Exam 1; fundamentals of nursing Flashcards by Brooklyn Mace

Levels of communication

intrapersonal
interpersonal
group
public speaking

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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

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Verbal communication factors

language
denotative vs. connotative
tone and pitch
clarity and brevity

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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

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nonverbal communication

facial expressions
posture and cait
personal appearance
gestures
touch

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Factors that affect communication in general

environment
developmental variations
gender
personal space
territoriality
roles and relationships

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Assertive communication

use “I” statements
accept criticism
speak clearly and positively

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SBAR

situation
background
assess
recommend

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key characteristics of therapeutic communication

empathy
respect
genuineness
concreteness
confrontation

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Assessment of communication

medications
language, vocabulary, literacy
cognitive function
hearing
vision
aphasia

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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

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Developmental Factors Affecting Safety: infants and toddlers

cannot recognize danger
tactile exploration of environment
totally dependent

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Developmental Factors Affecting Safety: preschoolers

play extends to outdoors
more adventerous

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Developmental Factors Affecting Safety: school age children

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

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Developmental Factors Affecting Safety: adolescents

false confidence
risk- taking behaviors
most lack adult judgement

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Developmental Factors Affecting Safety: Adults

may be exposed to injury
lifestyle choices impact health

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Developmental Factors Affecting Safety: older adults

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

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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

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

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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

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Safety hazards for healthcare workers

back injury
needlestick injury
radiation injury
violence
prevention

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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

all of the above

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Safety assessments

client environment
home safety
risk for violence

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how does the nurse assess carotid arteries

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

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what safety topic would be appropriate to educated adolescents on

driving

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

wheezing

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

verify with the client

types of questions that cant be answered with yes or no

open ended

RACE

rescue alarm contain extinguish

Normal capillary refill happens

1-3 seconds

normal temp

97-<100

What are the 7 rights of administrating drugs

patient drug dose time route reason documentation

what is the proper order for physical assessment

inspection palpate percuss auscultate

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

under the tongue

Name of test that measures balance

Romburg (close your eyes and stand up)

What does clubbing indicate

poor oxygen levels over a long period of time

How do you modify physical assessment for toddlers?

make it fun and have a parent present

How do you modify physical assessment for older adults?

Take frequent breaks, minimize changing positions, talk slower

What is Kypnosis

hunch back

What position must you be in for seeing JVD

semi fowlers and head turned

What does JVD indicate

right sided heart failure

What is the purpose of physical assessments

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

What is the position laying on your back

supine

what measure can a nurse take to no injure the back

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

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

aerobic

how to prepare for a health history

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

what are 3 safety interventions for older adults

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

8 ounces is how many mL

240

What are the heart valves (in order)

tricuspid, pulmonary, mitral, atrial

what is the tool used to look at ears

otoscope

how to prepare an environment for physical assessment

temp, smell, noise, privacy

What is a morse fall

history of recent falls

what is the normal range for an adult heart rate

60-100

Best way to communicate

at eye level

What is tenting

the action of pinching the skin and it staying there

How do you assess pupils

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

what is normal o2 levels

90%>

where is equilibrium maintained

inner ear

When do you do vitals

admission, changes, after surgery

What are the principles of body mechanics

body alignment balance coordination joint mobility

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

Benefits of exercise

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

Maximum heart rate and target heart rate

MHR= 220- age THR= 60% x MHR

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

what is the nurses role in assessment of a client

getting a baseline

Types of assessments: 5

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

Can you delegate assessments?

no it is the nurses job.

Directive interviewing vs. nondirective

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

how to prepare for a interview with a patient

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

how to prepare a space for an interview

privacy remove distractions position yourself at eyelevel

preparing the client for an interview

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

health history components

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

Variances in temperature: fever, hyperpyrexia, hypothermia, hyperthermia

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

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

D (because the hypothalamus is in the head)

Apnea Bradypnea Tachypnea

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

the nurse performs a physical examination to

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