Exam 2: NR410 REV Flashcards
Why do we restrain a patient?
- violence
- at risk to themselves or others
- last resort
- pulling out IV
What do you assess for after restraint?
- neurosensory, ever 2 hrs
- basics every 15-30min
- reasses for continued use
IOM 6 Aims
- Safe
- Timely
- Effective
- Efficient
- Equitable
- Patient-Centered
Good Questions to ask?
- What do you think caused your illness?
- Who would you like to be involve
- What have you done to treat your illness?
What is the sequence for using a cane
- Put weight on good foot
- Step out with bad foot
- Place cane forward
- Move good foot forward
What is therapeutic nurse-client relationship?
- info about health treatment
- wellness
- therapeutic communication
Blockers of communication
- false reassurance
- changing the subect
- refer to handout
- close ended questions
- asking “why”?
What statement about nonverbal communication is correct?
- nurses’ verbal communication should be reinforced by nonverbal cues
A patient with risk of falls is wondering halls, what do you do?
- Leave a night light on in the bathroom
- Provide scheduled toileting during the night shift.
- Keep the pathway from the bed to the bathroom clear.
What is the most important intervention when a patient is having a seizure?
- Clear the area around the child to protect the child from injury.
A patient gets out of bed often, is a fall risk, what is the initial nursing intervention?
Place a bed alarm device on the bed
Kardex or Client Care
- “down & dirty”
- demographic, medical diagnosis, allergies, diet, meds, safety, treatments
Do you take verbal orders only in emergency?
yes
Evolve:
Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (POST-OP)
- respiratory rate increases.
- The heart rate also increases because the heart is trying to improve oxygen levels.
- crackling
Name some causes of orthostatic hypotension
- dehydration
- medication
- heart problems
- thyroid/endocrine
- nervous system
Evolve:
Which action(s) are appropriate for the nurse to implement when a patient experiences orthostatic hypotension?
- Allow patient to sit down.
- Take patient’s blood pressure and pulse.
- If patient begins to faint, allow him to slide against the nurse’s leg to the floor
Evolve:
Which is the correct gait when a patient is ascending stairs on crutches?
- modified three-point gait.
- The unaffected leg is advanced between the crutches to the stairs
Evolve:
What does a 3 point gait require
- that the patient bear all their weight on one foot,
- For a patient with one injured foot/leg.
Evolve:
Which of the following activities does the nurse delegate to nursing assistive personnel in regard to crutch walking?
- Notify nurse if patient reports pain before, during, or after exercise
- Notify nurse of patient complaints of increased fatigue, dizziness, light-headedness when obtaining vital signs before and/or after exercise
- Notify nurse of vital sign values.
- Prepare the patient for exercise by assisting in dressing and putting on shoes.
Evolve:
What applies to the proper use of a cane?
- patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs
- The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times.
Evolve:
What are some critical thinking skills?
- ethics
- analytics
- self confidence
Evolve:
The pain scale is an example of which intellectual standard?
consistency
Evolve:
What is basic critical thinking?
concrete and based on a set of rules or principles
Evolve:
What is unique to the commitment level of critical thinking?
Anticipates when to make choices without others’ assistance.
What is the difference between negligence & malpractice?
when the patient is involved
What are the 5 rights in delegation
- task
- circumstance
- person (doesn’t have to be a CNA)
- direction
- supervision
What is the delegation process
- communicate, expectations
- monitor
- evaluate
- give feedback
What can a nurse not delegate, even to another nurse?
- assessment
- evaluation
- nursing judgment
How to prevent liability
- follow standards/protocols
- delegate appropriately
- keep up on information
- identify fall risk, decubitis
- safe environment
- document well
When should you question a physicians orders?
- when client questions
- question and record verbal orders
- avoid miscommunication
Causes of negligence?
- patient falls
- equipment injuries
- failure to monitor
- failure to communicate
- medication errors
- medical errors
Intervention errors
- not performing task correctly
- interpret carry out doc’s orders
- pursue the physician
What are the 6F’s
- asses/monitor
- changes
- adequate education
- standards/policies
- document
- failure to act as an advocate
Be able to determine negligence vs malpractice
Grief?
- physical, psychological, and spiritual responses to loss
Mourning
action associated with grief
What affects grief
- significance of the loss
- amount of support for the bereaved
- developmental stage
- timeliness of death
Hubler Ross 5 Stages of Grief
- denial
- anger
- bargaining
- depression
- acceptance
What are types of grief
- uncomplicated
- complicated
- chronic/masked/delayed
- disenfranchised- miscarriage, society doesnt recognize
- anticipatory- pre-grief
What are the stages of dying (assessment)
- 1-3mnths prior, withrawn, sleep more, not eating
- 1-2 wks, vitals change, skin color change, apnea, cheyne stokes, death rattle
- days to hours- walk, eat, energy, swallowing diff, dehydration
- moments to hours- unconsciousness
What is our assessment for end of life?
- knowledge
- history
- coping
- meaning of loss
- depression or grief
- physical assessment
- cutlural/spiritual assess
What are NANDA’s for end of life
- powerlessness
- hopelessness
- denial, ineffective
- coping, ineffective
- nutrition imbalance
Patient Self Determination Act
letting patient know their rights to advanced directive
Post Mordam Care
- comfort dignitiy cooperation
- who validates death?
- donor?
- autoposy? (everything stays in)
- making them presentable
Evolve:
What technique(s) best encourage(s) a patient to tell his or her full story?
- Active listening
- Back channeling
- Use of open-ended questions
Evolve:
What is validating?
comparing data with another ?source
Evolve:
A patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient?
- Lean forward when interacting with the patient
- Acknowledge the patient’s answers through head nodding
Evolve:
What is the related factor or risk?
a condition for which the nurse can implement preventive measures
Evolve:
A risk diagnosis does not have defining characteristics, instead what does it have?
Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem
Evolve:
Time Frame what it is & what it is NOT
- IS:
- when you expect a response to your nursing interventions
- helps to organize nursing priorities
- IS NOT
- which problem is most important
- a nurses work schedule
Evolve:
What must an outcome have to be a precise measurement?
- quality
- quantitly
- frequency
- length or weight
Evolve:
A goal specifies the expected behavior or response that indicates
Resolution of a nursing diagnosis or maintenance of a healthy state
Evolve:
The evaluation of interventions examines two factors:
- the appropriateness of the interventions selected
- the correct application of the intervention
Evolve:
An evaluative measure determines a
a patients response
Evolve:
Who makes the request for organ and tissue donation at the time of death?
Specially educated personnel make requests
Evolve:
How do you start the conversation about the goals of care at the end of life?
asking the patient to identify his or her beliefs about the goals of care while the family member is present
Evolve:
What action honors cultural beliefs at the end of life?
Giving people options in caregiving (i.e. family members)
Evolve:
What type of communication is used during the orientation phase of a relationship
unrelated small talk
Evolve:
What do you include in a hand off report
- patient’s name, age, and admitting diagnosis
- allergies
- patient pain raiting
Evolve:
A patient newly diagnosed with type 2 diabetes says, “My blood sugar was just a little high. I don’t have diabetes.” The nurse responds:
with silence, gives patients time to process their thoughts.
What are topic of the NCLEX
- Safe care environment
- Health promotion/maintenance
- psychosocial
- physiological
- nursing process
- communication, documentation, teaching
what organization developed the NCLEX testing system
National Council of State Boards of Nursing
What are the 4 recommendations of the IOM?
- practice to the full extent of their education and
training - achieve higher levels of education and training through an improved education system that promotes seamless academic progression
- full partners, w/ physicians and other health care
professionals, in redesigning health care in the United States. - Effective workforce planning and policy making require better data collection and an improved
information infrastructure.
What is the reasonable man standard?
a hypothetical person in society who exercises average care, skill, and judgment in conduct and who serves as a comparative standard for determining liability.
What are common examples of malpractice
- Doing or Saying Nothing When Action Is Required
- Injuring a Patient With Equipment
- Improper Administration of Medication
What is EMTALA
- no patient with an emergency medical condition, unable to pay may be treated differently than patients who are covered by health insurance
- Emergency Medical Treatment and Active Labor Act
What is the bill of rights for nursing?
nurse’s rights in the workforce
What are 4 elements that must exist for malpractice
- Duty
- Breach of Duty
- Causation
- Harm/Injury
What 2 components are mandatroy to report?
- communicable disease
- abuse
Intentional Torts Relevant to Nursing
- Confidentiality
- False imprisonment
- Assault and battery
- Fraud
- Invasion of privacy
This is a term for a published false statement that is damaging to a person’s reputation
Libel/Slander
Pronation is?
inward roll of the foot
supination
outward roll of the foot
It is important for nurses working with patients with a diagnosis of dementia to
adopt a common approach of care because these patients have consistency and sameness in their environment
What is caregiver burden?
increased morbidity & mortality of caregivers and increased risk of LTC placement
What are nursing interventions for a dementia patient?
- evaluate environmental and placement choices
- Maintain safe environment
- driving and occupational safety
- long term financial and legal planning
What is an intervention for delirium
take labs!
NANDA for delirium
acute confusion, disturbed throught processes, interrupted family processes, risk for infection, acute pain, ineffecting coping,
What are the steps for transferring a patient?
- high fowlers position, dizziness
- place a gait belt on the patient
- bring the patient to the edge of the bed and dangle their legs
- assist the patient to a standing position and transfer to the chair
What does a “problem” suggest”
Client Goals
What does etiology suggest?
interventions
What do cue clusters suggest?
- whether the correct nursing diagnosis has been identified
What is focus charting?
Clients Concerns & Strengths
COAL
Cane Opposite Affected Leg
WWAL
Walker With Affected Leg
unlicensed personnel get assigned what type of tasks?
- routine
- unchanging
- expected outcomes
