Potter Perry Chapter 26 - Documentation and Informatics, Potter-Perry Chapter 49 Sensory Alterations, Chapter 49 (Potter & Perry) Sensory Alterations, 211 exam

flow sheets

Data entry of assessments such as vital signs hygiene measures, ambulation, restraint checks

Problem oriented medical record (POMR)

Database, problem list, care plan, and progress notes

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A) "CPOE reduces transcription errors." B) "CPOE reduces the time necessary for health care providers to write orders." C) "Health care providers can write orders from any computer that has Internet access." D) "CPOE reduces the time nurses use to communicate with health care providers."

"CPOE reduces transcription errors."

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications C) Your evaluation that the patient is "needy" D) How much the patient ate for breakfast E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

When assessing a 45-year-old patient's sensory status, which of the following assessment findings does the nurse consider a normal part of aging? A. Presbyopia and the need for glasses for reading B. Reduced sensitivity to odors C. Impaired balance and coordination D. Reduced taste discrimination

A. Presbyopia and the need for glasses for reading Visual changes during adulthood from ages 40 to 50 include presbyopia and the need for glasses for reading. Gustatory and olfactory changes begin around age 50 and include reduced taste discrimination and reduced sensitivity to odors. Proprioceptive changes common after age 60 include increased difficulty with balance, spatial orientation, and coordination.

The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which strategy is not effective in enhancing a patient's impaired vision? A. Use of fluorescent lighting B. Use of warm incandescent lighting C. Use of colors with sharp contrast and intensity D. Use of yellow or amber lenses to decrease glare

A. Use of fluorescent lighting Interventions to enhance vision include the use of sharply contrasting colors, warm incandescent lighting, and yellow or amber lenses to decrease glare. Fluorescent lighting can contribute to indirect and direct glare.

The medical record of an older adult reveals a stroke affecting the right hemisphere of the brain. Which of these assessment findings should the nurse expect to find? (Select all that apply.) A. Visual spatial alterations such as loss of half of a visual field B. Loss of sensation and motor function on the right side of the body C. Inattention and neglect, especially to the left side D. Cloudy or opaque areas in part of the lens or the entire lens

A. Visual spatial alterations such as loss of half of a visual field C. Inattention and neglect, especially to the left side A stroke in the right hemisphere produces symptoms on the left side, which includes visual spatial alterations such as loss of half of a visual field or inattention and neglect, especially to the left side. A stroke affecting the right hemisphere of the brain may result in symptoms such as loss of sensation and motor function on the left side of the body. Cloudy or opaque areas in part of the lens or the entire lens indicate cataracts

15. The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury? a. Risk for falls b. Body image disturbance c. Social isolation d. Fear

ANS: A A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.

10. A home health nurse is assembling a puzzle with an elderly patient and notices that the patient is having difficulty connecting two puzzle pieces. The nurse knows that this is most likely related to which aspect of sensory deprivation? a. Perceptual b. Cognitive c. Affective d. Social

ANS: A Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is socializing with the home health nurse, so isolation is not a problem.

18. The home health nurse is caring for a patient with a tactile deficit; the nurse is concerned about injury related to inability to feel harmful stimuli. The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action? a. Places colored stickers on faucet handles to indicate temperature and keeps a thermometer near the tub b. Asks the nurse to test the temperature of the water before entering the bath c. Replaces all lace-up shoes with Velcro ones and purchases shampoo caps d. Dispenses all medications onto a plate for easy access in the morning

ANS: A By placing color-coded stickers and other reminders about dangerous stimuli, the patient is able to safely keep up hygiene. Asking the nurse to test the water does not promote independence, although it does promote safety. Zipper and Velcro clothing is easier for a patient with a tactile deficit to wear, and shower caps allow the patient to stay well groomed with minimal effort. Leaving the lids off of medications can be dangerous, as can placing all medications out at once. It may be difficult for the patient to sort through mixed medications and select the correct types and numbers of pills.

14. A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse would be most appropriate for this patient? a. "Rinse your mouth several times a day to hydrate your taste buds." b. "Blend foods together in interesting flavor combinations." c. "Eat soft foods that are easy to chew and swallow." d. "Avoid adding spices or aromatic ingredients to food to prevent nausea."

ANS: A Good oral hygiene is important to stimulate and hydrate taste buds. Having an unpleasant taste in the mouth discourages the patient from eating. Avoid blending foods together because this confuses the ability to discriminate flavors and taste. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable.

5. Which of the following sensory changes are normal with aging? a. Impaired night vision b. Difficulty hearing low pitch c. Increase in taste discrimination d. Heightened sense of smell

ANS: A Night vision becomes impaired as physiological changes in the eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.

12. Which nursing assessment best measures cognitive functioning? a. Administer a Mini-Mental Status Exam (MMSE). b. Ask the patient his name, where he is, and what month it is. c. Ask the patient's family if the patient is behaving normally. d. Evaluate the patient's ability to read the newspaper.

ANS: A The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitive functioning. Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. Reading a paper is not a means of comprehensive assessment; in addition, a patient may be high cognitive functioning and not know how to read English.

26. A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance? a. Place a raised Braille sticker on the call button, and instruct the patient to press for assistance. b. Instruct the patient to yell at the top of his lungs to get the attention of the staff. c. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything. d. Share cell phone numbers with the patient so he can call the nurse if he needs her.

ANS: A The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Yelling at the top of the lungs is stressful for the patient and for surrounding patients. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch with her at any time. Sharing personal phone numbers with the patient is inappropriate.

7. A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with attempting to eat his meal and is becoming tearful. The nurse includes which intervention in the patient's plan of care? a. Teach the patient about special devices used to assist patients with eating meals. b. Order the patient food that does not require utensils. c. Place a consult for a home health nurse. d. Obtain an order for antidepressant medications.

ANS: A The nurse should include implementations that help the patient adapt to his deficit while maintaining independence. Teaching the patient to use assistive devices allows the patient to care for himself. Changing the type of food the patient eats may not work for every culture, where touching food with fingers is unacceptable, or the patient may not enjoy eating foods that do not require utensils. A home health nurse is not necessary as long as the patient is able to care for himself. Instead of placing the patient on antidepressants, assist the patient in attempting to adapt behavior to the sensory deficit.

4. The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Disequilibrium c. Cataracts d. Peripheral neuropathy

ANS: A Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns.

3. A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit? a. The patient frequently cleans out his ears with a cotton swab. b. The patient turns one ear toward the nurse during conversation. c. The patient isolates himself from social situations. d. The patient asks the nurse to speak loudly during conversations.

ANS: B Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the ear would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive. Asking the nurse to speak loud alters the environment but does not adapt the patient's behavior.

9. A patient informs the nurse that she often becomes nauseated when riding in motor vehicles. The nurse knows that this is related to which sensory deficit? a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance deficit

ANS: D Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. This disequilibrium can cause nausea and vomiting. The other options would not result in nausea based on movement.

25. The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location. Which nursing intervention would be effective in orienting a patient with neurological deficit? a. Assessing the patient's level of consciousness and documenting every 4 hours b. Keeping a day-by-day calendar at the patient's bedside and having the patient manage it c. Placing a patient observer in the patient's room for safety d. Informing the patient that she cannot be discharged unless she is awake, alert, and oriented

ANS: B Keeping a calendar in the patient's room helps to orient the patient to the dates and gives the patient a sense of control over her environment. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.

16. The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia. a. Expressive b. Receptive c. Broca's d. Wernicke's

ANS: B Receptive aphasia occurs when patients have difficulty understanding spoken and written word. Expressive aphasia is seen when the patient has difficulty speaking or writing words. Broca and Wernicke refer to areas of the brain where language is processed.

22. The nurse is aware that which patient is most at risk for sensory deprivation? a. A patient in the ICU under constant monitoring following a myocardial infarction b. A patient on the unit with tuberculosis on airborne precautions c. A patient who recently had a stroke and has left-sided weakness d. A patient receiving hospice care for end-stage brain cancer

ANS: B Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation is at risk for sensory deprivation because he has limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke or with brain cancer may have difficulty with tactile sensation and may have sensory deficits, but is not at risk for sensory deprivation.

27. The nurse is developing a plan of care for a patient who is having a prosthetic eye placed. Which nursing diagnosis related to patient safety is the priority for the nurse to include in the plan of care? a. Self-care deficit b. Risk for injury c. Anxiety d. Body image disturbance

ANS: B The patient with a prosthetic eye will require a period of adjustment to new depth perception and visual sensation. Until the patient adapts, preventing injury should be the nurse's priority. The other options are not directly related to the safety of the patient for eye surgery.

23. What nursing action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli? a. Placing a "Do not disturb" sign on the patient's door b. Offering the patient a back rub c. Asking the patient if he would like a newspaper to read d. Placing the patient in the room farthest from the nurses' station

ANS: B The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-human interaction and promote further social isolation.

11. Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability? a. "Have you stopped reading books or switched to books on audiotape?" b. "Are you able to prepare a meal or write a check?" c. "How do you protect yourself from injury at work?" d. "How does your vision impairment make you feel?"

ANS: B To best understand how vision is affecting self-care ability, the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing, such as preparing meals and writing checks. Switching to books on audiotape gives the nurse an idea of the severity of the deficit, but not its impact on activity of daily living. Assessing whether the patient is taking measures to protect himself is important, but this does not address self-care activities. Emotional assessment of a patient is also important but does not properly address the goal of determining the effect of visual alterations on self-care ability.

19. Often blindness occurs during childhood. Which health preventative measure is most appropriate to prevent vision impairment? a. Screen young children early for visual impairments. b. Instruct parents to report reduced eye contact from their child immediately. c. Include rubella and syphilis screening in the preconception care plan. d. Administer prophylactic antibiotics to all newborns.

ANS: C Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible. Prophylactic antibiotics are not appropriate for all newborns. Reporting reduced eye contact is recommended but is not a preventative measure.

8. Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment? a. Self-care deficit b. Risk for falls c. Social isolation d. Impaired physical mobility

ANS: C In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Both self-care deficit and fall risk are physiological risks for the patient. Impaired physical mobility would not apply to this patient.

6. A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green. The patient asks the nurse if he should no longer drive. Which response by the nurse is most therapeutic? a. "Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk." b. "Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident." c. "No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is illuminated, it means stop, and if the bottom is illuminated, it means go." d. "No, instead you should see your ophthalmologist and get some glasses to help you see better."

ANS: C Part of the normal aging process is an inability to see colors. Much as with a younger adult who is color blind, the nurse should teach the patient new ways to adapt to his deficit. This patient's accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.

1. A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" The nurse knows that the ability to recognize and interpret stimuli is known as a. Sensation. b. Reception. c. Perception. d. Reaction.

ANS: C Perception occurs when the person becomes conscious of stimuli and interprets information signals. Reception refers to receiving stimuli and creating a nerve impulse. Reaction is how a person responds to a perceived stimulus. Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms.

28. A nurse is caring for a patient who is experiencing vertigo. Which nursing intervention would assist the patient in controlling the vertigo? a. Increasing fluid intake to 3 liters a day b. Watching television instead of reading books c. Avoiding riding in vehicles and making sudden motions d. Placing several antiemetic patches on the patient

ANS: C Sudden motions and motorized travel can worsen vertigo; avoiding these will lessen the severity of the vertigo. Increasing fluid intake, avoiding reading books, and using antiemetic patches do not affect vertigo.

24. The nurse is caring for a patient who is a well-known surgeon at the hospital. Because of his status, all the hospital's physicians want to be sure to pay him a visit. The nurse notices the patient becoming more agitated and withdrawn with each group of visitors. The nurse asks the patient if he would like a "Do not disturb" sign placed on the door. A few hours later, the nurse notices a physician who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate? a. Allowing the physician to enter because he has higher authority than the nurse b. Calling for security to remove the visitor c. Firmly explaining that the patient does not wish to have visitors at this time, so do not enter the room d. Scolding the physician for not obeying the signs on the door and respecting the patient's wishes.

ANS: C The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the visitor to leave regardless of position in the hospital. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle herself with professionalism when addressing the visitor; scolding the visitor is not appropriate.

29. A nurse is caring for a patient with right-sided weakness following a stroke. Which nursing action would be least effective in promoting positive adaptation of the patient's sensory deficit? a. Placing the patient's belongings on the affected side b. Approaching the patient from the affected side c. Teaching the patient how to create a safe environment d. Completing sentences that the patient cannot finish

ANS: D Completing the patient's sentences is not beneficial to the patient; instead provide the patient with plenty of time and opportunity to begin speaking. Creating a safe environment is important to reduce risk of injury. Placing objects on the patient's affected side and approaching the patient from the affected side cause the patient to be aware of the affected side and to learn to adapt and incorporate the affected part of the body. If the patient does not acknowledge the affected side, it will become neglected, and risk of injury will increase.

20. The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient? a. Provide the patient with a therapeutic back rub. b. Turn off the alarms on the monitoring devices. c. Administer an opioid medication to help the patient sleep. d. Provide the patient with earplugs.

ANS: D Giving the patient control over stimuli helps to decrease the frustration that results from sensory overload. Adding additional stimuli such as a back rub can increase sensory overload. Turning off monitors and alarms is unsafe; the nurse needs to be aware of critical situations. Opioid medications should not be the first option; however, antianxiety medications and sleep aids may be considered.

21. The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which desired outcome should be included in the plan of care? a. Patient will recover full use of speech vocabulary in 1 week. b. Patient will carry a pen and a pad of paper around for communication. c. Patient will thicken drinks to prevent aspiration. d. Patient will communicate nonverbally.

ANS: D Patients with expressive aphasia may take a prolonged time to regain speech function, depending on the cause of the incident. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. A patient who has expressive aphasia may not be able to speak or write words. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.

2. What is the involuntary motion of retracting the body from painful stimuli? a. Sensation b. Reception c. Perception d. Reaction

ANS: D Reaction is how a person responds to a perceived stimulus. Perception occurs when the person becomes conscious of stimuli and interprets information signals. Reception refers to receiving stimuli and creating a nerve impulse. Sensation is the combination of all three combined.

13. The nurse would utilize the Snellen chart for assessment of which patient? a. A patient who is having difficulty remembering how to perform familiar tasks b. A patient who turns the television up as loud as possible c. A patient who holds his newspaper 2 inches from his face d. A patient who frequently reports the incorrect time from the clock across the room

ANS: D The Snellen chart is used to assess vision using a distance of 20 feet. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental status. Turning the television up louder indicates the need for a hearing assessment. Holding a newspaper 2 inches from the face indicates the need for assessment of near vision.

17. The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking in a loud voice, enunciating every syllable b. Having direct conversation with the patient in his affected ear c. If the patient does not understand what the nurse is saying, repeating the phrase again d. Speaking with hands, face, and expressions

ANS: D Using gestures other than just speaking helps the patient understand what you are saying and makes it a meaningful stimulus. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear.

Which patient is most likely to experience sensory deprivation? A. A 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities B. A 14-year-old girl isolated in the hospital because of severe immune system suppression C. A hearing-impaired 66-year-old woman who lives in an assisted-living facility D. A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

B. A 14-year-old girl isolated in the hospital because of severe immune system suppression Patients isolated in a private room in a health care setting because of such conditions as severe immune system depression frequently experience sensory deprivation. Such individuals are at risk because of an unfamiliar and unresponsive environment, and they are unable to enjoy normal interactions with visitors.

A 74-year-old patient who has returned to the nursing home following surgical removal of bilateral cataracts reports feeling a little uncertain about walking by herself. Which of the following approaches do you use to assist her with ambulation? A. Walk one-half step behind and slightly to her side. B. Have her grasp your arm just above the elbow and walk at a comfortable pace, warning her when you approach obstacles. C. Allow her to stand alone in unfamiliar areas to encourage confidence building. D. If she requires assistance, place your hand around her waist.

B. Have her grasp your arm just above the elbow and walk at a comfortable pace, warning her when you approach obstacles. To help a visually impaired person with ambulation, offer an elbow or arm. Instruct the patient to grasp your arm just above the elbow. If necessary, physically assist the person by guiding his or her hand to your arm or elbow.

A patient with a history of a hearing deficit comes to the medical clinic for a routine checkup. His wife died 2 years ago, and he admits to feeling lonely much of the time. Interventions the nurse uses to reduce loneliness include: (Select all that apply.) A. Reassuring the patient that loneliness is a normal part of aging. B. Providing information about local social groups in the patient's neighborhood. C. Maintaining distance while talking to avoid overstimulating the patient. D. Recommending that the patient consider making living arrangements that will put him closer to family or friends.

B. Providing information about local social groups in the patient's neighborhood. D. Recommending that the patient consider making living arrangements that will put him closer to family or friends. Loneliness is not a normal part of aging. Principles for reducing loneliness include providing information about local social groups and recommending alterations in living arrangements if physical isolation occurs.

The nurse completes an assessment of a 67-year-old female patient who comes to the clinic for the first time. During the examination the patient ' s temperature is 99.6°F (37.6°C), heart rate 80 beats/min, respiratory rate 18 breaths/min, and blood pressure 142/84 mm Hg. She is not attentive as the nurse asks questions. At one point, she shouts answers to questions about her diet. However, as the nurse speaks, the patient consistently smiles and nods in agreement. The nurse's assessment indicates: A. A visual deficit. B. Patient is normal. C. A hearing deficit. D. Sensory overload.

C. A hearing deficit. Patient behaviors indicating a hearing deficit include decreased attention span, increased volume of speech, and smiling and nodding in approval when someone speaks.

A 72-year-old patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitate communication with her? A. Speak directly into the patient's left ear. B. Approach the patient from behind and speak frequently. C. Face the patient when speaking; speak slower and in a normal volume D. Face the patient when speaking; use a louder than normal tone of voice.

C. Face the patient when speaking; speak slower and in a normal volume To facilitate communication with a hearing-impaired person, face the patient when speaking, speak slower and in a normal tone, talk toward the patient's best or normal ear, and articulate clearly.

A nurse is performing an assessment on a patient admitted to the emergency department with eye trauma. The nurse's priority interventions include which of the following? (Select all that apply.) A. Conducting a home safety assessment and identifying hazards in the patient's living environment B. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury C. Placing necessary objects such as the call light and water in front of the patient to prevent falls due to reaching D. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye

C. Placing necessary objects such as the call light and water in front of the patient to prevent falls due to reaching D. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye Safety is a top concern when setting priorities for patients who experience eye trauma. Eye trauma patients may experience serious visual impairments. The patient needs to be oriented to the environment, and necessary objects placed in front of him or her to reduce anxiety and prevent further injury.

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry

Clinical decision support system

Organized

Communicate information in a logical order

The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements by the patient would indicate that additional teaching is needed? A. "I am at risk for injury from temperature extremes." B. "I may be able to dress more easily with zippers or pullover sweaters." C. "A home care referral may help me achieve a maximum degree of independence." D. "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first."

D. "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first." If tactile sensation is diminished, the patient can dress more easily with zippers or Velcro strips, pullover sweaters or blouses, and elasticized waists. Patients with diminished tactile sensation are at risk for injury from temperature extremes and may benefit from a home care referral. If a patient has partial paralysis and reduced sensation, he or she dresses the affected side first.

A patient has been on contact isolation for 4 days because of a gastrointestinal infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Nursing measures to reduce sensory deprivation include: (Select all that apply.) A. Arranging for him to have a roommate. B. Turning off the lights and closing the room drapes. C. Arranging for peacefulness and frequent rest periods. D. Helping him to a chair or bringing a flower into the room. E. Sitting down, speaking, touching, and listening to his feelings and perceptions.

D. Helping him to a chair or bringing a flower into the room. E. Sitting down, speaking, touching, and listening to his feelings and perceptions. Patients who are isolated in a health care setting are at risk for sensory deprivation because they are unable to enjoy normal interactions with others. To help them adjust to their environment, promote meaningful stimulation. You can do this best by assisting the patient out of bed and sitting down, speaking, touching, and listening to his or her feelings and perceptions.

Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to: A. Avoid activities in which there may be crowds. B. Delay childhood immunizations until hearing can be verified. C. Prophylactically administer antibiotics to reduce the incidence of infections. D. Take precautions when involved in activities associated with high-intensity noises

D. Take precautions when involved in activities associated with high-intensity noises Good sensory function begins with prevention. Nurses need to routinely assess children for noise exposure and reinforce the use of protective devices to minimize hearing loss.

When communicating with a patient who has expressive aphasia, the highest priority for the nurse is: A. To ask open-ended questions. B. To understand that the patient will be uncooperative. C. To coach the patient to respond. D. To offer pictures or a communication board so the patient can point.

D. To offer pictures or a communication board so the patient can point. Patients who have expressive aphasia understand questions but have difficulty expressing an answer. To promote interaction with the patient, offer pictures or a communication board so the patient can point to key words or images. Listen to the patient and wait for him or her to communicate. Use simple, short questions and facial gestures to give additional cues.

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." Which of the following teaching strategies should not be implemented? A. Demonstrating hearing aid battery replacement B. Reviewing method to check volume on hearing aid C. Discussing measures for cleaning battery D. Turning dial to minimum setting and, in a louder-than-normal voice, asking the patient, "Is this voice clear?"

D. Turning dial to minimum setting and, in a louder-than-normal voice, asking the patient, "Is this voice clear?" The dial should be turned to maximum gain, and the patient should be asked in a normal tone "Is this voice clear?"

The nurse is caring for an older patient with glaucoma. When developing a discharge plan, which of the priority interventions enables the patient to function safely with existing deficits and continue a normal lifestyle? A. Encourage the patient's family to visit him or her once a month. B. Suggest to the patient that he or she consider moving to a long-term care facility. C. Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration. D. Work closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources.

D. Work closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources. A safe environment is a priority for patients with sensory deficits. The presence of visual alterations makes it difficult for a person to conduct normal activities of living within the home. Nursing interventions involve the patient and family so the patient is able to maintain a safe, pleasant, and stimulating sensory environment. This includes helping the individual patient learn and adapt to a changed lifestyle based on the specific sensory impairment.

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A) Documented medication given by another nursing student. B) Included the date and time of all entries in the chart. C) Stood with his back against the wall while documenting on the computer. D) Signed all documentation electronically.

Documented medication given by another nursing student.

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.

Electronic health record.

Discharge summary forms

Emphasize previous learning by the client and the care that should be continued.

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.

Enter only objective and factual information about the patient.

What are the five guidelines for quality documentation and reporting

Factual Accurate Complete Current Organized

Charting by exception

Focuses on deviation from the established norm or abnormal findings, highlights trends or changes

Research

Gathering of statistical data of clinical disorders, complications, therapies, recovery and deaths

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.

Gives a newly ordered medication before entering the order in the patient's medical record.

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A) HIPAA allows all hospital staff access to your medical record. B) HIPAA limits the information that is documented in your medical record. C) HIPAA provides you with greater control over your personal health care information. D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

HIPAA provides you with greater control over your personal health care information.

Kardex

Has activity, treatment, nursing care plan sections that organize information for quick reference

Case Management

Incorporates a multidisciplinary approach to documenting care

A patient asks for a copy of her medical record. The best response by the nurse is to: A) State that only her family may read the record. B) Indicate that she has the right to read her record. C) Tell her that she is not allowed to read her record. D) Explain that only health care workers have access to her record.

Indicate that she has the right to read her record.

Focus charting

Involves the use of data, action, and response

Accreditation

Joint Commission specifies guidelines for documentation

Education

Learning the nature of an illness and the individual client's responses

Critical Pathways

Multidisciplinary care plans that include client problems, key interventions, and expected outcomes.

Auditing

Objective, ongoing reviews to determine the degree to which quality improvement standards are met.

Legal Documentation

Once of the best defenses for legal claims

Which of the following charting entries is most accurate? A) Patient walked up and down hallway with assistance, tolerated well. B) Patient up, out of bed, walked down hallway and back to room, tolerated well. C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

What is an appropriate way for a nurse to dispose of printed patient information? A) Rip several times and place in a standard trash can B) Place in the patient's paper-based chart C) Place in a secure canister marked for shredding D) Burn the documents

Place in a secure canister marked for shredding

PIE

Problem, intervention, and evaluation

List 9 major areas to include in a change of shift report

Provide only essential background information. Identify the client's nursing diagnosis or health care problems and their related causes. Describe objective measurements or observations about condition and responses tohealth problem. Share significant information about family members. Continuously review ongoing discharge plan. Relay to staff any significant changes in the way therapies are to be given. Describe instructions given in teaching plan and the responses to instructions. Evaluate results of nursing or medical care measures. Be clear about priorities to which oncoming staff must attend.

SOAPIE

SOAP with intervention and evaluation added

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A) The patient has a defiant attitude and is demanding his test results. B) The patient appears to be upset with his nurse because he wants his test results immediately. C) The patient is demanding and complains frequently about his doctor. D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.

The patient stated that he felt frustrated by the lack of information he received regarding his tests.

Source record

Separate section for each discipline

SOAP

Subjective, objective, assessment, and plan

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A) The nurses forgot to document on the pulmonary system. B) The nurses were charting by exception. C) The computer is not working correctly. D) The physician does not have authorization to view the nursing assessment.

The nurses were charting by exception.

Financial Billing

To determine the accurate and timely reimbursement

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B) You need to use words the patients can understand when writing the directions. C) The form needs to be given to patients in a sealed envelope to protect their health information. D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.

You need to use words the patients can understand when writing the directions.

Reports

oral, written, or audiotaped exchanges between caregivers

Referrals

an arrangement for services by another care provider

Documentation

anything written or printed that you rely on as record or proof

Complete

containing appropriate and essential information

Explain the new rights for clients related to HIPPA

client education on privacy protections ensuring client's access to his or her medical records receiving client consent before information is released providing recourse if privacy protections are violated

List 9 major information areas in a transfer report.

client's name, age, primary physician, and medical diagnosis summary of progress current health status allergies emergency code status family support current nursing diagnoses or problem and care plan any critical assessments or interventions to be completed need for any additional equipment

Factual

descriptive, objective information about what a nurse sees, hears, feels, and smells

Guidelines the nurse should follow when receiving a telephone order

determine the client's name, room number, and diagnosis repeat any prescribed orders back to the physician use clarification questions write TO or VO, including the date and time, name of the client, and the complete order, and sign the physician name and the nurse follow agency policies physician must co-sign the order within the time frame required by the institution

Acuity records

determine the hours of care and staff required for a given group of clients

Consultations

form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver

Client record

is a confidential, permanent legal documentation of information relevant to a client'shealth care

Communication

means by which client needs and progress, individual therapies, client education, and discharge planning are conveyed to others in the health care team

standardized care plans

preprinted established guidelines used to care for the client

Admission nursing history forms

provide baseline data to compare with changes in the clients condition

The standards of documentation by the Joint Commission require

requires documentation within the context of the nursing process, as well as evidenceof client and family teaching and discharge planning

Define Diagnosis-realted group (DRG)

series of decision trees designed to cluster groups of clients together by diagnosis,surgical procedures, complications, co-morbidities, and age

Accurate

the use of accepted abbreviations, symbols, and system of measures that are clear andeasy to understand

Current

timely entries; immediate documentation of information as it is collected from theclient

Information that needs to be documented with telephone reports

when the call was made, who made it, who was called, to whom information was given, what information was given, and what information was received.