Week 2 Flashcards
True or false… weight and height is generally measured and noted during the first interaction with the client
True
True or false…. The head-to-toe approach involves a number of position changes required of the client.
False
True or false ….. The Rivne test is an assessment technique for comparing air versus bone conduction of sound
True
True or false….Prolonged “tenting” of the skin when assessing skin turbot indicated edema in the client
False
True or false….The lub-dub sounds of the heart are called “S1 and S2”
True
The method of ___________ involves striking or tapping part of the clients body with the fingertips to produce vibratory sounds.
Percussion
________ are whistling or squeaking sounds heard in the lungs caused by air moving through a narrowed passage
Wheezes
A skin _____ is an area that has been rubbed away by friction
Abrasion
_________ is a sophisticated test of range of hearing that measures hearing acuity at various sound frequencies
Audiometry
Bowel sounds are described as _____ if no sound is heard for two to five minutes
Absent
True or false ….. objective data consists of information that only the client feels and can describe
False
True or false… The nurse obtains database information beginning during admission interview and physical examination
True
True or false …. NANDA international is the clearinghouse for proposals suggesting diagnoses that fall within the independent domain of nursing practice
True
True or false….. planning is the way by which nurses determine whether a client has reached a goal
False
True or false …… Concept mapping is a method of organizing information in a graphic or pictorial form
True
__________ is the systematic collection of facts or data
Assessment
A ______ assessment is information that provides more details about specific problems and expands the original data base
Focus
A _______ results from analyzing the collected data and determining whether they suggest normal or abnormal findings
Diagnosis
Setting and evaluating a ______ helps the nursing team know whether the nursing care has been appropriate for managing the clients nursing diagnosis and collaborative problems
Goal
_________ means carrying out the plan of care
Implementation
Which statement best describes clinical judgment?
A-clinical judgment applies to the process in which nurses make patient care decisions in the hospital
B- clinical judgment refers to interpretations and inferences that influence actions nurses use in clinical practice in all settings
C- clinical judgment denotes which nursing interventions qualify for individual payment
D- clinical judgement is reserved for nurses who have achieved a baccalaureate degree or higher.
B- clinical judgment refers to interpretations and inferences that influence actions nurses use in clinical practice in all settings
_____________ is the thinking process by which a nurse reaches a clinical judgment.
Clinical reasoning
Which of the following are true regarding the use of algorithms ( select all that apply)
A- algorithms are especially useful for beginning clinicians who lack experience
B- algorithms account for individualized patient needs
C- algorithms direct care in emergent situations that involve inter professional personnel.
D- algorithms encourage a wide exploration of treatment options
A and C
Which reasoning process is most likely used by the novice or expert nurse who encounters an unfamiliar patient situation. A- analytic reasoning B- intuitive reasoning C- tacit reasoning D- interpretation
A. Analytic reasoning
Through clinical reasoning patterns, data collection, and collaborating with colleagues, nurses develop an understanding of a particular clinical situation. Which term best describes this process? A- responding B- interpreting C- interacting D- assessing
B- interpreting
Which statement best describes the process of reflection in action? Reflection in action refers to:
A- the nurses understanding of patient responses to nursing actions while care is occurring
B- when the nurse reflects on a patient situation after the nursing actions are completed and the outcomes are known
C- when a nurse pursues further education to improve his or her ability to apply what has been learned regarding various nursing actions
D- the various types of reasoning nurses use when deciding which nursing actions to utilize in a given patient situation
A- the nurses understanding of patient responses to nursing actions while care is occurring
Which type of reasoning process is used when nurses make sense of patient situations through telling and interpreting stories? A- intuitive reasoning B- tacit reasoning C- storytelling D- narrative
D- narrative
Clinical judgement is required for every patient care activity and every nursing intervention
A- true
B- false
B- false
Which of the following are typically true regarding novice nurses?(select all that apply)
A- they rely more heavily on intuitive reasoning than experienced nurses
B- they tend to treat all pieces of patient data with similar importance
C- they have difficulty individualizing patient care
D- they rely on theoretical knowledge to make clinical judgements
E- they are more often proficient with providing holistic care
B
C
D
To improve clinical judgment which of these actions would be most beneficial for novice nurses?
A- limit exposure to various clinical settings, thus avoiding confusion
B- analyze situations in which there are clear cut patient care solutions because this will assist with learning to recognize patterns
C- work closely with experienced nurses, paying attention to how clinical judgments are made
D- avoid examining their own nursing values, thus preventing bias.
B- analyze situations in which there are clear cut patient care solutions because this will assist with learning to recognize patterns
Conversing face to face, reading a newspaper, and texting via cell phone are examples of which category of communication? A- linguistic B- paralinguistic C- meta communication D- megacommunication
A- linguistic
Silence is a form of communication
A-true
B- false
A- true
A nurses scrub uniform is an example of which category of communication A- linguistic B- paralinguistic C- meta communication D- megacommunication
B- paralinguistic
The ultimate goal of communication is to create _________
Meaning
Which of the following are true regarding communication? (Select all that apply)
A- communication is an innate skill
B- communication occurs through a series of transmissions between a sender and receiver.
C- the relationship between the sender and receiver always affects the communication process
D- individuals typically show little change in their communication process through the lifespan
E- physical and mental health conditions impact the communication process.
B
C
E
Which statement best described the communication process?
A- the sender decodes a message, the message is transmitted, and the receiver encodes the message
B- the sender encodes a message and sends the message upon perceiving the message the receiver decides and interprets the message.
C- a message is transmitted and the sender and receiver both interpret the message and respond according to their individual perceptions of the content
D- the message is encoded by the sender and receiver, the message is sent via verbal and nonverbal cues, and finally the message is decoded and interpreted by both the sender and receiver.
B- the sender encodes a message and sends the message upon perceiving the message the receiver decides and interprets the message.
Communication competence in nursing means that communication is both ______ and ________
Effective and appropriate
Communication is cited as the leading cause of sentinel events
A- true
B- false
A- true
The institute of medicine recommends that nurses learn about the communication tool SBAR. What does SBAR stand for ??
Situation
Background
Assessment
And recommendation
The use of electronic health records as a communication tool is essential. What is the most significant Harris to using electronic health records.
A- the time it takes to bring up electronic health records in an emergency situation
B- the electronic health record is not considered to be legal documentation
C- the electronic health record is difficult to read and interpret
D- the potential for personal health care information to be accessed by those who do not have the right to access it.
D- the potential for personal health care information to be accessed by those who do not have the right to access it.
A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be go the highest priority keeping in mind the clients condition. A- risk for activity intolerance B- risk for ineffective coping C- risk for infection D- risk for imbalanced nutrition
C- risk for infection
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and e-cards the vital signs. Which data collected can be classified as subjective data. A- blood pressure B- nausea C- heart rate D- respiratory rate
B- nausea
A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan.
A- risk for impaired physical mobility due to surgery
B- ineffective denial related to poor coping mechanisms
C- disturbed body image related to the incision scar
D- risk of injury related to the surgical outcomes
C- disturbed body image related to the incision scar
A client who has undergone resection of the intestine is on a liquid diet with a nasogastric tube in place. He refuses the food tray with regular food that comes to his room and insists that a physician be called. The nurse insists that it is the right food and makes the silent take it. The client develops complications and requires another operation. How is negligence determined in this situation.
A- the nurse did not call the physician when the client asked.
B- the nurse did not realize the importance of the tube
C- the dietary department sent the wrong diet for the client
D- the nurse insisted the client have the solid food
B- the nurse did not realize the importance of the tube
A client who is scheduled for hernioplasty needs clarification regarding the procedure. The nurse calls the physician at the clients insistence. The physician, who is in a bad mood, is overheard telling the client that the nurse does not know anything. Which legal tort has the physician committed? A- libel B- battery C- assault D- slander
D- slander… orally.
A nurse enters a clients room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report?
A- the nurse documents a complete description of the happenings in the clients records.
B- the nurse makes a copy of the incident report and places it in the clients records
C- the nurse makes a copy of the incident report to give to the physician
D- the nurse mentions in the clients report that an incident report was complete
A- the nurse documents a complete description of the happenings in the clients records.
A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding? A- 1+ pitting edema B- 2+ pitting edema C- 3+ pitting edema D- 5+ brawny edema
C- 3+ pitting edema
A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the clients bowel sounds as hypoactive.
A- if sounds occur 30 to 34 times a minute.
B- if sounds occur frequently
C- if sounds occur after a long interval
D- if no sound is heard for 3 - 5 minutes
C- if sounds occur after a long interval
The nurse is examining the anus of a client with a history of chronic constipation. What is indicative of chronic constipation?
A- presence of rectal fissures
B- area is more pigmented than adjacent skin
C- area is moist and hairless
D- presence of signs of trauma
A- presence of rectal fissures
True or false constitutional laws are enacted by federal, state, or local legislatures
False
True or false a misdemeanor is a serious criminal offense, such as murder, falsifying medical records, insurance fraud, and stealing narcotics
False
True or false
According to the Good Samaritan laws, legal immunity is provided to passerby who provides emergency first aid to victims of accidents.
True
True or false
An incident report is a written account of an unusual, potentially injurious event involving a client, employee or visitor
True
True or false
Nomaleficence means “doing good” or acting for another’s benefit.
False
______ law refers to legislation that falls outside the realm of constitutional, statutory, and administrative law.
Common
______ torts are lawsuits in which the plaintiff charges that a defendant committed a deliberately aggressive act
Intentional
_______ is an ethical theory that prioritizes the final outcome of a situation
Teleology
______ refers to a competent persons right to make his or her choice without intimidation or influence
Autonomy
Free speech and privacy are examples of rights protected by _____ law
Constitutional
Which law protects fundamental rights and freedoms of U.S citizens.
Defines the duties and limitations of the executive, legislative, and judicial branches of government.
Protected the entire nation
Identified rights and privileges of U.S citizens
Constitutional laws.
Which law identifies local, state, or federal rules necessary for the publics welfare.
Statutory
Which law develops regulations by which to carry out the mission of public agency.
State boards of nursing, nurse licensure compacts
A) common law
B) statutory law
C) administrative law
D) civil law
Administrative law
Which law interprets legal issues based on previous court decisions in similar cases (legal precedents)
Based on the principle of stare decisis
Refers to litigation
Common law
