Exam 1; fundamentals of nursing Flashcards
Levels of communication
- intrapersonal
- interpersonal
- group
- public speaking
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
B
Verbal communication factors
language
denotative vs. connotative
tone and pitch
clarity and brevity
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
B
nonverbal communication
facial expressions
posture and cait
personal appearance
gestures
touch
Factors that affect communication in general
environment
developmental variations
gender
personal space
territoriality
roles and relationships
Assertive communication
use “I” statements
accept criticism
speak clearly and positively
SBAR
situation
background
assess
recommend
key characteristics of therapeutic communication
empathy
respect
genuineness
concreteness
confrontation
Assessment of communication
medications
language, vocabulary, literacy
cognitive function
hearing
vision
aphasia
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
D
Developmental Factors Affecting Safety: infants and toddlers
cannot recognize danger
tactile exploration of environment
totally dependent
Developmental Factors Affecting Safety: preschoolers
play extends to outdoors
more adventerous
Developmental Factors Affecting Safety: school age children
try new activities without practice
more time outside the home
increased safety risk outside the home
Developmental Factors Affecting Safety: adolescents
false confidence
risk- taking behaviors
most lack adult judgement
Developmental Factors Affecting Safety: Adults
may be exposed to injury
lifestyle choices impact health
Developmental Factors Affecting Safety: older adults
loss of muscle strength, joint mobility, slowing reflexes, sensory losses
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
D
A child has had hiccups for 2 hours. Is this a sign of suspected ingestion of poison?
A. yes
B. no
B
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
C
Safety hazards for healthcare workers
back injury
needlestick injury
radiation injury
violence
prevention
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
Safety assessments
client environment
home safety
risk for violence
how does the nurse assess carotid arteries
one side at a time to not cut off oxygen to the brain
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
B
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
C
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
