233 Exam 1
A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?
"I know that you are anxious, but the IV location needs to be changed."
The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?
"We need to validate the information obtained in this assessment."
the act of listening with a stethoscope to sounds produced within the body; one of the four methods are used to collect data during the physical assessment
Auscultation
_______________ wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing.
Benner and Wrubel (1989)
begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs
Gordon's functional health patterns
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?
Impaired Physical Mobility related to pain
What is the most beneficial use of the nursing process in addressing the needs of the client?
Provides a universally applicable framework for nursing activities
short, focused, prioritized assessments you do to gain the most important information you need to have first. They are important because they can "flag" existing problems and risks
QPAs (Quick priority assessments)
Professional nursing requires cultivated personal attributes, mastery of the science of nursing, and reflective clinical experience in which nurses develop the blended and ________ competencies that promote thoughtful and effective patient-centered practice.
QSEN
physical examination of all body systems in a systematic manner as part of the nursing assessment
ROS (review of systems)
A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process?
The nurse reassesses the patient and decides how best to intervene in her care.
_______________, an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences.
Travelbee (1971)
T or F: Assessment related to communication involves gathering information in both verbal and nonverbal forms.
True
____________'s theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.
Watson
A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation? a. The client stares at the floor and states, "I feel fine." b. The client looks at the nurse and states, "I am still not feeling my best."
a
includes all the pertinent patient information collected by the nurse and other health care professionals
a database
To enable sound clinical reasoning, nursing assessments should have the following characteristics: purposeful, prioritized, complete, systematic, __________, relevant, and recorded in a standard format.
accurate
___________ nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics.
actual
standing up for one's rights in a negative manner that violates the rights of others
aggressive behavior
The patient data collected by the nurse, both initially and as patient contact continues, are of no benefit to the patient and the health care team unless they are...
appropriately communicated (involves correct timing and proper documentation)
ability to stand up for oneself and others using open, honest, and direct communication
assertive behavior
the systematic and continuous collection, analysis, validation, and communication of patient data, or information. These data reflect how health functioning is enhanced by health promotion or compromised by illness and injury
assessing
the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing
blended competencies
moral imperative that guides nursing praxis (education, practice, and research); action and competencies that aim toward the good and welfare of others
caring
a stereotyped, trite, or pat answer
cliche
usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems)
critical reasoning
verbal and nonverbal evidence that the message is received and understood
feedback
The process of prioritizing nursing diagnoses is the _______step in planning care
first
assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient
focused
The body system model is based on the ___________ of the major body systems.
functioning
study of a group's characteristics and ways of functioning
group dynamics
The SBAR technique (Situation, Background, Assessment, and Recommendations) is one format for _____________ communication used in health care.
hand-off
Two cues must be present for a valid ___________nursing diagnosis: a desire for a higher level of wellness and an effective present status or function.
health promotion
When developing professional therapeutic communication skills, nurses should develop conversation and listening skills; use silence, touch, and ___________ appropriately; and improve __________ techniques.
humor, interviewing
It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy?
identifying with the client's feelings
__________assessment: comprehensive nursing assessment resulting in baseline data that enable the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient
initial
The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?
inspection
Problem solving that is ____________ refers to a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible.
intuitive
The outcome of critical thinking or clinical reasoning is known as clinical ____________, the conclusion, decision, or opinion the nurse makes.
judgement
prescribed way of using words; a means to express thoughts and feelings
language
A key nursing skill when performing both the nursing history and the physical examination is ____________, the conscious and deliberate use of the five senses to gather data.
observation
problems in data collection include inappropriate organization of the database, ___________ of pertinent data, inclusion of irrelevant or duplicate data, erroneous or misinterpreted data, failure to establish rapport and partnership with the patient, recording an interpretation of data rather than observed behavior, and failure to update the database
omission
process of communication that involves individuals and groups to achieve established goals
organizational communication
During the ____________ phase of the helping relationship, the tone and guidelines for the relationship are established.
orientation
the chief means of communication among members of the interdisciplinary team.
patient record
a ___________ zone occurs when people interact with close friends.
personal
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?
reflection
a purposeful activity that leads to action, improvement of practice, and better patient outcomes. It is about looking at an event, understanding it, and learning from it. Learning from reflection is not automatic; it requires a deeper understanding of how and why reflection contributes to the competence of the effective nurse.
reflective practice
the basic components of a nursing diagnosis: definition, defining characteristics, and ________factors or risk factors
related
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should:
remain honest, open, and frank
----------- nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation.
risk
Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on...?
scientific problem solving
Diagnosing is the ________ step of the nursing process
second (begins after the nurse has collected and recorded the patient data.)
study of the meaning of words
semantics
communication that occurs when two or more nurses interact with two or more individuals, allowing the members to achieve a goal through communication
small group communication
Although most people consider their hands, arms, shoulders, and back within a _______zone, increasing levels of privacy are according to (1) mouth and feet; (2) face, neck, and front of body; and (3) genitalia.
social
web-based technologies that allow users to create, share, and participate in dialogue in virtual communities and networks
social media
information perceived only by the affected person; these data cannot be perceived or verified by another person
subjective
To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?
therapeutic communication
The purpose of _______________ data is to keep information, an important part of assessment, free from error, bias, and misinterpretation as much as possible.
validating
communication tool to assist in effective communication related to patient safety concerns; the acronym stands for I'm Concerned, I'm Uncomfortable, This is unSafe (or This is a Safety issue)
CUS
tool for assessing patient complexity using the social determinants of health that often explain why patients with the same or similar health conditions differ in their ability to manage their health and in their outcomes
PCAM (patient-centered assessment method)
___________________ involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing ____________ by using information and technology to communicate, manage knowledge, and support decision making.
Quality improvement, informatics
Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?
Reporting signs and symptoms related to the client's kidney failure
The overall goal of the Quality and ____________ for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care system within which they work.
Safety Education
Which are characteristics of one who has developed critical thinking skills?
Self-aware, honest, persistent, and authentic
A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory?
Swanson (1991)
A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?
assume a position at eye level with the client and continue with the interview.
Four methods are used to collect data during a physical assessment: inspection, palpation, percussion, and _______________
auscultation
A client is reluctant to undergo surgery and is discussing it with the nurse. The nurse says, "Surgery is your only option. You need this operation." That response reflects an ___________ approach
authoritarian
A client presents to the urgent care clinic with ear pain. The client reports a medical history of trigeminal neuralgia. The nurse is not familiar with trigeminal neuralgia. When the client asks whether the two conditions could be related, which response by the nurse is best? a. "When you were diagnosed with trigeminal neuralgia, did you have ear pain?" b. "I honestly do not remember specific details regarding trigeminal neuralgia; let me research it."
b
Which statements accurately describe the unique focus of nursing assessments? Select all that apply. a. The focus of a nursing assessment is on actual, not potential, health problems. b. Nursing assessments focus on the client's responses to health problems. c. Nursing assessments target data pointing to pathologic conditions. d. The findings from a nursing assessment may contribute to the identification of a medical diagnosis. e. An initial assessment establishes a complete database for problem solving and care planning. f. nursing assessments are the same as medical assessments
b, d, e
Factors influencing communication include level of development; __________________; _____________ differences; roles and responsibilities; space and territoriality; physical, mental and emotional state; and environment
biological sex, sociocultural
negative, often repetitive, disruptive behavior; also referred to as horizontal violence, lateral violence, and professional incivility
bullying
Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice? a. empathy b. comfortable sense of self c. analysis d. positive regard
c
In order for a communication process to occur, three components are needed: a source or sender, the message, and the __________, the medium the sender selects to send the message.
channel
term used in communication theory to denote the medium selected to convey the message; may target any of the receiver's senses
channel
The failure to verbalize_________ly and ________________ly blocks effective communication
clear, compassionate
refers to the result (outcome) of critical thinking or clinical reasoning---the conclusion, decision, or opinion you reach.
clinical judgement
Nurses must be as proficient in communication skills as they are in...
clinical skills
Using critical thinking and learning medication dosages are_________ competencies, Performing procedures correctly is a__________skill
cognitive, technical
Which type of health problem requires both physician- and nurse-prescribed actions to address?
collaborative
_______________ is influenced by the way people value themselves, one another, and the purpose of any human interaction
communication
improved _______________ between nurses and other health care professionals is probably the most important benefit of accurate, up-to-date diagnoses---expressed in well-defined and standardized terminology---for nurses and their patients
communication
process of sharing information; process of generating and transmitting meanings
communication
the process of exchanging information and generating and transmitting meanings between two or more people.
communication
________________--an instructional strategy to identify, graphically display and link key concepts---is an example of a critical-thinking approach to care planning.
concept mapping
Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?
consultation
the purpose of evaluation in the nursing process is to decide whether to
continue, modify, or terminate client care
For reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow) nurses usually use what?
critical thinking
is defined as "a systematic way to form and shape one's thinking."
critical thinking
Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice
critical thinking indicators (CTIs)
data is defined as information, while a _______ is significant information that is helpful in making decisions
cue
refers to the common lifestyles, languages, behavior patterns, traditions, and beliefs that are learned and passed from one generation to the next
culture
A client was recently diagnosed with metastatic lung cancer. The nurse finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy? a. "I am sorry to hear you have cancer. I would be upset too, is there anything I can do?" b. "I have seen a lot of cancer patients here who have ended up perfectly fine." c. "I noticed you are crying. Do you want me to call someone for you?" d. "I see you are upset. Would you like to talk?"
d
"I have been busy with other clients that required my immediate attention." is a __________ response from a nurse
defending
Most nursing diagnoses are written either as two-part statements listing the patient's problem and its cause or as three-part statements that also include the problem's...
defining characteristic
The purpose of the assessment offers the best guideline about what type and how much data to collect. Assessment priorities are influenced by the patient's health orientation, ____________ stage, culture, and need for nursing.
developmental
A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process?
diagnosis
Which step of the nursing process involves reporting or analysis of data to identify and define health problems?
diagnosis
A thoughtful nurse is considerate and compassionate, keeping the person at the center of all deliberations in order to promote the humanity, ____________, and well-being of the person being cared for
dignity
Incivility and bullying, horizontal violence and lateral violence are all forms of _____________ behavior and communication.
disruptive
The ability to communicate clearly is a critical nursing skill. Accurate, concise, timely, and relevant _______________ provides all the members of the caregiving team with a picture of the patient.
documentation
Nursing assessments include the comprehensive initial assessment, the focused assessment, the ______________ assessment, and the time-lapsed assessment.
emergency (type of rapid focused assessment conducted when addressing a life-threatening or unstable situation)
(1) objective understanding of the way in which a patient sees his or her situation, identifying with the way another person feels, putting oneself in another person's circumstances and imagining what it would be like to share that person's feelings; (2) intellectually identifying with the way another person feels
empathy
The therapeutic communication technique known as ___________ is the skill of identifying with the way another person feels.
empathy
David K. Berlo (1960) is credited with the classic description of the communication process, which involves a source (____________), message, channel, and receiver (__________).
encoder, decoder
The purposes of diagnosing are to: (1) identify how a person, group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (______________); and (3) identify resources or strengths the person, group, or community can draw on to prevent or resolve problems.
etiologies
The nursing process is a systematic method that directs the nurse, with the patient's participation, to accomplish the following: (1) assess the patient to determine the need for nursing care, (2) determine nursing diagnoses for actual and potential health problems, (3) identify expected outcomes and plan care, (4) implement the care, and (5)...?
evaluate the results
A ____________ assessment is conducted to gather data about a specific problem that has already been identified
focused
The nurse may also perform a nursing physical examination to collect data. The nursing physical assessment involves the examination of all body systems, review of systems (ROS), in a systematic manner, commonly using a _____________ format.
head-to-toe
Nurse critical thinkers work methodically through five types of considerations: the purpose of thinking, adequacy of knowledge, potential problems, _____________, and critique of judgment/decision.
helpful resources
A _____________ relationship exists among people who provide and receive assistance in meeting human needs.
helping
interaction that sets the climate of movement of the participants toward common goals
helping relationship
The nursing _____________ identifies the patient's health status, strengths, health problems, health risks, and need for nursing care.
history
Nurses who practice patient-centered care are committed to developing caring professional relationships based on respect and mutual trust. This _________ approach, which is consistent with theories based on human caring, seeks to promote humanism, health, and quality of living. Caring is viewed as universal and is practiced through interpersonal relationships.
holistic
anger and aggressive behavior between nurses or nurse-to-nurse hostility
horizontal violence
include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling
human responses
Which component of the nursing process involves engaging the patient and family with therapeutic communication to execute the nursing plan?
implementation (step where we actually intervene to help them, give drugs, educate, monitor)
____________ is rude, disruptive, intimidating, and undesirable behavior directed at another person
incivility
rude, intimidating, and undesirable behavior directed at another person
incivility
The primary benefit of nursing diagnosis for the patient is...
individualization of patient care (The use of nursing diagnoses also allows patients to be informed and willing participants in their care, as they validate their diagnoses and assist in prioritizing them)
Nurses now use the language of cues and inferences to describe the early analysis of data. The collective subjective and objective data you identify is a cue that something may be wrong. The judgment you reach about the cue is called...
inference
the process of performing deliberate, purposeful observations in a systematic manner; one of the four methods are used to collect data during the physical assessment
inspection
Disruptive behavior has a negative effect on clinical outcomes, patient safety, and ___________________ communication
interpersonal
The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process?
interpersonal
communication that occurs between two or more people with a goal to exchange messages
interpersonal
helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is what kind of skill?
interpersonal
experienced nurses identify the quality of their _________________ as the single most significant element in determining their helper effectiveness. On nursing units where nurses freely exchange ideas and information, solve problems together when something goes wrong rather than assigning blame, complement one another, and use humor creatively, staff morale is high and there is a higher level of attainment of patient outcomes
interpersonal relationships
planned communication for a specific purpose (e.g., data collection)
interview
________________ communication, or self-talk, is the communication that happens within the individual.
intrapersonal
communication techniques or self-talk to enhance positive interaction with the patient and family
intrapersonal
The nurse obtains a nursing history by interviewing the patient. An interview is a planned communication with four phases: the preparatory phase, _____________, working phase, and termination
introduction
The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy?
just take your time. i am listening
The overall goal of the QSEN (Quality and Safety Education for Nurses) project is to meet the challenge of preparing future nurses who will have the KSAs necessary to continuously improve the quality and safety of the health care systems within which they work. What are KSA's?
knowledge, skills, and attitudes
Personal attributes that prepare you for thoughtful patient-centered care include open-mindedness, a profound sense of the values of the person, self-awareness and knowledge of your own beliefs and values, a sense of personal responsibility for your actions, motivation to perform to the best of your ability because you care about the well-being of those entrusted to your care, ____________, and bravery to question "the system."
leadership skills
H = Help: Observe the first signs patient may need help. Look for signs of distress (pallor, pain, labored breathing). E = Environmental equipment: Look for safety hazards; ensure that all equipment is working (IVs, oxygen, catheter). L = _______: Examine patient thoroughly. P = _________: Who are the people in the room? What are they doing?
look, People
model based on the human needs hierarchy
maslow's
_______ assessments target data pointing to pathologic conditions
medical
term used in communication theory to denote the actual physical product of the source or encoder (e.g., a speech, interview, phone conversation, chart)
message
Most schools of nursing and health care institutions establish a _____________data set that specifies the information that must be collected from every patient.
minimum
Interpersonal skills are essential to the practice of thoughtful patient-centered practice. Interpersonal caring involves promoting the dignity and respect of patients as people and establishing a caring relationship. As a result, both you and the patient experience ...?
mutual enrichment
What meds are you taking at home? Is that open-ended?
no
Factors that distort the quality of the message, known as __________, can interfere with communication at any point in the process.
noise
factors that distort the quality of a message and interfere with the communication process
noise
What kind of communication involves body language??
nonverbal
The _______ process is systematic, dynamic, interpersonal, outcome oriented, and universally applicable
nursing
_______ assessments focus on the patient's responses to health problems.
nursing
observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing it.
objective
three holistic models (Maslow's human needs, Gordon's functional health patterns, and human response patterns) along with the body system medical model can all be used to...?
organize or cluster the data
The four levels of communication include intrapersonal communication, interpersonal communication, small-group communication, and ___________ communication
organized
Once you have _______________ your data according to the purpose of your assessment, you look for and test your initial impressions about patterns of human functioning
organized (clustered)
use of the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body; one of the four methods are used to collect data during the physical assessment
palpation
An intimate communication zone occurs during interaction between...
parents and children
The challenges of using social media to communicate include protecting ____________________ and preventing unintended consequences for the nurse and the employer.
patient privacy and confidentiality
the act of striking one object against another to produce sound; one of the four methods are used to collect data during the physical assessment
percussion
Patient safety and transparency of information are two principles of ___________-centered care that can be used by every organization.
person
When a procedure demands manual dexterity or a complex series of steps, ___________ until you feel confident in its execution before attempting to perform it with a patient. Never be ashamed to ask for help when feeling unsure of how to perform a procedure or manage equipment
practice the necessary skill
While clinical reasoning can be broken down into steps---look, collect, ______,__________, plan, act, evaluate and reflect---in reality, the phases merge and the boundaries between them are often blurred. Clinical reasoning includes the ability to recognize clinical problems and solve them using the cognitive skills of critical thinking, creative thinking, and intuitive thinking.
process, decide
is the study of distance zones between people during communication. Each person has a sense of how much personal or private space is needed and what distance between people is optimum
proxemics
When preparing for data collection, identify the ___________ of the nursing assessment first, then gather the appropriate data.
purpose
a feeling of mutual trust experienced by people in a satisfactory relationship
rapport
The components of the communication process include a stimulus, a source, the message, the channel of communication, a ___________, and feedback
receiver
------------- nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.
syndrome
observing silence is meant for who to take time to think of responses/calm down, etc.: the patient or the nurse or both?
the patient
Unless specified otherwise, the data recorded in the nursing history are assumed to have been collected from...
the patient (Other sources include family and significant others, the patient record, assessment technology, other health care professionals, and the nursing and other literature)
When the relationship between the carer and the cared for is used for promoting or restoring the health and well-being of people within the relationship, it becomes a _____________relationship.
therapeutic
the care of a patient by a clinician who utilizes clinical reasoning and reflective practice to guide thoughtful actions and person-centered processes of care
thoughtful practice
an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier
time-lapsed
When collecting data on a client, the nurse implements which nonverbal communication form as one of the most effective to express feelings?
touch
method of problem solving that involves testing any number of solutions until one is found that works for that particular problem
trial-and-error problem solving
what kind of communication depends on language??
verbal
Messages can be sent and received through ________________ communication techniques
verbal and nonverbal
NANDA-I describes five types of nursing diagnoses: actual, risk, possible, ___________, and syndrome
wellness
A helping relationship has three phases: the orientation phase, the ______________ phase, and the termination phase.
working
