nrsg 2200 unit 4

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?"

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

"What day of the week is it?"

empathy:

(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

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

Accurately documenting client care on the client record

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity and rest

Which are characteristics of one who has developed critical thinking skills?

Self-aware, honest, persistent, and authentic

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in?

Supportive

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client.

nursing intervention:

any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated, and collaborative interventions

Outcome and Assessment Information Set (OASIS):

assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home health care patients that forms the basis for measuring patient outcomes for the purpose of improving the quality of care provided

critical/collaborative pathway:

case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

clinical pathways (critical pathways, CareMaps):

case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay

physician-initiated intervention:

dependent nursing actions, involving carrying out physician-prescribed orders

Nursing Outcomes Classification (NOC):

developed by the Iowa Outcomes Project and presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning.

variance charting:

documentation method in case management when a patient fails to meet an expected outcome or when a planned intervention is not implemented that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate; typically used for variances that affect quality, coast, or length of stay; also called occurrence charting

problem-oriented medical record (POMR)

documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes

Nursing Interventions Classification (NIC):

first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions

graphic record:

form used to record specific patient variables

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

have group members confront the dominant member to promote the needed team work.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

nurse-initiated intervention:

independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional and that result from their assessment of patient needs

collaborative interventions:

interdependent nursing actions performed jointly by nurses and other members of the health care team

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

SOAP format:

method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:

outcome.

initial planning:

planning that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care

purposeful rounding:

proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs

organizational communication:

process of communication that involves individuals and groups to achieve established goals

narrative notes:

progress notes written by nurses in a source-oriented record

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head.

scientific problem solving

systematic problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation resulting in conclusion or revision of the study

channel:

term used in communication theory to denote the medium selected to convey the message; the channel may target any of the receiver's senses

thoughtful practice:

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

A client comes into the urgent care center to have sutures removed on an arm. The nurse finds significant crusting along the suture line. The client states not having time to get the sutures removed a week prior, as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls the arm away and tells the nurse, "You are taking too long and it is hurting a little bit. Just pull them out and get it over with." Which statement is an example of appropriate therapeutic response?

"It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

Which nurse would most likely be the best communicator?

A nurse who easily develops a rapport with clients

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?

Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation?

Assisting the client to sit up in a chair

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?

Be silent and allow the client to continue speaking when ready.

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority?

By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms

Which activity is the clearest example of the evaluation step in the nursing process?

Checking the client's blood pressure 30 minutes after administering captopril

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

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing.

Which organization audits charts regularly?

The Joint Commission

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.

A nurse touches the client's hand while discussing the client's diagnosis. This action is:

a communication channel.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

horizontal violence:

anger and aggressive behavior between nurses or nurse-to-nurse hostility

intrapersonal communication:

communication techniques or self-talk to enhance positive interaction with the patient and family

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

A pregnant client presents to the emergency department with vaginal bleeding. A transvaginal ultrasound is performed, and the health care provider informs the client that there are normal fetal heart tones noted. The client begins to tear-up and has a worried appearance. To facilitate therapeutic communication, what statement would the nurse make after observing the client's nonverbal communication?

"Take your time and tell me how you are feeling. I have plenty of time to answer your questions and discuss any thoughts or feelings with you."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

When the preoperative client tells the nurse that the client cannot sleep because the client keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is:

"The thought of having surgery is keeping you awake."

Which is an open-ended question?

"Why did the health care provider prescribe this medication for you?"

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?

2130

Which guidelines should the nurse consider when writing outcomes? Select all that apply.

At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should write outcomes that are brief and specific and support the overall plan of care.

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

A nurse is conducting a client interview and gathers information from secondary sources. Which sources might the nurse use? Select all that apply.

Client's children Client's caregiver Client's physcian Client's previous admission record

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented?

Clinical reasoning

Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client.

A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client?

Critical reflectivity

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

Which action exemplifies the purpose of evaluation in the nursing process?

Decide whether to continue, modify, or terminate client care.

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Developing the plan without client input

Which are appropriate actions for protecting clients' identities? Select all that apply.

Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard.

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply

Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate?

Explain the reason why information cannot be disclosed.

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

The nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist?

Interpersonal

Which statements are true about informatics in nursing practice? Select all that apply.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

Ongoing

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

Orientation phase

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

Which is the most appropriate example of the assessment phase of the nursing process?

Palpating a mass in the right lower quadrant of the abdomen

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?

Planning

A nurse documents the following data in the client record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

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

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?

Remind the UAP about the client's right to privacy.

The nursing is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities?

The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needleless syringe.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

focus charting

a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format

ISBAR communication:

a process for effective handoff communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back

creative thinking:

a process involving imagination, intuition, and spontaneity—factors that underpin the art of nursing

clinical reasoning:

a specific term usually referring to ways of thinking about patient care issues (determining, preventing, and managing patient problems); for reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow); nurses usually use critical thinking

minimum data set

a standard established by health care institutions that specifies the information that must be collected from every patient

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by:

asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate.

standards for critical thinking:

clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair

interpersonal communication:

communication that occurs between two or more people with a goal to exchange messages

small-group communication

communication that occurs when two or more nurses interact with two or more individuals, allowing the members to achieve a goal through communication

CUS (communication tool)

communication tool to assist in effective communication related to patient safety concerns; the acronym CUS stands for I'm Concerned, I'm Uncomfortable, This is unSafe (or This is a Safety issue)

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete the postoperative assessment

SBAR (communication tool):

consistent, clear, structured, and easy-to-use method of communication between health care personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations. semantics: study of the meaning of words

intuitive problem solving:

direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible

critical thinking indicators

evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

Besides being an instrument of continuous client care, the client's health care record also serves as a(an):

legal document.

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using:

medical terminology.

reflective practice:

occurs when the caregiver has a profound awareness of self, and one's own biases, prejudgments, prejudices, and assumptions, and understands how these may affect the therapeutic relationship

clinical judgment:

refers to the result (outcome) of critical thinking or clinical reasoning; the conclusion, decision, or opinion a nurse makes

therapeutic relationship:

relationship between the caregiver and patient that is focused on promoting or restoring health and well-being of the patient

group dynamics:

study of a group's characteristics and ways of functioning

blended competencies:

the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing

critical thinking:

thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned; a systematic way to form and shape one's thinking that functions purposefully and exactingly

variance report

tool used by health care facilities to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor; also called an incident report or occurrence report