NUR 372 CLASS 1 HIPAA

Question 1

FACTORS AFFECTING/INFLUENCING SENSORY FUNCTION

Answer 1

• age
• illness: DM, HTN
• medications: gentamicin (hearing loss), lasix (ototoxicity), CNS depressants, digoxin
• environment
• lifestyle: smoking

Question 2

SENSORY OVERLOAD RISK FACTORS

Answer 2

• internal factors: new diagnosis, impending surgery
• environment: may need to talk in quiet place
• information: may need to incorporate teaching

Question 3

SENSORY DEPRIVATION RISK FACTORS

Answer 3

• bed rest
• isolation
• impaired ability to receive environmental stimuli (blind/deaf)
• patients with bandages, traction or casts
• medication (sedatives/narcotics)
• SCI
• TBI

Question 4

NURSING INTERVENTION - SENSORY DEPRIVATION

Answer 4

• being present for your pt
• clocks, calendars, pictures
• calling pt by name
• what do you prefer to be called? *always ask
• talk to them, read something to them
• good mouth care
• back rubs
• ROM
• hygiene and grooming

Question 5

RESULTS OF ALTERED SENSATION IN PATIENTS

Answer 5

• functional impairment (ADLs and IADLs)
• anxiety: Newly diagnosed, new environment
• cognitive dysfunction-difficulty remembering, reasoning.
• depression

Question 6

PHYSIOLOGIC FACTORS AFFECTING COGNITIVE FUNCTION

Answer 6

• blood Flow - need O2, hemoglobin; hypoxia
• nutrition and metabolism - glucose for energy (anemia)
• fluid and electrolyte balances - brain needs for functioning (Na, K, Ca)
• sleep and rest - needed for short and long term memory
• infectious processes - infections, tumors
• pharmacologic agents - CNS depressants
• environmental factors- amount of stimuli in hospital

Question 7

SYMPTOMS OF PATIENTS WITH ALTERED COGNITIVE FUNCTION

Answer 7

• hallucinations: sensory Impressions based on internal stimulation, no basis in reality (hearing voices)
• delusions: beliefs not based in reality (hospital food is poisoned)
• impaired thought processes: could be hyperactive or lethargic, obtunded, comatose
  Poor attention span
• delirium - could be acute (may need meds, too much stimuli)
• sundown syndrome - nocturnal delirium, seen in geriatric setting

Question 8

IMPAIRED COMMUNICATION

Answer 8

• aphasia: complete or partial loss of language abilities
• expressive (can’t come up with the words)
• receptive (difficulty understanding spoken word)
• global (can’t speak or understand)

Question 9

RESTRAINTS

Answer 9

• any device that restricts: freedom of movement, physical activity, normal access to body, seclusion

Question 10

RESTRAINTS DO NOT INCLUDE

Answer 10

• orthopedic devices
• surgical dressings
• protective Helmets
• patients with low platelet count, risk for falls
• holding patient to do exam
• pediatrics, trying to put IV in

Question 11

TYPES OF RESTRAINTS

Answer 11

• posey vest
• wrist
• leather
• mitts (only a restraint if tied to bed, sometimes used to prevent patients from taking out IV, tubing, etc)
• canopy bed

Question 12

WHY USE RESTRAINTS

Answer 12

• agitated/combative
• prevent interruption of therapy
• short-term only

Question 13

REASONS WHY PEOPLE COULD BE AGGRESSIVE OR IN POSSIBLE NEED OF A RESTRAINT

Answer 13

• infection
• hypoxia
• pain
• urinary retention
• fecal impaction
• dehydration
• hypoglycemia
• urinary tract infection
• prior behavior

Question 14

RESTRAINT ORDERS

Answer 14

• RN can apply in emergency (provider assessment within 60 min, written order)
• no PRN
• renewed q8h for 4 point
• renewed q24h for posey or 2 point
• must include type/use/reason
• must have a specific time period

Question 15

ALTERNATIVES TO RESTRAINTS

Answer 15

• mitts
• room visible from nursing station
• bed alarms, chair alarms
• exit alarms
• wander guards
• commode / toileting schedule
• yellow gowns to identify pt at risk for falls

Question 16

CONSEQUENCES OF RESTRAINT USE

Answer 16

• psychological: fear, confusion, anger, feeling of hopelessness, punishment
• physical: skin trauma / breakdown, incontinence / constipation, lack of stimulation

Question 17

HAZARDS ASSOCIATED WITH RESTRAINTS

Answer 17

• suffocation from entrapment
• impaired circulation - two fingers under restraint
• altered skin integrity - pressure ulcers
• diminished muscle and bone mass
• fractures
• altered nutrition and hydration
• aspiration and breathing difficulties
• incontinence
• changes in mental status

Question 18

CRITERIA FOR REMOVING RESTRAINTS

Answer 18

• no longer has behavior that lead to restraint use
• alert, follows commands (not pulling tubes)
• less restrictive measures effective
• if behavior reoccurs after removal, you need to obtain a new order for the restraint

Question 19

ASSESSMENT OF RESTRAINTS

Answer 19

• every 30 min:
  CMS check (color, motion and sensation), patient status, interventions, evaluation of restraint effectiveness
• every 2 hours
  release of restraint: ROM, more in depth assessment of skin, etc., assessment - bring other person if patient is combative

Question 20

DELEGATION

Answer 20

• process of transferring the authority and responsibility to another healthcare team member while retaining accountability

Question 21

LPN DELEGATION TASKS

Answer 21

• monitoring client findings (as input to the RNs ongoing assessment)
• reinforcing client teaching
• performing tracheostomy care
• suctioning
• checking nasogastric tube patency
• administering enteral feedings
• inserting a urinary catheter
• administering medications

Question 22

UAP DELEGATION TASKS

Answer 22

• ADLs (bathing, grooming, dressing)
• toileting
• ambulating
• feeding (without swallowing precautions)
• positioning
• bed making
• specimen collection
• intake and output
• vital signs (stable clients)

Question 23

SBAR COMMUNICATION MODEL

Answer 23

• S: situation: what is going on now, identifying data, purpose of communication
  B: background: what happened, pertinent & brief information to situation
  A: assessment: what you think is going on, assessment findings, analysis of data
  R: recommendations: what you want done, request or recommend action, identify priority issues

Question 24

DATAS

Answer 24

• nurse-to-nurse report
  D: description (name, age, history)
  A: active issues (vitals, diet, pertinent labs, care delivered, where is patient now)
  T: to do: labs, tests, f/u
  A: anticipatory: watch for…pain, safety, mental changes
  S: special needs: social issues, referrals, isolation

Question 25

HIPAA

Answer 25

• health insurance portability and accountability act
• requires that the nurse protect all written and verbal communication about clients
• clients have the right to read and obtain a copy of their medical record
• e-record should be password protected

Question 26

HIPAA VIOLATIONS

Answer 26

• look up a neighbors test result because you saw them in the ED and you are
  concerned or curious
• look up a family member’s medical records, even if they said you could
• review a former spouse’s billing or medical records
• look up your coworkers, colleagues record
• you should never be discussing or sharing PHI: in hallways, elevators, cafeteria, social media platforms,