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Nursing Skills > Exam 1; fundamentals of nursing > Flashcards

Exam 1; fundamentals of nursing Flashcards

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1
Q

Levels of communication

A
  1. intrapersonal
  2. interpersonal
  3. group
  4. public speaking
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2
Q

During the communication process, “decoding is”
A. the selection of words by the sender
B. The interpretation of the message by the receiver
C. the method by which the message is given
D. the way in which feedback back is interpreted

A

B

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3
Q

Verbal communication factors

A

language
denotative vs. connotative
tone and pitch
clarity and brevity

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4
Q

the nurse is teaching the client about his upcoming procedure and the client is very stressed. what is most important for the nurse to do?
A. use humor first to decrease the clients stress level
B. determine if the teaching should take place at a different time
C. introduce himself as the RN to give credibility to his message
D. speak to the client when family members are there so they can teach the client

A

B

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5
Q

nonverbal communication

A

facial expressions
posture and cait
personal appearance
gestures
touch

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6
Q

Factors that affect communication in general

A

environment
developmental variations
gender
personal space
territoriality
roles and relationships

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7
Q

Assertive communication

A

use “I” statements
accept criticism
speak clearly and positively

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8
Q

SBAR

A

situation
background
assess
recommend

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9
Q

key characteristics of therapeutic communication

A

empathy
respect
genuineness
concreteness
confrontation

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10
Q

Assessment of communication

A

medications
language, vocabulary, literacy
cognitive function
hearing
vision
aphasia

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11
Q

Use of the statements “tell me more about …” or “i see” encourages clients to continue talking and expressing themselves. This is called
A. summarizing
B. open- ended questions
C. focusing
D. exploring issue

A

D

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12
Q

Developmental Factors Affecting Safety: infants and toddlers

A

cannot recognize danger
tactile exploration of environment
totally dependent

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13
Q

Developmental Factors Affecting Safety: preschoolers

A

play extends to outdoors
more adventerous

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14
Q

Developmental Factors Affecting Safety: school age children

A

try new activities without practice
more time outside the home
increased safety risk outside the home

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15
Q

Developmental Factors Affecting Safety: adolescents

A

false confidence
risk- taking behaviors
most lack adult judgement

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16
Q

Developmental Factors Affecting Safety: Adults

A

may be exposed to injury
lifestyle choices impact health

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17
Q

Developmental Factors Affecting Safety: older adults

A

loss of muscle strength, joint mobility, slowing reflexes, sensory losses

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18
Q

in meeting the safety needs of the adolescent client, it would be most important for the nurse to focus his or her teaching on
A. smoking cessation
B. sports injuries
C. alcohol abuse
D. driver’s education

A

D

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19
Q

A child has had hiccups for 2 hours. Is this a sign of suspected ingestion of poison?
A. yes
B. no

A

B

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20
Q

When implementing the use of restraints on a hospitalized client, the nurse should
A. restrain all confused clients so that they do not sustain a fall injury
B. tie the restraint to the bottom of the side rail so the client cannot reach it
C. ensure that the primary care provider renews the order for restraints once every 24 hours
D. release the restraints and provide skin care at least once every shift

A

C

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21
Q

Safety hazards for healthcare workers

A

back injury
needlestick injury
radiation injury
violence
prevention

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22
Q

How would you, as the nurse, support a culture of safety? (select all that apply)
1. completing incident reports when appropriate
2. completing incident reports for a near miss
3. communicating product concerns to an immediate supervisor
4. identifying the person responsible for an incident

A

all of the above

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23
Q

Safety assessments

A

client environment
home safety
risk for violence

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24
Q

how does the nurse assess carotid arteries

A

one side at a time to not cut off oxygen to the brain

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25
Q

what safety topic would be appropriate to educated adolescents on

A

driving

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26
Q

name the lung sound that is high pitched and produced by a narrow air way

A

wheezing

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27
Q

What action does the nurse to clients verbal actions do not match their nonverbal actions

A

verify with the client

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28
Q

types of questions that cant be answered with yes or no

A

open ended

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29
Q

RACE

A

rescue
alarm
contain
extinguish

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30
Q

Normal capillary refill happens

A

1-3 seconds

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31
Q

normal temp

A

97-<100

32
Q

What are the 7 rights of administrating drugs

A

patient
drug
dose
time
route
reason
documentation

33
Q

what is the proper order for physical assessment

A

inspection
palpate
percuss
auscultate

34
Q

where is the best place to identify skin color change on dark skinned people?

A

under the tongue

35
Q

Name of test that measures balance

A

Romburg (close your eyes and stand up)

36
Q

What does clubbing indicate

A

poor oxygen levels over a long period of time

37
Q

How do you modify physical assessment for toddlers?

A

make it fun and have a parent present

38
Q

How do you modify physical assessment for older adults?

A

Take frequent breaks, minimize changing positions, talk slower

39
Q

What is Kypnosis

A

hunch back

40
Q

What position must you be in for seeing JVD

A

semi fowlers and head turned

41
Q

What does JVD indicate

A

right sided heart failure

42
Q

What is the purpose of physical assessments

A

being able to identify any changes, having a baseline at the beginning of assessment

43
Q

What is the position laying on your back

A

supine

44
Q

what measure can a nurse take to no injure the back

A

raising bed, standing with feet apart, avoid lifting utilize lifts when necessary, keep objects close to body

45
Q

What is it when the exercise of O2 meets or exceeds the amount of O2 required to preform activity

A

aerobic

46
Q

how to prepare for a health history

A

read charts
gather information
talk to other nurses
have goals when talking to your patient
have questions ready to ask

47
Q

what are 3 safety interventions for older adults

A

non skid socks, lower bed, have lights on, clear pathway, assistive device

48
Q

8 ounces is how many mL

A

240

49
Q

What are the heart valves (in order)

A

tricuspid, pulmonary, mitral, atrial

50
Q

what is the tool used to look at ears

A

otoscope

51
Q

how to prepare an environment for physical assessment

A

temp, smell, noise, privacy

52
Q

What is a morse fall

A

history of recent falls

53
Q

what is the normal range for an adult heart rate

A

60-100

54
Q

Best way to communicate

A

at eye level

55
Q

What is tenting

A

the action of pinching the skin and it staying there

56
Q

How do you assess pupils

A

PERRLA
pupils, equal, round, reactive, light, accommodate

57
Q

what is normal o2 levels

A

90%>

58
Q

where is equilibrium maintained

A

inner ear

59
Q

When do you do vitals

A

admission, changes, after surgery

60
Q

What are the principles of body mechanics

A

body alignment
balance
coordination
joint mobility

61
Q

To maintain proper posture it is important to,
A. sleep on the softest mattress possible
B. avoid arching shoulders when sitting
C. keep your knees locked when standing upright
D. keep your stomach muscles relaxed to prevent back spasms

A

B

62
Q

Benefits of exercise

A

improves cardiovascular health
increases muscle tone and flexibility
enhances immune system
promotes weight loss
decreases stress/ increases overall feeling of well-being

63
Q

Maximum heart rate and target heart rate

A

MHR= 220- age
THR= 60% x MHR

64
Q

Of the following interventions for the client who is immobile the nurse will give priority to
A. encouraging a diet high in fiber and extra fluids
B. administering the prn medications for sleep
C. having the client repositioned every 2 hours with PROM
D. massaging the client’s legs every hour

A

C

65
Q

what is the nurses role in assessment of a client

A

getting a baseline

66
Q

Types of assessments: 5

A

initial
ongoing
comprehensive: home health and hospice
focused: looking at something specific
special needs: full assessment (braden scale)

67
Q

Can you delegate assessments?

A

no it is the nurses job.

68
Q

Directive interviewing vs. nondirective

A

directive: to obtain factual, easily categorized information (nurse controls it)
nondirective: the patient controls the conversation and subject matter, nurses role is to summarize and clarify

69
Q

how to prepare for a interview with a patient

A

know the purpose
read the clients chart
form some goals and opening questions
have your forms and equipment ready
compose yourself

70
Q

how to prepare a space for an interview

A

privacy
remove distractions
position yourself at eyelevel

71
Q

preparing the client for an interview

A

introduce yourself
call client by name
tell the client what you will be doing and why
assess readiness to discuss health issues
assess for anxiety

72
Q

health history components

A

demographic data
current health status and medical care
chief complaint
psychosocial history
family history
medical history
procedural/ surgical history

73
Q

Variances in temperature: fever, hyperpyrexia, hypothermia, hyperthermia

A

fever: 100>
hyperpyrexia: 105.8>
hypothermia: 95<
hyperthermia: heat exhaustion and heat stroke

74
Q

The nurse would monitor the body temperature most closely/ frequently to a patient with:
A/ with an infection
B/ who is an infant
C/ who has experienced a heat stroke
D/ with a head injury

A

D (because the hypothalamus is in the head)

75
Q

Apnea
Bradypnea
Tachypnea

A

Apnea: cessation of breathing
Bradypnea: abnormally slow
Tachypnea: abnormally fast

76
Q

the nurse performs a physical examination to

A

establish a baseline
identify nursing diagnoses,
collaborative problems, or wellness diagnoses
monitor the status of an identified problem
screen for health problems

Nursing Skills (16 decks)

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