Med Surg Exam Flashcards
What does ADPIE stand for?
Assessment, Diagnosis, Planning, Implementation, Evaluation
What do you do during the assessment phase?
Gather info, review history
Most communication takes place in the____ stage
assessment
What do you do during the diagnosis phase?
identify problem list
What do you do during the planning phase?
develop goals, desired outcomes
What do you do during the implementation phase?
perform nursing actions
What do you do during the evaluation phase?
determine whether goals were achieved
Therapeutic communication
face to face process of interacting that focuses on advancing the physical and emotional well being of a patient
Nurses use therapeutic communication to provide_____ and _____ to patients
support and information
Examples of personal factors that can impede accurate communication
emotional and social support, cultural and language difference, lifestyle differences, cognitive factors
Examples of environmental factors that can impede accurate communication
physical factors and societal factors
Examples of symmetrical relationships
equal:friends and colleagues
Examples of complementary relationships
unequal: difference in status and power such as between a nurse and patient or teach and student
Communication is __% verbal and __% nonverbal
10%, 90%
about how you say it not what you say
Verbal Language
represents public self
can be straight forward comments or can be used to distort, conceal, deny or distinguish true feelings
Verbal communication is
language
Nonverbal communication is
body language
Nonverbal communication
covers wide range of human activities from body movements to responses to messages of others
Double messages
are conflicting messages or mixed messages
Types of nonverbal communication
facial expressions, touch, eye contact, posture, gait, gestures, general physical appearance, mode of dressing and grooming, sounds and silence, electronic communication
Effective communication skills include
appropriate, sensitive use of silence
active listening
clarifying techniques, paraphrasing(restating and reflection of feelings)
exploring
projective questions(what if)
presupposition questions(assumed to be true, left unstated)
Everything you hear is ___ by the patients filters and your own filters
modified
Active listening principles strengthens the patients ability to use____ to solve problems
critical thinking
Undivided attention is when the nurse communicates patient is
not alone
Problematic areas for the nurse when interpreting specific verbal and nonverbal messages of the patient include
communication
use of eye contact
perception of touch
cultural filters
Therapeutic communication techniques
using silence
summarizing
offering self
giving recognition
accepting
voicing doubt
Non therapeutic communication
Asking excessive questions
disapproving
asking why questions
minimizing feelings
Aims of patient education
maintaining and promoting health
preventing illness
restoring health
facilitating cooping
Cognitive learning domain
storing and recalling of new knowledge in the brain
Psychomotor learning domain
learning a physical skill
Affective learning domain
changing attitudes, values, and feelings
Which action is an example of cognitive learning?
A. A patient demonstrates how to change his wound
dressing.
B. A new mother follows instructions for caring for the
umbilical cord.
C. A patient describes how to portion food to maintain
within a prescribed calorie range.
D. A patient expresses renewed confidence following a
teaching session on caring for her mother at home.
C. A patient describes how to portion food to maintain
within a prescribed calorie range.
Factors affecting patient learning
age and developmental level
family support networks
financial resources
cultural influences
language deficits
health literacy level
What does ISBARR stands for
Identify/info
Situation
Background
Assessment
Recommendation
Read back of orders/response
What happens during the situation part of ISBARR
vital signs obtained, stress concerns
What happens during the background part of ISBARR
check mental status, skin observation
What happens during change of shift/hand off reports
-basic identifying info about each patient(name, room #, bed designation, diagnosis, attending and consulting physicians
-current appraisal of each patients health status
-current orders
-abnormal occurrences during change
-any unfilled orders that need to be continued
-patient and family questions and concerns
-reports on transfers and discharge
What are the 4 p’s
pain, position, potty, and proximity
Traditional knowledge
passed down from generation to generation
Authoritative knowledge
comes from expert, accepted as truth based on persons perceived expertise
Scientific knowledge
obtained through scientific method of research
T/F
Traditional and authoritative knowledge are
practical to implement, but are often based on subjective
data, limiting their usefulness in a wide variety of settings.
true
Types of nursing knowledge
science
philosophy
process
Science nursing knowledge
knowledge in and out of nursing
Philosophy nursing knowledge
study of wisdom, fundamental knowledge and process used to constrict life
Process nursing knowledge
conceptual frameworks and theories
Influences on nursing knowledge
historical
societal
Culture
shared beliefs system, values and behavioral expectations that provide social structure for daily living
Define roles and interactions with others and in families and communities
True or false.
Culture includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one’s family.
true
Subculture
Large group of people who are members of a
larger cultural group
Example of subculture
nursing is the subculture of healthcare
Groups in society are
dominant group
minority group
Dominant group
-usuallty the largest group
Group has the most authority to control values and
sanctions of society
Minority group
smaller group
A physical or cultural characteristic identifies the people
as different from dominant group.
Cultural assimilation (acculturation)
Minorities living within a dominant group lose the characteristics that made them different.
Values replaced by those of dominant culture
Culture shock
The feelings a person experiences when placed in a different culture
May result in psychological discomfort or disturbances
Which of the following occurs when members of a minority group, living with a dominant group,
begins to blend in and lose the characteristics that
made them distinct?
A. Cultural imposition
B. Cultural conflict
C. Cultural assimilation (acculturation)
D. Cultural shock
Cultural Assimilation
Ethnicity
Sense of identification with a collective cultural group
shared identity, bond or kinship people feel with their country of birth or place of ancestral origin. Largely
based on group’s common heritage
Race
Typically based on specific characteristics
Skin pigmentation, body stature, facial features, hair
texture
Stereotyping
The assumption that all members of a culture or ethnic group act alike
Stereotypes are ___ and ___ beliefs about people
preconceived and untested
Negative stereotypes are
racism, sexism, ageism
Cultural imposition
Belief that everyone should conform to the majority belief
system
Cultural blindness
Ignores differences and proceeds as if they did not exist
Culture conflict
People become aware of differences and feel threatened.
Response—ridiculing beliefs and traditions of others to make themselves feel more secure
Ethnocentrism
Belief that one’s ideas, beliefs, and practice are the best or superior, or are most preferred to those
of others
Which term describes what occurs when a nurse believes that one’s own ideas, beliefs, and
practices are the best or superior to those of colleagues and patients?
Ethnocentrism
Cultural Influences on Health Care
Physiologic variations
Reactions to pain
Mental health
Gender roles
Language and communication Orientation to space and time(sitting too close/too far from patient
Family support
Socioeconomic factors
food and nutrition
Be sensitive to nonverbal signals of discomfort such as
holding or applying pressure to the painful area or avoiding activities that intensify the pain.
T/F
The health care system is a culture of its own, with nursing being its largest subculture.
true
Religious beliefs may prohibit the presence of males, including husbands, in the delivery room.
This may be observed among
devout Hindus and Orthodox Jews
Traditional Western medicine uses medication administration as a method of
treatment
Encourage caregivers to participate in spiritual behaviors or practices such as____to enhance spiritual well-being when appropriate.
prayer, attending religious services
Orthodox Jews maintain a Kosher diet which excludes
seafood
Buddhist belief to not move deceased patient until
cold
The Islamic religion does not prefer the use of health care
professionals of the___unless it is difficult to locate one of the same gender.
opposite gender
____woman usually bathed and cared for by family members
post-op and/or while hospitalized
Chinese
What are the elements of cultural competence
Developing self-awareness
Demonstrating knowledge and understanding of a patient’s culture
Accepting and respecting cultural differences
Not assuming that the health care provider’s beliefs and values are the same as the client’s
Resisting judgmental attitudes such as “different is not as good”
Being open to and comfortable with cultural encounters
Accepting responsibility for one’s own cultural competency
Who may refuse breathing exercises and performing own hygienic care
Chinese women
A nurse is conducting an intake interview with a client. Which should the nurse do to best facilitate
therapeutic communication with this client?
A. Talk about expectations.
B. Use probing questions.
C. Ask direct questions.
D. Listen attentively
D. Listen attentively
A client’s son has just died. The client states, “I can’t believe that I have lost my son. Can you
believe it?” Which is the nurse’s best response?
A. Touch the client’s hand and say, “I am very sorry.”
B. Leave the room and allow the client to grieve in private.
C. Encourage a family member to stay and provide support.
D. Assume a serious facial expression and say, “I can’t believe it either.”
A. Touch the client’s hand and say, “I am very sorry.”
A nurse identifies that a usually talkative client is withdrawn. Which is the nurse’s best response?
A. “What is bothering you?”
B. “You are very quiet today.”
C. “Tell me what you’re upset about.”
D. “Why are you so withdrawn today?”
B. “You are very quiet today.”
A client is being discharged to a nursing home. While preparing the discharge summary, the client
says, “I feel that nobody cares about me.” Which is the nurse’s best response?
A. “You feel as if nobody cares.”
B. “We all are concerned about you.”
C. “It’s hard to be angry at your family.”
D. “Your family doesn’t have the skills to care for you
A. “You feel as if nobody cares.”
A client tells the nurse, “The doctor just told me I have cancer” and then begins to cry. Which is the
best response by the nurse?
A. “Try to focus on something else.”
B. “Sometimes it helps to talk about it.”
C. “Deep breathing may help you regain control.”
D. “Tears are good because it gets it out of your system.”
B. “Sometimes it helps to talk about it.”
. A client has a history of verbally aggressive behavior. One afternoon the client starts to shout at
another client in the lounge. Which are appropriate responses by the nurse? Select all that apply.
A. ____ “Stop what you are doing.”
B. ____ “Let’s go talk in your room.”
C. ____ “Sit down until you are calm.”
D. ____ “Come with me for a walk in the hall.”
E. ____ “Do not raise your voice in a hospital.”
B. ____ “Let’s go talk in your room.”
D. ____ “Come with me for a walk in the hall.”
A nurse is collecting data for an admission nursing history. Which question by the nurse is best to
open the discussion?
A. “What brought you to the hospital?”
B. “Would it help to discuss your feelings?”
C. “Do you want to talk about your concerns?”
D. “Would you like to talk about why you are here?”
A. “What brought you to the hospital?”
A nurse is using military time when entering information into a patient’s clinical record. Which
number in military time should the nurse enter to document a wound irrigation that was
implemented at 9 p.m.?
A. 0900
B. 1900
C. 2100
D. 2300
C. 2100
A nurse is caring for a confused patient with a diagnosis of dementia of the Alzheimer’s type. Which
should the nurse say when assisting the patient to eat?
A. “Please eat your meat.”
B. “It’s important that you eat.”
C. “What would you like to eat?”
D. “If you don’t eat, you can’t have dessert.”
A. “Please eat your meat.”
A mother whose young daughter has died of leukemia is crying and is unable to talk about her
feelings. Which is the best response by the nurse?
A. “Everyone will remember her because she was so cute. She was one of our favorites.”
B. “As hard as this is, it is probably for the best because she was in a lot of pain.”
C. “She put up the good fight but now she is out of pain and in heaven.”
D. “It must be hard to deal with such a precious loss.”
D. “It must be hard to deal with such a precious loss.”
A patient states, “My wife is going to be very upset that my prostate surgery probably is going to
leave me impotent.” Which is the best response by the nurse?
A. “I’m sure your wife will be willing to make this sacrifice in exchange for your well-being.”
B. “The surgeons are getting great results with nerve-sparing surgery today.”
C. “Your wife may not put as much emphasis on sex as you think.”
D. “Let’s talk about how you feel about this surgery.”
D. “Let’s talk about how you feel about this surgery.”
Which should a nurse never do when documenting information on a patient’s electronic medical
record? Select all that apply.
A. _____ Leave the patient’s medical record open on the computer screen when entering the patient’s
room to administer a medication.
B. _____ Share information verbally about a patient with another nurse who is also caring for the
patient.
C. _____ Document nursing care administered to a patient immediately after it is completed.
D. _____Give a personal access code to another member of the health-care team.
E. _____Document exact quotes of a patient’s subjective information.
A. _____ Leave the patient’s medical record open on the computer screen when entering the patient’s
D. _____Give a personal access code to another member of the health-care team.
A client is admitted to the hospital with multiple health problems. Which nursing intervention is
least effective in meeting the client’s psychosocial needs?
A. Addressing the client by name
B. Assisting the client with meals
C. Identifying achievement of client goals
D. Explaining care before it is to be given to the client
B. Assisting the client with meals
Examples of Nursing Diagnosis associated with Nutrition
-Impaired swallowing
-Dysfunctional Gastrointestinal Motility
-Imbalanced Nutrition:Less Than Body Requirements
- Impaired Oral Mucous Membrane
-Nausea
Autonomy
self sufficiency-competent
In safety, if you see something, you _____ _____
say something
not a solo efforts-works as a team
Beneficence
kind and true
Nonmaleficence
no harm
Justice
honest and fair
A go kit for yourself and family is used for
shelter in place or evacuation-circumstance specific
Individual readiness
General disaster readiness for
individual healthcare workers and their family and significant others is essential for a readied workforce
and critical to the national preparedness goal
What is the acronym we use for fire safety?
RACE
R is race stands for
rescue anyone in immediate danger
The A in RACE stands for
activate fire code system and notify
appropriate personnel
The C in RACE stands for
confine fire by closing doors and windows
The E in RACE stands for
evacuate patients and persons to a safe area
Institution policy usually identifies plans for
vertical, horizontal or both
