the same culture or religion as the patient.

Active listening is a. Hearing what the patient has to say and then providing direction or advice. b. Hearing what the patient has to say and then expressing your feelings about the content. c. Hearing what the patient has to say, being attentive to nonverbal messages, and providing feedback. d. Hearing what the patient has to say, being attentive to nonverbal messages, and providing an interpretation to the patient.

congruent

Agreement between verbal and nonverbal communications

An LPN/LVN working in the hospital overhears a CNA mocking a patient for her belief that an evil spell has been cast on her, causing her illness. The nurse understands the need to (select all that apply) a. Reprimand the CNA in front of other staff for disrespectful behavior. b. Tell the CNA and other staff about other patients in the past with strange beliefs. c. Take the CNA aside and explain that these words are insensitive to the patient's cultural beliefs. d. Require the CNA to apologize to the patient and staff for being disrespectful.

Another nurse working on your floor reports that one of the patients has an apical pulse of 87 bpm and a pulse deficit of 9. You know that means the patient's radial pulse was a. 96 bpm. b. 87 bpm with 9 skips. c. 78 bpm. d. 9 bpm.

palpation

Application of your hands to the external surfaces of the body to detect abnormalities of the skin or tissues just below the skin is termed ____________________.

As a team leader, you have a responsibility to tell the people you supervise about your facility's policies and procedures. (T/F)

Asking a patient, "Do you understand?" after giving directions is an appropriate way to confirm knowledge. (T/F)

At which of the following locations can you best hear the sound of the aortic valve? a. Just to the left of the sternum in the third intercostal space b. To the left of the sternum in the fifth intercostal space in the midclavicular line c. Just to the right of the sternum in the second intercostal space d. Just to the right of the sternum in the fourth intercostal space

Transcultural nursing

Care that crosses cultural boundaries or combines elements of more than one culture

Retractions

Chest wall appears sunken in between the ribs or under the xiphoid process as the patient inhales

Cultural competence

Choosing to be aware of and familiarize oneself with aspects of cultural differences

a, c, d

Communicating with the hearing impaired can be a challenge. Which of the following techniques has been identified as helpful? (Select all that apply.) a. Facing the person and getting their attention before starting to communicate b. Speaking clearly with markedly increased volume c. Speaking to the patient, not the interpreter, if there is one present d. Eliminating background noise or other distractions e. Arranging for an interpreter to be present

Communication between two people is called one-sided communication because one side gives communication, and the other side receives the communication. (T/F)

Communication is the process of informing. (T/F)

Accommodation response

Constriction of the pupils when focusing on a close object and dilation when focusing on a far object

Provide information and conversational communication to the patient who is unresponsive. By doing so, you address both the psychological and physiological needs of the patient. Use simple, conversational language and explain what you are doing. Use therapeutic touch and stroke the patient to convey a sense of security. Remember not to discuss other patients in front of the patient who is unresponsive, who may be able to hear and misinterpret the information.

Describe how one can communicate with a patient who is comatose or unresponsive

Cultural diversity

Differences between groups of people in a certain geographical area, such as a country or medical community

Orthopnea

Difficulty breathing while lying flat

Dysphasia (partial loss)

Difficulty coordinating and organizing the words correctly

Open-ended questions or statements

Discourages answering questions with one or two words

Upward communication can be improved by stating the issues very clearly, explaining the reason for the communication (whether it is a complaint, comment, or request), and explaining the benefits to yourself and others if a change is requested. People in authority expect communication to come through the chain of command.

Discuss ways to improve upward communication in a facility.

Downward communication is communication with people you supervise. (T/F)

Sordes

Dried mucus or food caked on the lips and teeth

Ptosis

Drooping of the eyelid

During a focused assessment of a patient's circulatory system, you were unable to palpate the left pedal pulse although the right pedal pulse was strong. What should be your first action? a. Notify the health-care provider. b. Check the blood pressure in the left leg. c. Palpate for the left posterior tibialis pulse. d. Obtain a Doppler ultrasound of the pedal pulses.

paresthesia

During assessment of your patient, you notice that the patient has numbness of the left side of their face. You would use the medical term _________________ to document this finding.

1st shine light in left eye while observing size and rate of constriction of left pupil. Shine light in the left eye again while observing size and rate of constriction of right pupil. Repeat process for the right eye. Both pupils should be the same size, constrict to both sources of light stimulus, and constrict at the same rate.

During examination of the eyes, you check something known as consensual reflex. How is this done?

Providing general leads

Encourages initiation or elaboration of a conversation

Excursion

Equal chest expansion during inspiration

Placing the patient in a comfortable position to communicate, making sure the patient has their eyeglasses or hearing aid (or both, if applicable), and determining which communication method works best for the patient (e.g., a portable text-to-speech communication device, a communication board, or just a pad for writing). If a formal conversation is planned, make sure all the patient's needs have been addressed and that they are as comfortable as possible. For everyday patient care interactions, try communicating with the patient by asking yes-or-no questions and asking them to blink their eyes or shake their head for a response. Remember, being intubated is highly stressful for the responsive patient. Try to alleviate the stress by developing effective communication strategies.

Explain how to enhance communication with a patient who is mechanically ventilated.

The purpose of performing an initial shift assessment is to establish a baseline regarding the patient's condition. It is used to to compare against any changes the patient may make, including improvement and deterioration.

Explain the importance of performing an initial shift assessment within the first hour of your shift.

body language

Facial expressions, posture, body position, behavior, gestures, touch, and general appearance

Religion

Formal structured system of beliefs, values, rituals, and practices of a person or group based on teachings of a spiritual leader

Giving reports to the oncoming shift is considered confidential. (T/F)

Looking at alternatives

Helps patients explore options when making decisions

Seeking clarification

Helps to verify that the message sent was what was intended

Rural areas may have more limited access to health care providers and facilities. Residents in low income areas of larger cities may have difficulty accessing health care providers and facilities.

How can geography be a barrier to health care?

How can you communicate in a stressful situation? a. Use the ISBARR communication format, which, if followed, will cover all aspects of communicating in a stressful situation. b. Use the ISBARR format, allow your voice to reflect the urgency of the situation, and make sure your movements are purposeful and focused. c. Allow your voice to reflect the urgency of the situation, make sure your movements are purposeful and focused, and inform others of what you think is wrong. d. Allow your voice to reflect the urgency of the situation, make sure your movements are purposeful and focused, and let the most senior person in the room do the communicating.

State what the problem is and what you think is causing it to occur.

How does the nurse "Assess the situation" using ISBARR?

So that you can look at the patient and make eye contact as they answer

How should you position the computer screen when you are obtaining information from the patient that must be entered into the electronic health record?

If you hear a shrill, high-pitched, crowing sound coming from the room of a 3-year-old child who has croup, you recognize the ominous sign known as a. Crackles. b. Wheezes. c. Pleural friction rub. d. Stridor.

When communicating with other nurses, such as a nurse supervisor or IV team nurse, or when questions are anticipated and answered.

In what circumstance would it be best to communicate information using the ISBARQ format?

incivility

Interacting with a lack of courtesy or respect toward others is ________________________________.

Interpreting information is not a part of communication but is a part of listening. (T/F)

It is not important for the shift report to be standardized in a facility, but it is important that the nurses coming on duty have plenty of time to ask questions. (T/F)

1. vital sings 2. level of consciousness 3. orientation to four spheres 4. ability to follow simple commands 5. Pupillary response to light (direct reflex, consensual reflex, & accommodation) 6. speech clarity and appropriateness 7. left and right facial symmetry (eyelids & smile) 8. movement, strength, and equality of hand grips 9. movement, strength, and equality of dorsal flexion & plantar flexion

List all the assessments that are part of a neurological examination.

1. economics 2. education 3. geography 4. language stereotyping 5. prejudice 6. discrimination 7. misunderstanding

List three barriers related to culture and explain how they can hinder access to health care.

Auscultation

Listening to the sounds produced by the body (typically using stethoscope to assess the quieter sounds made by the heart, lungs, intestinal tract, and arteries of the neck)

Stereotyping

Looking at a person or group with preconceived ideas; may lead to mistreatment

Multiple areas of the brain are involved with all forms of communication. Which of the following is the likely outcome if your patient has a stroke that affects the left frontal lobe (Broca area)? a. Loss of ability to perceive touch b. Loss of vision c. Loss of ability to formulate thoughts d. Loss of movement in muscles that control speech

shared meaning

Mutual understanding of the meaning of a message

Nonverbal language can be expressive. As a nurse and a human being, you may experience negative feelings toward a patient, even though you try to overcome it, and you can strongly convey this negativity by your attitude. Which of the following is the best course of action for you should you find you have negative feelings toward a patient? a. Ask to be reassigned. b. Maintain a greater distance between you and the patient, which will provide a buffer for your feelings. c. Be aware of the attitude you display by exhibiting open, focused, nonverbal communication. d. Communicate your feelings to the patient in a nonjudgmental manner.

Nurses should be mindful that the complications of illness, trauma, or any medical condition may lead a patient to question their faith. (T/F)

One barrier to health care is when the patient is not fluent in the same language as the medical staff. (T/F)

People will let you know how well you are communicating by giving you feedback. (T/F)

Giving information

Provides relevant data

Restatement (validation)

Relates in different words the heart of what a patient said

Spirituality

Relationship of the spirit to the body, mind, environment, and other people

Reflection

Repeats same words back to the patient

Research studies have found that there is no relationship between an individual's religious beliefs or practices and their health. (T/F)

Summarizing

Restates the important points

Select a sequence to present each patient's report so you will be less likely to forget something. (T/F)

c, e, f

Select the symptom(s) from this list of assessment findings. (Select all that apply.) a. Flushing b. Fever of 102.8°F (39.3°C) c. Nausea d. Vomiting e. Light-headedness f. Cramping g. Guarding h. Hypoactive bowel sounds

Shared meaning refers to two people deciding what another person meant. (T/F)

Offering self

Shows concern and willingness to help

Spiritual care is an understanding of the differences between spirituality and religion, as well as an understanding of one's own spirituality, beliefs, and values. (T/F)

Spiritual distress only occurs during one's own illness or injury, especially if the illness is terminal. (T/F)

The Joint Commission recommends which type of shift-to-shift reporting? a. A recorded report so the on-coming staff can listen to specific information again if needed. b. A group report where all on-coming staff are in a room with all the off-going staff. c. A bedside report where on-coming and off-going staff go to each patient's room together. d. No shift report because it is a violation of HIPAA.

Some cultural barriers to communication include language differences, differences in nonverbal communication messages, and differences in perceptions of authority. Language barriers may be the easiest to overcome by obtaining an interpreter who is acceptable to the patient. Body language, such as whether to make eye contact, how close to get to the patient, or whether to sit or stand during communication, can all send the wrong message when people from different cultures interact. The best way to avoid this is to ask the patient about their preferences and any cultural considerations that might be needed. It is also true that different cultures have differing mores regarding authority figures. A nurse must find out who the family views as the authority when family teaching is required.

The United States is culturally diverse. Discuss two or three cultural factors that can interfere with nurse-patient communication and how you would overcome these obstacles.

empathy

The ability to identify intellectually (not emotionally) with the experience, feelings, thoughts, or attitudes of others is called _____________________.

CTA stands for clear to auscultation. This refers to the lungs and means that there is air moving in and out during respiration, and that no adventitious breath sounds are heard.

The acronym CTA stands for what? Which means what?

PMI stands for point of maximal impulse, which is located over the apex of the heart. One can steal the heart contraction by placing ones fingertips over the PMI. This is generally located in the fifth intercoastal space, in the left midclavicular line of the adults chest.

The acronym PMI stands for what? Which means what?

The basis of (essential to) the nurse-patient relationship is a. Admiration. b. Integrity. c. Trust. d. Caring.

The bottom of the lower lobes of the lungs extends down to which of the following? a. Eighth intercostal space in the midclavicular line, anteriorly b. Sixth intercostal space, laterally c. 10th intercostal space, anteriorly d. Sixth intercostal space in the midclavicular line, anteriorly

Ethnicity

The categorization of a group of people by a distinctive trait

non verbal communication

The communication revealed through facial expressions, posture, body position, behavior, gestures, touch, and general appearance

The cone portion of each lung extends approximately 1 inch above the medial aspect of the clavicle and is called what? a. Lower lobe b. PMI c. Bronchus d. Apex

verbal communication

The conscious use of words, either spoken or written

The correct sequence to follow when assessing the abdomen is a. Auscultation, olfaction, observation, palpation, and percussion. b. Observation, auscultation, palpation, percussion, and olfaction. c. Observation, palpation, percussion, auscultation, and olfaction. d. Olfaction, auscultation, observation, palpation, and percussion. e. Olfaction, observation, auscultation, percussion, and palpation.

proxemics

The distance, or personal space, people place between themselves and others

Assess the patient to ensure that she is awake, alert, and oriented in all 4 spheres. Observe her for strength during your interaction, such as during her speech and movement as you assess pressure points for erythema, edema, and skin integrity. Assess her mucous membranes for moister and check her skin turgor for elasticity. Offer her fluid to drink and assess her intake/output thus far today. Assess her radial and pedal pulses for strength and equality, and assess her for discomfort and pain. Ensure that the bed is in the lowest position, the call light is within reach, and rails are up as needed according to policy.

The female patient in room 314 is 81 years old and is dehydrated. She was too weak to get out of bed at home for several days and has been an inpatient on bedrest with intravenous (IV) fluid replacement for 3 days. She is weak and has to be repositioned every 2 hours or more often as needed to prevent skin breakdown. Describe the assessments that should be performed in relation to these limited data.

symptoms

The information that the patient tells you provides you with subjective data that require validation. What are these pieces of subjective data called? ______________.

The language used during communication has a significant impact on how that communication is received. Which of the following statements can be used as a guide for communicating a plan of care to your teenage patient and her family? a. Speak to all of them as mature adults. b. Speak to the teenager in common, widely acceptable slang terms to put her at ease. c. Use the correct medical terminology when describing the plan to all of them. d. Use common, everyday language to describe the plan.

The nurse must show respect for the patient's beliefs about health care and promote good health practices. (T/F)

The off-going nurse reported to you that one of your patients had been having an irregular pulse for several hours. You plan to assess this patient's heart rate carefully during your initial patient rounds at the beginning of your shift. Which of the following would be the most accurate way to do this? a. Palpate a radial pulse in both wrists for 30 seconds. b. Auscultate the apical pulse for 60 seconds. c. Take a second nurse with you to palpate the radial pulse at the same time that you auscultate the apical pulse for 60 seconds. d. Palpate the PMI for a full minute.

The shift-to-shift report is so important that The Joint Commission has made it a patient safety goal. (T/F)

Feedback

To complete the communication process, a return message is sent by the receiver of the original communication to indicate the message has been received, processed, and comprehended

4/14/28 1115 BP-158/84. T-98F, P-79 2+ reg, even. Awake , alert, and oriented x4. SpO2 99%. Reports mild, dull, aching discomfort at site of left lower leg wound rates it 4 on scale of 0 to 10. Denies need for pain med. or any other discomforts. Speech clear & appropriate. Follows simple commands. Talkative. Smiling. Pupils 5mm. PEARLA. Conjunctiva pink & moist. Oral mucous membranes pink and moist. NO JVD. Skin olive, warm, dry. Turgor elastic. Heart sounds distinct and reg. 70 bpm. Auscultated breath sounds CTA in 4 lobes with fine rales in RLL. Bowel sounds hypoactive in LLQ active x3 quads. Abd. flat, soft, nontender to palpation. States last BM was last night and voided last about 1 hr ago. IV in left lower forearm infusing 1000 mL 1/2 NS 30 mL/hr via pump. IV site drsg. intact. no erythema or edema Left hand grip weaker than right. States due to stroke 5 years ago. Cap refill brisk in hands bilat. and sluggish

Today is April 14, 2028. The time is 11:15 a.m. Gabe Cravenson, a 37-year-old male patient, has been newly diagnosed with type 1 diabetes (insulin dependent). He also has an infected wound on the left lower leg that is dressed. His blood pressure is 153/84. His strength of his lower extremities is strong and equal on both sides (dorsal flexion and also plantar flexion). His apical pulse is 70 bpm, and his radial pulse is 70 bpm. There is no jugular vein distention. His respirations are 19 per minute. His oral temperature is 98.2°F (36.8°C). He is wide awake and talking. His speech is clear and makes sense. His oxygen saturation level is 98%. He is oriented to person, place, time, and situation. He has an IV in his left forearm that is infusing 1,000 mL of half-strength normal saline solution. The IV rate is 30 mL/hr and is controlled by an IV pump. His conjunctivae are both pink and moist. Both of his pupils constrict from 5 mm to 3 mm very quickly when a light is shined in each of them. The right pupil also constricts when shining the light in the left eye and vice versa. When he changes his focus from a distant object to a near object, the pupils constrict and vice versa. His mouth, lips, tongue, and gums are pink and moist, and membranes are intact. His heart sounds are distinct. His heart rhythm and respirations are regular. His breath sounds are clear in all the left lobes and the right upper and right middle lobes, but the right lower lobe has fine rales. His hand grips show the right one to be significantly stronger than the left. He states it is because of a small stroke he suffered 5 years ago. The capillary refill in nailbeds of both hands is brisk. The capillary refill in both feet is sluggish at 5 seconds. The leg wound is 4 inches by 3 inches and one-eighth inch deep. The base of the wound is pale with o

signs

Use of your four senses allows you to detect evidence of illness or injury. This evidence that you collect, with the exception of something the patient may tell you, provides you with objective data. What are these pieces of objective data called? ___________________.

Using silence

Uses pauses of up to several minutes without verbalizing

active listening

Using all the senses to interpret verbal and nonverbal messages is called _____________________.

a, c, e, f

What are the acronyms used to indicate the quadrants of the abdomen? (Select all that apply.) a. RLQ b. LMQ c. LUQ d. RMQ e. RUQ f. LLQ

1. expressive (Broca) aphasia: know what they want to say, but can't say it 2. receptive (Wernicke) aphasia: cannot comprehend spoken language 3. global aphasia: cannot speak or understand

What are the three types of aphasia?

Assessments of the lower extremities includes checking color and temperature of the feet; ability to move hip, knee, and ankle joints the full range of motion of normal function; for edema; for presence, strength, and equality of pedal pulses from left to right; capillary refill in nailbeds of both feet and compare length of time of refill in left toe vessels with that of the right; strength and equality of plantar and dorsal flexion.

What assessments should you make of the lower extremities in an initial shift assessment?

introduction, situation, background, assessment, recommendation, questions

What is ISBARQ?

introduction, situation, background, assessment, recommendation, read back

What is ISBARR

Used to communicated in stressful situation in the medical field. (ex. report medication error to doctor)

What is ISBARR used for?

To prevent depersonalizing the patient and focusing on the computer, not on the patient, allowing you to promote trust and project caring

What is the reason for positioning the screen in this manner?

lethargic

What medical term would describe a patient who is drowsy or mentally sluggish? ____________________________________.

What type of assessment is performed on admission? a. A focused assessment b. An initial head-to-toe shift assessment c. A comprehensive health assessment d. A brief admission systems assessment

What type of communication style is this? "I want to talk with you about Mrs. G's dressing change. It was supposed to have been changed 2 hours ago." a. Assertive b. Avoidant c. Aggressive

What type of communication style is this? "I'm going to change Mrs. G's dressing; I see you didn't get to it. Did you get busy?" a. Assertive b. Avoidant c. Aggressive

What type of communication style is this? "You need to understand that your work reflects on me." a. Assertive b. Avoidant c. Aggressive

When assigning tasks to a team, you should explain how one task relates to another even if two different people are doing the tasks separately. This is called "job rationale." (T/F)

When caring for a patient in clinical, you are aware that he only responds with "yes" or "no" when you talk with him. What strategies could you use to better communicate with this patient? a. Rely on nonverbal communication only, watching him closely at all times. b. Try to find out his favorite sports team and talk with him about it. c. Use open-ended questions when eliciting information from him. d. Ask his family how to get him to talk more

a, b, c, d

When communicating with older adults, it is important to be aware of (select all that apply) a. Any impairments in vision or hearing. b. Chronic pain issues. c. Dementia that interferes with communication. d. Environmental distractions. e. The need to speak more slowly and loudly than usual.

When communicating with patients of various ages, it is important to match your communication strategies to each patient's a. Style of communication. b. Developmental stage. c. Reading level. d. Cultural sensitivity

a, d

When the LPN/LVN is providing home care for patients of different cultures or religions, the LPN/LVN should expect to (select all that apply) a. Show respect for the patient's beliefs. b. Educate the patient on the unscientific nature of their beliefs. c. Be pressured by the patient to convert the nurse to their religion. d. Adapt their services even more than in the hospital setting.

Clear information about who is involved (patient name and room number) and a brief overview of the problem.

When using the ISBARR method of communication, what is included in the "Situation" step?

When you assessed the radial pulse and the apical pulse of one of your patients, you noted that one of the pulses was slower than the other one. Which one of the following describes the assessment finding that you obtained? a. The radial pulse was faster than the apical pulse. b. The apical pulse was faster than the radial pulse. c. The radial pulse was the same as the apical pulse. d. The apical pulse was slower than the radial pulse

When you communicate effectively and professionally, you are role modeling, too (T/F)

Which communication form will be compromised if your patient has a stroke that affects the occipital lobe? a. Loss of ability to perceive touch b. Loss of vision c. Loss of ability to make gestures d. Loss of movement in muscles that control speech

Which communication form will be compromised if your patient has a stroke that affects the parietal lobes? a. Loss of ability to perceive touch b. Loss of vision c. Loss of ability to make gestures d. Loss of movement in muscles that control speech

Which lobe of the lungs is not accessible for auscultation posteriorly? a. The left upper lobe b. The left lower lobe c. The right upper lobe d. The right middle lobe

a, b, c, e

Which lobe(s) of the lungs is (are) accessible for auscultation both anteriorly and posteriorly? (Select all that apply.) a. The left upper lobe b. The left lower lobe c. The right upper lobe d. The right middle lobe e. The right lower lobe

a, b, c, d

Which of the following are barriers to communication? (Select all that apply.) a. Using clichés b. Asking personal, probing questions c. Being frank about disapproval d. Standing over a seated person e. Using silence

b, c, d

Which of the following assessment findings is not within the textbook normal range? (Select all that apply.) a. 23 bowel sounds per minute in each quadrant b. Capillary refill of 5 seconds in a 41-year-old male patient c. Respiratory rate of 24 per minute d. Systolic pressure of 86 mm Hg e. Diastolic pressure of 62 mm Hg

Which of the following can be indicators of a person's hydration level? a. Temperature of skin on lower extremities b. Sluggish capillary refill c. Positive consensual reflex d. Weight

Which of the following findings would indicate an abnormal neurological check? a. Thick, dirty hair b. Lethargy c. Pink color of the lower extremity nailbeds d. Pulse rate of 44 bpm

a, b, d, e

Which of the following interventions are appropriate to assist a patient for whom you have identified spiritual distress? (Select all that apply.) a. Use therapeutic communication techniques to encourage expression of feelings. b. Allow the patient plenty of opportunities to express their feelings. c. Teach the patient how your religious beliefs will help the patient to feel better. d. Offer presence. e. Spend adequate time with the patient and pay attention to their actions, responses, and affect. f. Encourage the patient by telling them that they need not feel abandoned.

a, b, c

Which of the following organizations helped establish standards that promote the rights of patients to receive spiritually sensitive care? (Select all that apply.) a. The Joint Commission b. North American Nursing Diagnosis Association c. American Nurses Association d. American Association of Nurse Practitioners e. Professional/Vocational Nurse Association

Which of the following would be the most accurate description of dorsal flexion assessment? a. Ask the patient to press their toes toward the foot of the bed, applying pressure against the palms of your hands so you can assess the strength and equality of the flexion between the two sides. b. Ask the patient to pull their toes toward the head, pulling against the palms of your hands so you can assess the strength and equality of the flexion between the two sides. c. Ask the patient to gently point their toes toward the foot of the bed so you can assess agility and coordination of the lower extremities. d. Ask the patient to gently point their toes toward the head so you can assess the neuromuscular activity of his lower extremities

S1 is louder

Which of the two heart sounds is the loudest? _______________________________.

b, c, d

Which of these are examples of cultural diversity in a hospital? (Select all that apply.) a. Using RNs, LPN/LVNs, and CNAs as part of the nursing staff b. Having employees from a variety of countries and cultures c. Employing people of a variety of races d. Employing people who may speak a variety of languages as well as English e. Accepting only patients of selected ethnicities and cultures

halitosis

While assessing the patient's oral mucosa, you detect severely unpleasant sour breath. What is the correct medical terminology for this finding? ______________.

denotative meaning, connotative meaning

Words can have two layers of meaning. ___________ refers to the literal meaning, while _______________ refers to the emotional associations attached to a word. (ex. love, cancer, & death)

Jaundice

Yellow or orange coloring of the skin and mucous membranes

a, c, e

You are assigned to care for a female patient with severe vision impairment. How can you best communicate with her? (Select all that apply.) a. Identify yourself when you enter the room. b. Announce when you will be performing direct patient care before you touch the patient. c. Avoid raising the volume of your voice. d. Avoid using body language because she cannot see you do so. e. Before leaving the room, ask if she needs anything and tell her that you are leaving.

Ask the patient what she would like to be called, and use that name. Refer to her using the pronoun of her gender identity. Be kind and courteous while speaking to her about her health needs, remembering that the LGBTQ+ community has higher rates of sexually transmitted diseases, HIV, AIDS, and depression. Find out if she has kept up with screenings for her sex assigned at birth, such as prostate examination, if appropriate. Encourage your fellow nursing staff to use the pronouns of her gender identity and to call her by the name she wishes to use. Do not encourage ridicule of any kind. Help them see her as a patient with specific needs and help them deliver nursing care in a kind, caring, and thoughtful way.

You are assigned to care for a new admission whose legal name is Trevor Taylor. However, Trevor is a male-to-female transgender person. Several of the nursing staff are discussing this situation and say they are not sure what to call the patient. One staff member says, "Just use 'it,'" and laughs. How will you approach this patient? What, if anything, will you say to your coworkers?

You are caring for a patient with narrowing of the mitral valve. You plan to assess the mitral valve during your initial assessment. Where will you be best able to auscultate the mitral valve? a. The right base of the heart b. The left base of the heart c. The PMI d. The left lateral sternal border

You are helping bathe a 27-year-old female patient who has had back surgery. Of the following, which is the best way to communicate your respect for the fact that you are "invading" her personal space? a. Pull the curtains so no one can see you or the patient while you help with her bath. b. Pull the curtains, give her a dry towel, and tell her she can use it to "cover up." c. Pull the curtains and ask her how you can help her. d. Pull the curtains and tell her to wash her face and hands, then you will wash her back, and then she can "finish."

You are interviewing a new patient who is being admitted to the psychiatric unit. Your technique in this interview will largely be a. Nondirective, with many open-ended questions. b. Directive, with many closed-ended questions. c. Directive, with many open-ended questions. d. Nondirective, with many closed-ended questions.

You ask an LPN on your team to interview a patient being admitted for surgery. You walk by the room and observe that the nurse is seated in the chair while the patient is seated on the bed. The nurse is leaning forward slightly. By her body position, you would conclude that a. She is conducting the interview in an appropriate manner. b. She is too casual and should not be sitting.

You enter your patient's room and find him sitting in a chair with his eyes closed. He has a grimace on his face and is holding his body rigidly. You ask him if he is feeling okay, and he says, "Yes, I'm fine. Really." Which of the following best explains this situation in terms of communication? a. He is communicating to you that he's fine. b. His verbal and nonverbal messages are congruent. c. His verbal and nonverbal messages are incongruent. d. He is sarcastic, but it is understandable.

PERRLA

You have assessed the patient's pupils by shining a light into both pupils as you learned to assess both pupil reflexes and accommodation response. What acronym would you use to document that all findings were within normal parameters? ______________.

a, b, d, e

You have just completed an initial shift assessment of a male patient in his 30s with a history of hypertension and elevated cholesterol. Which of the following assessment findings provides information about his circulatory system? (Select all that apply.) a. Skin is pale, warm, and dry. b. BP is 164/98. c. R is 27 regular and even. d. AP is 94 regular and 2+, RP is 90 irregular and 2+, and pulse deficit is 4. e. Pedal pulses are weak and equal bilaterally.

You have just completed an initial shift assessment of your 72-year-old female patient who has heart failure. Which of the following assessment findings causes you the most concern? a. Fine papular rash under both breasts b. Reports her last BM was 2 days ago c. AP 78 regular and distant d. Has not voided in 12 hours

You have just completed auscultation of the patient's lungs. The sounds that you heard were sort of rattling; however, they cleared when the patient coughed. What term accurately describes what you heard? a. Crackles b. Rhonchi c. Wheezes d. Stridor

rapport

Two people are said to have a _________________ when their relationship is characterized by mutual trust and understanding.

Unconscious bias

Unconscious stereotyping, judging, or discriminating against an individual or a group of people

When talking with a health-care provider, receiving orders, and then reading the orders back to be sure that you have heard it all correctly.

Under which circumstances is ISBARR most appropriate to use?

intimate (proxemics)

physical contact to 18 inches

Practice on paper...

Today is your first day on an Alzheimer's unit in a long-term care facility. Which of the following is the best way to begin to establish a connection with your patients? a. Have a peer formally introduce you to the patients. b. Smile at the patients. c. Sit among the patients. d. Read aloud to the patients

a, c, e

Transcultural nursing is about recognizing and addressing (select all that apply) a. Cultural differences among patients. b. Treating all patients exactly the same. c. Cultural differences among the health-care staff. d. The difficulties of communicating with patients from different cultures. e. The culture of the individual nurse.

b, d, e, f, h, i

You know that it is important to foster rapport and communication with all of your patients. Which of the following actions and interventions would be helpful to increase the effectiveness of your communication during the patient interview? (Select all that apply.) a. Talk most of the time you are with the patient so that they do not get nervous. b. Smile frequently. c. Think of a good nickname you can call the patient to put them at ease. d. Sit in a chair beside the bed and give the patient at least 5 to 10 minutes of your time. e. Smile and be genuine. f. Always introduce yourself while you are smiling and explain what you are about to do before you perform an intervention or assessment. g. Avoid touching the patient to prevent offending them. h. Be nonjudgmental even when you do not agree with some aspect of the patient's life situations, experiences, beliefs, or opinions. i. Be aware of possible cultural restrictions or influences. Verify them when uncertain.

You know that when assessing the pulse there is more than one characteristic you should assess. Which of the following best identifies the characteristics you must assess? a. Rate, rhythm, and strength b. Rate, volume, and strength c. Regularity and number of beats per minute d. Site of PMI, rate, and strength

a, d

You work the day shift. A nurse on the evening shift, one whom you frequently report off to, is often 20 minutes late. She says it isn't her fault because she leaves in time for work, but the parking lot is so full when she arrives that she has to wait for a space to open up. Which of the following statements on your part reflects a good approach to resolving this conflict? (Select all that apply.) a. "I have to be home on time for my kids. If you're late, I get nervous and worried." b. "You have to allow more time for parking. You make me late getting home for my kids, and that is really wrong." c. "Think about how you would feel if the night shift was late most of the time." d. "I've put up with this for a long time now. I'm going to speak with the nurse manager about this." e. "I don't care what the problem is. You need to be here on time so I can leave on time."

Assess the patient's lungs for adventitious breath sounds, respiratory rate and characteristics, and effort to ensure that he is not getting into fluid overload problems. Review his intake/output thus far for the day. Determine where he is with regard to fluid restrictions and volume of urine output. Assess any urine for amount, color, and clarity. Assess for edema of extremities and strength of peripheral pulses. Asses apical pulse rate and characteristics. Assess for shortness of breath upon exertion, discomfort, and pain. Also assess for weight gain. Assess safety factors such as bed position, rails, and call-light accessibility.

Your 76-year-old male patient has impaired kidney function. He is on a fluid restriction of 1,500 mL per 24 hours. You need to perform a focused assessment of his renal system before discharging another patient who is also assigned to you. Describe the assessments that you will perform to establish the status of his kidney function and ensure that he is not getting into fluid overload problems.

b, d, f

Your instructor has asked you to come to the patient's room to hear a good example of a murmur and a bruit. You know that there are specific instances when you use the bell versus the diaphragm side on your stethoscope and when you use light pressure as opposed to pressing to make a firm seal against the patient's skin. Which of the following correctly describes how to use the bell and diaphragm chest piece of your stethoscope? (Select all that apply.) a. Use the flat diaphragm to auscultate lower-pitched sounds. b. Use the bell to auscultate lower-pitched sounds. c. When using the bell, press firmly to seal it against the skin. d. When using the flat diaphragm, press it firmly to seal it against the skin. e. Murmurs and bruits are considered high-pitched sounds. f. The S1 and S2 are considered high-pitched sounds.

Your patient had spine surgery 2 days ago and is scheduled for discharge tomorrow. He has been taking narcotic pain relievers every 4 hours around the clock. You note that the patient has not had a bowel movement since surgery. You know that the narcotics can be constipating, and you think it would be best if the problem is handled before the patient leaves for home. There is no order on the chart for a laxative. From the following possible actions, choose which you think represents the most focused and necessary thing(s) for you to do as you prepare to call the doctor for a verbal order for a laxative. a. Gather information about the patient's usual bowel habits; ask if he feels constipated and if he has used laxatives in the past. b. Ask the patient what laxative has worked for him in the past. c. Ask the patient to try to have a bowel movement. d. Get the chart, and have a pen ready.

Your patient has an infected wound with a lot of dead tissue called eschar that is preventing healing. The doctor plans to debride the wound, which means to remove the dead tissue. You go in to prepare the patient for the procedure, which is done right at the bedside. Which of the following is the best way to communicate what will happen? a. "The doctor is going to cut away all the black, dead skin." b. "The doctor is going to debride the eschar." c. "The doctor is going to remove dead tissue so the wound can heal." d. "The doctor is going to clean the wound."

08-22-28 0800 Refused food. States she feels "like a freak" due to her illness and dislikes feeling different from her friends. Encouraged to express feelings---------------------------------------------------------R. Casillas LVN 08-22-28 1100 Discussed fears of becoming sicker and anger that she has these health issues. Offered written info about kidney failure and dialysis. Discussed people who remain on dialysis for many years and do very well. Offered information on transplants as well, with pt. was eager to hear about. Referral to transplant team for info session-------------------R. Casillas LVN

Your patient is a 14-year-old female, Charlene Jefferson, who has chronic renal failure from an inherited disorder. She has been started on dialysis and has a dialysis shunt in her left forearm. She is refusing to eat and will not speak to her doctors. Her doctors told her she will have to get a feeding tube if she does not eat. Based on your understanding of developmental issues, you believe Charlene is sad and angry about her diagnosis and probably does not like that she looks different because of the shunt in her arm. You realize that addressing all the issues will take several conversations, but your goal now is to establish a rapport with Charlene. You have just a few minutes and you enter her room. You introduce yourself and give her a big smile. You pull up a chair and sit with her so that you are at eye level with her. You have a relaxed posture but focus your attention on her by making eye contact. "Hi, Charlene, my name is Cathy. I'm your nurse today. How are you doing?" Charlene quietly says, "Okay," and stares out the window. "I sense you're not happy, Charlene. What happened?" you ask. Charlene tells you a little bit about her health issues and ends by saying, "I hate having this problem. I feel like a freak!" "Do you feel different from your friends?" you ask. When she nods her head yes, you say, "I really want to help you, Charlene. Can we set up a time to talk later today?" Charlene nods yes, and you determine that you can come back at 11 a.m. to talk with her. You come back at 11 a.m. on the dot, sit down, and smile at her. You change your facial expression to one of concern, and say, "Let's pick up where we left off, Charlene. Tell me about your friends and how you feel different." Charlene begins to open up a bit about her life, expressing some general anger at her situation and her fears that she wi

Therapeutic communication

________________________________ is patient centered and promotes a greater understanding of a patient's needs, concerns, and feelings.

aphasia (total loss)

________________________________ is the inability to speak or understand language.

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