week 6 sherpath Flashcards
Match the type of communication to its characteristic.
Has fluid ethical and legal boundaries
Has sharing but in a limited capacity from the nurse
Has the focus on the nurse
Answer choices
Nontherapeutic
Therapeutic
Social
Has fluid ethical and legal boundaries
Social
Has sharing but in a limited capacity from the nurse
Therapeutic
Has the focus on the nurse
Nontherapeutic
Which feature of the nurse–patient helping relationship is legally upheld by the Health Insurance Portability and Accountability Act (HIPAA)?
Confidentiality
Respect
Caring
Empathy
Confidentiality
Match the key concept of professional communication to its example.
Nurse asks the patient’s name preference during initial contact
Nurse defends the rights of others, especially vulnerable patients
Nurse has confidence and commands respect
Nurse keeps the nurse–patient relationship therapeutic, not social
Answer choices
Assertiveness
Respect
Professional boundaries
Advocacy
Nurse asks the patient’s name preference during initial contact
Respect
Nurse defends the rights of others, especially vulnerable patients
Advocacy
Nurse has confidence and commands respect
Assertiveness
Nurse keeps the nurse–patient relationship therapeutic, not social
Professional boundaries
For which reason would the nurse avoid nontherapeutic communication in a nurse–patient helping (therapeutic) relationship?
Focuses on patient’s options
Exhibits empathy to the patient
Shifts the emphasis to the patient
Requires justification of actions from the patient
Requires justification of actions from the patient
Which nursing responses are considered nontherapeutic?
Select all that apply.
Asking “why” questions
Using open-ended questions
Offering advice
Agreeing with the patient
Providing general leads
Asking “why” questions
Offering advice
Agreeing with the patient
Match the phase of the nurse–patient helping relationship with its activity.
Collaborating among the nurse, patient, and others
Transitioning to another caregiver
Predetermining topics of interaction
Observing, interviewing, and assessing patients
Answer choices
Working
Orientation
Preorientation
Termination
Collaborating among the nurse, patient, and others
Working
Transitioning to another caregiver
Termination
Predetermining topics of interaction
Preorientation
Observing, interviewing, and assessing patients
Orientation
Which distance range (in feet) is considered social space in proxemics? Record your answer as whole numbers separated by a hyphen.
4-12 feet
Which behaviors would the nurse implement when using active listening?
Select all that apply.
Lightly touching the patient’s arm
Maintaining eye level with the patient
Keeping arms uncrossed
Facing the patient
Leaning toward the patient
Allowing time for the patient to answer
Maintaining eye level with the patient
Keeping arms uncrossed
Facing the patient
Leaning toward the patient
Match the verbal therapeutic technique to its example.
“I’ll sit with you for a while.”
“You seem frustrated.”
“Tell me about some of your concerns.”
“It is time for physical therapy.”
Answer choices
Offering self
Sharing observations
Giving information
Using open-ended comments
“I’ll sit with you for a while.”
Offering self
“You seem frustrated.”
Sharing observations
“Tell me about some of your concerns.”
Using open-ended comments
“It is time for physical therapy.”
Giving information
Which techniques promote therapeutic communication?
Select all that apply.
Asking “yes” or “no” questions
Conveying acceptance
Using focused comments
Using humor
Offering generalized responses
Conveying acceptance
Using focused comments
Using humor
Which impairments may impede communication?
Select all that apply.
Gustatory
Hearing
Visual
Cognitive
Olfactory
Physical
Hearing
Visual
Cognitive
Physical
Which technique would the nurse use to facilitate communication with a hearing-impaired patient?
Learn sign language.
Provide background music to block out extraneous sounds.
Stand at a distance greater than 8 feet while talking.
Make sure the area is well lit.
Make sure the area is well lit.
Which strategy would the nurse use to facilitate communication with a visually impaired patient?
Allow the patient to explore the room independently.
Use analog clock descriptors to specify location.
Place bright colors in various areas of the room.
Provide a writing board for the patient to write messages.
Use analog clock descriptors to specify location.
Match the defense mechanism to its definition.
Refusing to admit the reality of a situation
Using personal strengths to overcome feelings of inadequacy
Choosing not to think consciously about unpleasant feelings
Taking on certain characteristics of another
Answer choices
Repression
Introjection
Suppression
Denial
Displacement
Compensation
Refusing to admit the reality of a situation
Denial
Using personal strengths to overcome feelings of inadequacy
Compensation
Choosing not to think consciously about unpleasant feelings
Suppression
Taking on certain characteristics of another
Introjection
Which important patient insight may be gained by communicating with family members?
Identifying cognitive impairment in a family member
Providing data from primary sources
Recognizing the existence of support systems
Determining assistive devices to use for interpreting gestures
Recognizing the existence of support systems
Which scenario complies with regulations of confidentiality?
Whispering in a crowded elevator to another nurse about a patient’s diagnosis
Providing laboratory test results to the adult patient’s mother
Posting a picture of the patient and nurse with the patient’s status on social media
Refusing to tell the patient’s partner about the diagnosis without patient authorization.
Refusing to tell the patient’s partner about the diagnosis without patient authorization.
Which scenario complies with professional role boundaries?
Visiting a patient to provide home health care
Accepting a $10 tip from the patient’s family for excellent care
Going to the movies with the patient and paying for the patient’s way
Borrowing a patient’s car because the nurse’s car needs repairs
Visiting a patient to provide home health care
Which standard communication strategies would the nurse use to positively influence the nurse–patient helping relationship?
Select all that apply.
Leaning toward the patient as the patient speaks
Completing the patient interview standing at the patient’s bedside
Holding the patient’s hand while the health care provider provides the results of a biopsy
Remaining silent while being present in the room
Standing in the doorway while asking if there is anything the patient needs
Leaning toward the patient as the patient speaks
Holding the patient’s hand while the health care provider provides the results of a biopsy
Remaining silent while being present in the room
Which communication strategies would the nurse use for a patient with dementia?
Select all that apply.
Avoiding eye contact
Using computer-enabled communication
Reminiscing with the patient
Accepting the patient’s erroneous line of thinking
Continually reorienting the patient to the present
Reminiscing with the patient
Accepting the patient’s erroneous line of thinking
Which response would the nurse use when the patient avoids eye contact when discussing a sensitive subject?
“You seem uncomfortable.”
“Is there a reason why you are ignoring me?”
“I think you should look at me when talking.”
“Why do you avoid eye contact with me?”
“You seem uncomfortable.”
Which action would the male nurse take when a female patient from another culture does not want him to perform an assessment?
Gently let the patient know the assessment will be performed by the nurse.
Request a female nurse to perform the assessment.
Distract the patient and then reintroduce the assessment at a later time.
Obtain an interpreter to explain the benefits of letting the male nurse perform the assessment.
Request a female nurse to perform the assessment.
Which actions would the nurse implement for a patient with visual and hearing impairments?
Select all that apply.
Raise voice slightly above normal level.
Speak to the patient before touching.
Verify patient understanding with a “yes” answer.
Display active listening.
Use audiobooks to facilitate learning.
Raise voice slightly above normal level.
Speak to the patient before touching.
Display active listening.
Which question or comment is an effective verbal technique for obtaining more information?
“Do you exercise regularly?”
“You look like a smoker.”
“Tell me more about your diet.”
“Have you traveled recently?”
“Tell me more about your diet.”
Which key concepts of professional communication are represented when the circulating nurse in the operating room says, “The patient’s arm is not straight; it needs to be repositioned”?
Select all that apply.
Respect
Assertiveness
Advocacy
Empathy
Confidentiality
Assertiveness
Advocacy
Which techniques would the nurse use for a male patient who identifies as a female?
Select all that apply.
Say, “Sweetie, it is time for you to eat lunch.”
Establish trust.
Complete care quickly.
Touch the patient’s shoulder for comfort.
Use “he” when with the health care team.
Establish trust.
Touch the patient’s shoulder for comfort.
Which approach would the nurse use to communicate with a patient who is on a ventilator and is paralyzed in all extremities?
Use eye movements to indicate “yes” or “no.”
Avoid teaching the patient at this time.
Avoid correcting an erroneous line of thinking in this patient.
Allow the patient to squeeze the nurse’s hand to indicate affirmation of a question.
Use eye movements to indicate “yes” or “no.”
Which response would the nurse make to a patient who is about to undergo a stressful procedure in 1 hour and yells at the nurse who is 5 minutes late with the medications?
“Stop yelling at me.”
“You’re mad because your partner isn’t here to help you through this procedure.”
“Why are you acting this way? I haven’t done anything to you.”
“I understand that you are probably nervous; tell me about how you are feeling.”
“I understand that you are probably nervous; tell me about how you are feeling.”
Which action would the nurse take for an older adult female patient who left her glasses at home but is wearing her hearing aid and wants information about her newly prescribed medications?
Disregard the question because she is probably confused.
Write down the medications so she can read about them.
Sit down with the patient to verbally answer questions.
Talk very loudly, staying within 3 feet of the patient.
Sit down with the patient to verbally answer questions.
Which nursing behaviors are therapeutic?
Select all that apply.
Allowing the older adult more time to answer questions
Not touching the top of a patient’s head who is from another country
Using personal space to give a bed bath to a patient
Asking family members to leave when talking about personal issues
Using detailed explanations for a young child
Allowing the older adult more time to answer questions
Not touching the top of a patient’s head who is from another country
Asking family members to leave when talking about personal issues
Which response would the nurse make to a female patient who is crying and asks the nurse if she should get chemotherapy treatments?
“So what would you like to order for dinner?”
“There’s no reason to cry; you are going to be alright.”
“What are your concerns about the chemotherapy?”
“My mother’s chemotherapy didn’t work, but it might for you.”
“What are your concerns about the chemotherapy?”
Which phase of the nurse–patient helping relationship is represented when the nurse is summarizing care?
Preorientation
Orientation
Working
Termination
Termination
Match the communication technique to its example.
“You have no reason to be crying.”
“You won’t get better care anywhere else.”
“And then?”
“It will work out.”
Answer choices
General leads
Defensiveness
Restate
Approval/disapproval
Generalized responses
Validate
“You have no reason to be crying.”
Approval/disapproval
“You won’t get better care anywhere else.”
Defensiveness
“And then?”
General leads
“It will work out.”
Generalized responses
Which techniques are being used when the nurse says, “Mrs. Sharp, we have discussed your medications, treatments, and next appointment. What else would you like to discuss?”
Select all that apply.
Summarizing
Validating
Verbalizing the implied
Using open-ended questions
Calling the patient by name
Offering self
Summarizing
Using open-ended questions
Calling the patient by name
Which patient situation describes projection?
An adult patient feels ugly but calls the nurse ugly.
An adult patient admits to drinking alcohol because work is stressful.
A school-age patient starts to wet the bed after treatments.
A school-age patient who wants to fight starts taking boxing lessons.
An adult patient feels ugly but calls the nurse ugly.
Which actions would the nurse take for a patient who is comatose?
Select all that apply.
Not allowing friends in the room
Speaking before touching the patient
Observing for grimacing
Monitoring for restlessness
Maintaining quietness when providing care
Speaking before touching the patient
Observing for grimacing
Monitoring for restlessness
Which actions would strengthen the nurse–patient helping relationship?
Select all that apply.
Using a family member to help interpret for a patient who does not speak the same language as the nurse
Not leaving a severely anxious patient alone
Postponing teaching if the patient is in severe pain
Giving detailed explanations to patients with moderate pain
Observing family dynamics when interacting with patients and families
Not leaving a severely anxious patient alone
Postponing teaching if the patient is in severe pain
Observing family dynamics when interacting with patients and families
Which situation describes collaboration?
Three individuals listening to a lecture on respect for team members
Two individuals working on different patient teams
One individual preparing an online seminar for working in teams
Two or more individuals working toward a common goal
Two or more individuals working toward a common goal
Which health care team member would the nurse consult to help a patient get dressed in the morning?
Occupational therapist
Physical therapist
Health care provider
Social worker
Occupational therapist
Which information is correct about delegating care?
The nurse can delegate evaluation.
The nurse relies on the national nurse practice act for delegation.
The nurse retains accountability for tasks delegated.
The nurse avoids the scope of practice when delegating.
The nurse retains accountability for tasks delegated.
Which example is one of the five rights of delegation?
Right time
Right direction or communication
Right drug or prescription
Right documentation
Right direction or communication
Which skills or components are needed to be an effective nurse collaborator?
Select all that apply.
Team building
Critical thinking
Communication
Personal purpose
Independent goal
Team building
Critical thinking
Communication
Which team-building skills would the nurse use to be an effective collaborator?
Select all that apply.
Recognizing resource limitations
Starting and ending a meeting on time
Advocating on the patient’s behalf
Aggressively challenging team members
Avoiding conflict about safety issues
Recognizing resource limitations
Starting and ending a meeting on time
Advocating on the patient’s behalf
Which factors are components of critical thinking?
Select all that apply.
Scientific research
Best practices
Volunteer input
Continual learning
Clinical experience
Scientific research
Best practices
Continual learning
Clinical experience
Which nursing behavior would enhance health care team communication when directly caring for patients?
Conversing with the hospital board members
Rounding with health care providers
Validating an acquaintance’s feelings
Reviewing an education pamphlet
Rounding with health care providers
Which question represents one of the areas of the acronym SBAR?
What is happening in the future?
Which assignments should be delegated?
Has the nurse contacted the health care provider?
What action(s) should be initiated for this problem?
What action(s) should be initiated for this problem?
Which organization states that collaboration can enhance health diplomacy and lower health disparities?
American Nurses Association (ANA)
International Council of Nurses (ICN)
National League for Nursing (NLN)
Institute of Medicine (IOM)
American Nurses Association (ANA)
Under which heading is collaboration listed as a standard in the book, Nursing: Scope and Standards of Practice?
Standards of Practice
Standards of Professional Performance
Core Proficiency and Competency
Core Scope of Practice Competency
Standards of Professional Performance
Which organization determined that collaboration, or working as part of the interdisciplinary team, is one of five core proficiencies for both students and professionals?
Institute of Medicine (IOM)
American Nurses Association (ANA)
National League for Nursing (NLN)
International Council of Nurses (ICN)
Institute of Medicine (IOM)
Which competencies are associated with Quality and Safety Education for Nurses (QSEN)?
Select all that apply.
Patient-centered care
Teamwork and collaboration
Infection control
Evidence-based practice
Informatics
Patient-centered care
Teamwork and collaboration
Evidence-based practice
Informatics
Which situation represents collaboration?
Nurse and dietitian working on different quality improvement teams
Nurse preparing a community presentation about support groups
Nurse improving self to become a better team member
Nurse and physical therapist discussing options for patient care.
Nurse and physical therapist discussing options for patient care.
Which situation represents effective delegation?
Nurse assigns the pharmacist to administer medications.
Nurse assigns the unlicensed assistive personnel to assess a patient.
Nurse assigns another registered nurse (RN) to care for an unstable patient.
Nurse assigns a licensed practical nurse (LPN) to suture a small wound.
Nurse assigns another registered nurse (RN) to care for an unstable patient.
Match the right of delegation to its description.
Appropriate patient care situation
Appropriate task assigned to the right individual
Appropriate (clear, concise) instructions
Appropriate follow-up and feedback by the nurse
Answer choices
Right person
Right supervision
Right circumstance
Right task
Right direction
Appropriate patient care situation
Right circumstance
Appropriate task assigned to the right individual
Right person
Appropriate (clear, concise) instructions
Right direction
Appropriate follow-up and feedback by the nurse
Right supervision
Which nursing behaviors demonstrate safe delegation?
Select all that apply.
Taking over the delegated task
Validating that instructions are understood
Permitting unlicensed assistive personnel to administer intravenous medications
Assessing the patient before assigning a task
Allowing unlicensed assistive personnel to delegate vital signs to other unlicensed assistive personnel
Validating that instructions are understood
Assessing the patient before assigning a task
Which tasks would the nurse assign to unlicensed assistive personnel (UAP)?
Select all that apply.
Vital signs
Assessment of dressing
Pain management
Hygienic care
Ambulation with a walker
Vital signs
Hygienic care
Ambulation with a walker
Which patient scenario fits within Background for SBAR?
Health care provider notified
Needs pain medication
Currently reporting moderate pain
Recent past medical history of an arm fracture
Recent past medical history of an arm fracture
Which behaviors would the nurse implement for collaboration?
Select all that apply.
Using humor
Maintaining clinical competence
Using strategies for taking charge
Using Situation, Background, Assessment, and Recommendation (SBAR)
Reading progress notes
Using humor
Maintaining clinical competence
Using Situation, Background, Assessment, and Recommendation (SBAR)
Reading progress notes
Which response from the nurse indicates effective collaboration and communication with the health care provider?
“Something is wrong with this patient.”
“I believe the patient might be dehydrated and recommend fluids.”
“The patient is 76 years old with abnormal laboratory test values, so you should do something.”
“The patient is having chest pain.”
“I believe the patient might be dehydrated and recommend fluids.”
Which result is associated with competency in teamwork and collaboration?
Full nursing proficiency
Effective time management
Shared decision-making
Improved research protocols
Shared decision-making
Place the information in the correct order for Situation, Background, Assessment, and Recommendation (SBAR) communication.
Patient is short of breath with swelling in ankles and feet.
Patient was admitted with heart failure and diabetes 2 days ago.
Patient’s problems include lungs filling with fluid and having too much fluid (fluid overload).
Patient’s health care provider notified to obtain medication to help the patient breathe easier and rid the body of fluid.
Patient is short of breath with swelling in ankles and feet.
Patient was admitted with heart failure and diabetes 2 days ago.
Patient’s problems include lungs filling with fluid and having too much fluid (fluid overload).
Patient’s health care provider notified to obtain medication to help the patient breathe easier and rid the body of fluid
Which nursing scenario represents delegation?
Talking to a health care provider about home health care for a patient
Discussing with the patient when a shower can be taken
Asking an unlicensed assistive personnel to feed a patient
Notifying a social worker about community resources for a patient.
Asking an unlicensed assistive personnel to feed a patient
Match the health care team member to the patients needs
Patient needs help with activities of daily living
Patient needs help with joint and muscle movement
Patient needs help determining interactions of medications
Patient needs help obtaining supplies for a new treatment
Answer choices
Physical therapist
Social worker
Occupational therapist
Pharmacist
Clergy
Dietitian
Patient needs help with activities of daily living
Occupational therapist
Patient needs help with joint and muscle movement
Physical therapist
Patient needs help determining interactions of medications
Pharmacist
Patient needs help obtaining supplies for a new treatment
Social worker
Which situations indicate the nurse used critical thinking?
Select all that apply.
The nurse delegated a stable patient to a licensed practical nurse (LPN).
The nurse identified an allergy to a medication and notified the health care provider.
The nurse offered a review of best practices in an interdisciplinary care conference.
The nurse offered a long, detailed summary to the health care team.
The nurse avoided a conflict with a health care team member by ignoring the issue.
The nurse delegated a stable patient to a licensed practical nurse (LPN).
The nurse identified an allergy to a medication and notified the health care provider.
The nurse offered a review of best practices in an interdisciplinary care conference.
Which organizations use collaboration in their code of ethics?
Select all that apply.
Institute of Medicine (IOM)
American Nurses Association (ANA)
International Council of Nurses (ICN)
National Academy of Medicine (NAM)
Quality and Safety Education for Nurses (QSEN)
American Nurses Association (ANA)
International Council of Nurses (ICN)
Match the components of SBAR to its example.
Need to find source of infection and contamination
Review all equipment used and match infection to source
Infection rate up 14% in cardiac rehabilitation unit
Never used to have infections in the cardiac rehabilitation unit
Answer choices
Recommendation
Assessment
Situation
Background
Need to find source of infection and contamination
Assessment
Review all equipment used and match infection to source
Recommendation
Infection rate up 14% in cardiac rehabilitation unit
Situation
Never used to have infections in the cardiac rehabilitation unit
Background
Which action by the nurse is an important aspect of collaboration?
Communicating to the team
Assuming all care of the patient
Being task oriented
Achieving personal outcomes
Communicating to the team
Which concepts are associated with collaboration?
Select all that apply.
Competency
Standard
Skill
Rights of delegation
Level of quality
Competency
Standard
Skill
Level of quality
Which behaviors are skills of collaboration in the Quality and Safety Education for Nurses (QSEN) competencies?
Select all that apply.
Starts conflict resolution when necessary
Appreciates the risks connected to handoff communication
States own personal viewpoints in patient care conferences
Values patients’, families’, and team members’ styles of communication
Describes how team functioning affects safety and the quality of patient care
Starts conflict resolution when necessary
States own personal viewpoints in patient care conferences
Which nursing action facilitates team building directly with the patient?
Notifying the health care provider about the patient’s limited resources
Keeping the patient aware about the status of the health care team collaboration
Contacting the occupational and physical therapists about the patient’s rehabilitation potential
Collaborating with the health care provider and family members about the patient’s rehabilitation
Keeping the patient aware about the status of the health care team collaboration
Which attitude for collaboration is described in the Quality and Safety Education for Nurses (QSEN) competency?
Esteems the expertise of all group members
Functions competently in the role as a nurse
Recognizes the impact of own personal communication on team members
Identifies team members’ roles and scopes of practice
Esteems the expertise of all group members
When would the nurse assess the patient’s health literacy?
During the admissions process
Before providing discharge teaching
During each patient interaction
When initiating the nursing education plan
During each patient interaction
Which patient behaviors could indicate low health literacy?
Select all that apply.
Wants to wait for family before signing consent form
Has laboratory results that do not support the patient’s prescribed treatment plan
Refers to medications by the color of the pill
Frequently misses follow-up appointments
Requests family to be present at the patient care conference
Wants to wait for family before signing consent form
Has laboratory results that do not support the patient’s prescribed treatment plan
Refers to medications by the color of the pill
Frequently misses follow-up appointments
Which question would be most appropriate for the nurse to ask when trying to gauge the patient’s current knowledge of health care needs?
“Most people with heart failure take an angiotensin-converting enzyme (ACE) inhibitor. Do you take an ACE inhibitor medication for your heart failure?”
“Were you prescribed diuretics for your heart failure?”
“Diuretics can sometimes cause you to lose potassium. Do you eat a diet high in potassium?”
“Which medications do you take for your high blood pressure?”
“Which medications do you take for your high blood pressure?”
Which descriptors are accurate for an appropriately written patient education goal?
Select all that apply.
Discrete
Specific
Patient-centered
Measurable
Individualized
Specific
Patient-centered
Measurable
Individualized
A patient in the emergency department with known supraventricular tachycardia starts experiencing shortness of breath and is no longer tolerating the dysrhythmia. Which teaching approach is most likely to be used when informing the patient about the need for cardioversion?
Sensitive
Telling
Entrusting
Participating
Telling
Match the teaching approach to its description.
Patient is given opportunity to manage personal care
Patient and nurse are both involved in the learning process
Nurse presents direct, clear, and precise information to the patient
Nurse provides a stimulus that produces a desired response
Answer choices
Entrusting
Participating
Reinforcing
Telling
Patient is given opportunity to manage personal care
Entrusting
Patient and nurse are both involved in the learning process
Participating
Nurse presents direct, clear, and precise information to the patient
Telling
Nurse provides a stimulus that produces a desired response
Reinforcing
Which environmental factors are important to consider before providing patient education?
Select all that apply.
Space
Privacy
Noise
Comfort
Location
Space
Privacy
Noise
Comfort
Which approaches have been shown to improve the understanding of difficult information?
Select all that apply.
Use simple words.
Cover a single topic at a time.
Limit information to what is most important.
Use simple pictures and drawings when able.
Present the information using bullet points.
Use simple words.
Limit information to what is most important.
Use simple pictures and drawings when able.
Present the information using bullet points.
Which questions by the nurse would be effective for verifying that the patient has learned the information?
Select all that apply.
“Can you tell me three signs of heart failure?”
“Do you take the medicine in the morning and at nighttime?”
“When will you visit your primary health care provider next after you are discharged?”
“Can you explain when you will take this medication at home?”
“Do you understand what I taught you?”
“Can you tell me three signs of heart failure?”
“When will you visit your primary health care provider next after you are discharged?”
“Can you explain when you will take this medication at home?”
Which cue is an example of physiologic evidence indicating that a patient newly diagnosed with diabetes may not have understood the discharge education clearly?
Patient’s stating daily insulin doses incorrectly
Family member’s stating the patient is still eating too much sugar
Consistently elevated blood glucose levels
Prescription refills being picked up every 45 days
Consistently elevated blood glucose levels
Which patient statements could indicate a low health literacy?
Select all that apply.
“I don’t have very good handwriting. Can I just tell you the information to write down?”
“I forgot my glasses at home, and this print is just too small for me to ready clearly.”
“I take a blue pill in the morning and evening and a white pill every evening.”
“I am sorry I missed that appointment. I guess I was distracted and forgot about it.”
“I would like to have my family present when the physician comes to discuss my treatment options.”
“I don’t have very good handwriting. Can I just tell you the information to write down?”
“I forgot my glasses at home, and this print is just too small for me to ready clearly.”
“I take a blue pill in the morning and evening and a white pill every evening.”
“I am sorry I missed that appointment. I guess I was distracted and forgot about it.”
Match the health literacy assessment tool to its description.
Patient determines which two of three words are more closely related
Patient’s ability to pronounce seven common medical words is assessed
Patient is asked a series of questions specific to a nutritional label
Tests reading comprehension and numeracy related to medical information
Answer choices
Test of Functional Health Literacy in Adults
Rapid Estimate of Adult Literacy in Medicine
Newest Vital Sign
Medical Terminology Achievement Reading Test
Wide Range Achievement Test
Short Assessment of Health Literacy
Patient determines which two of three words are more closely related
Short Assessment of Health Literacy
Patient’s ability to pronounce seven common medical words is assessed
Rapid Estimate of Adult Literacy in Medicine
Patient is asked a series of questions specific to a nutritional label
Newest Vital Sign
Tests reading comprehension and numeracy related to medical information
Test of Functional Health Literacy in Adults
Which factors are most important in the educational assessment of an older adult patient?
Select all that apply.
Visual impairment
Hearing limitations
Cognitive ability
Spiritual belief
Emotional concerns
Visual impairment
Hearing limitations
Cognitive ability
Emotional concerns
A 56-year-old male is undergoing emergency surgery for a ruptured appendix. The nurse gives his wife the registration paperwork and asks her to complete the forms. Which action by the spouse could be indicative of a health literacy issue?
Select all that apply.
Puts on her eyeglasses before beginning paperwork
Asks the nurse to read the forms because she “forgot her glasses and can’t read the small print”
Waits for their daughter to arrive to complete the paperwork
Returns the paperwork only partially completed
Starts the paperwork but takes a moment to pray before completing the forms
Asks the nurse to read the forms because she “forgot her glasses and can’t read the small print”
Waits for their daughter to arrive to complete the paperwork
Returns the paperwork only partially completed
The nurse is generating educational goals for her patients. Which patient educational goal is written correctly?
The patient will be more accepting of the new diagnosis by time of discharge.
The patient will participate in the central venous line sterile dressing change before discharge.
The patient will understand the signs associated with heart failure.
The patient will administer the correct dose of insulin after obtaining a blood glucose level.
The patient will be more accepting of the new diagnosis by time of discharge.
The patient will participate in the central venous line sterile dressing change before discharge.
The patient will understand the signs associated with heart failure.
The nurse is providing patient education to the parents of an infant born with tetralogy of Fallot. The infant is currently stable, and surgery is planned for 3 days from now. Which teaching approach would be best for this situation?
Entrusting
Telling
Participating
Skillful
Participating
A newly graduated registered nurse is creating a solution in an educational plan for a patient with heart failure. Which statement by the nurse indicates a need for further education?
Select all that apply.
“Specifically defined interventions clarify what the patient needs to accomplish.”
“The patient must be clearly identified as the one to accomplish the goal.”
“The desired goal must be clearly defined.”
“The goal can be related to increasing knowledge or learning a skill.”
“The action for achieving the goal should be simple and specific.”
“Specifically defined interventions clarify what the patient needs to accomplish.”
“The desired goal must be clearly defined.”
“The goal can be related to increasing knowledge or learning a skill.”
“The action for achieving the goal should be simple and specific.”
To promote a positive learning experience for a 75-year-old patient, which environmental concerns would the nurse address?
Select all that apply.
Keep the patient’s door closed.
Keep the door open for adequate ventilation.
Ask the patient about room temperature preference.
Ensure adequate lighting.
Open the window to enjoy the cool breeze and fresh air.
Keep the patient’s door closed.
Ask the patient about room temperature preference.
Ensure adequate lighting.
The nurse is providing discharge teaching to the parents of a child with a congenital heart defect. Which statement best presents the desired information to the parents?
“Call the primary health care provider if the baby has decreased PO intake and emesis.”
“Call the primary health care provider if you notice the baby has tachypnea and looks mottled.”
“Call the primary health care provider if you notice your baby is breathing fast and refusing to breastfeed or take a bottle.”
“Call the primary health care provider about any signs of respiratory distress.”
“Call the primary health care provider if you notice your baby is breathing fast and refusing to breastfeed or take a bottle.”
Which nursing action would best ensure patient understanding of how to perform a dressing change in the home environment?
Ask the patient to verbalize the correct steps when performing a dressing change.
Clearly ask the patient, “Do you have any questions?”
Assess the patient’s pain level after the dressing change and before discharge.
Have the patient demonstrate a correct dressing change before discharge.
Have the patient demonstrate a correct dressing change before discharge.
Which scenario would be the best example of an informal educational interaction with a parent while the infant is hospitalized?
Leaving an informative teaching sheet for the parent at the infant’s bedside
Teaching about the side effects of diuretics to the parent when administering intravenous (IV) medication to the infant
Verbal discussion with a parent while the infant is having an IV line placed
Asking the parent to demonstrate how to check a pulse rate on the infant
Teaching about the side effects of diuretics to the parent when administering intravenous (IV) medication to the infant
Which key element must nurses understand about the electronic health record (EHR)?
It was developed to create a safe, secure environment for patient data.
It was developed to complement a paper chart.
It was developed to help meet government regulations.
It was developed to be a data storage system.
It was developed to create a safe, secure environment for patient data.
Match the electronic health record benefit with the example.
Nurse getting patient data from mobile device
Patient checks his/her blood sugar result
Electronic care instructions
Connectivity to all hospital systems
Answer choices
Power outage reduction
Convenient access to patient records
Electronic health record (EHR) system interface
Discharge planning
Self-participation in care
Nurse getting patient data from mobile device
Convenient access to patient records
Patient checks his/her blood sugar result
Self-participation in care
Electronic care instructions
Discharge planning
Connectivity to all hospital systems
Electronic health record (EHR) system interface
The nurse is caring for a patient admitted to the unit with a cough and fever. Which example illustrates enhanced decision support as a benefit of the electronic health record?
Taking action based on rapid blood sugar test results
Accessing patient data from a mobile device
Accessing a chest x-ray and laboratory results for a patient with breathing difficulty
Providing electronic copies of discharge prescriptions
Taking action based on rapid blood sugar test results
The nurse is caring for an older adult patient with diabetes. Which statements identify the use of key documentation standards developed by the American Nurses Association (ANA)?
Select all that apply.
The nurse documents the patient’s diabetes medication administration in the electronic - Medication Administration Record (eMAR).
The nurse logs out of the computer after entering patient information and data.
The nurse documents the patient’s blood sugar per prescriptions 2 hours after breakfast.
The nurse documents his or her thoughts about what medications the patient should be taking because the patient’s blood sugar is elevated.
The nurse documents the patient assessment in his or her own words to better describe the patient’s needs.
The nurse documents the patient’s diabetes medication administration in the electronic - Medication Administration Record (eMAR).
The nurse logs out of the computer after entering patient information and data.
The nurse documents the patient’s blood sugar per prescriptions 2 hours after breakfast.
The nurse is caring for a patient with hypertension, frequently taking the patient’s blood pressure, and documenting it in the electronic health record. Blood pressure is an example of which type of data?
Objective data
Subjective data
Care-planning data
Outcome data
Objective data
Match the type of documentation error to its probable result.
Inappropriate order of care
Missing medication dose
Misinterpretation
Patient care not validated
Answer choices
Late entry
Lack of clarity
Omission
Erroneous abbreviation
Inappropriate order of care
Late entry
Missing medication dose
Omission
Misinterpretation
Erroneous abbreviation
Patient care not validated
Lack of clarity
The nurse is using SOAP notes to document care on a postoperative patient. Which elements comprise a SOAP note?
Summary, objective, assessment, and problem
Staff name, objective data, assessment, and problem
Subjective data, objective data, assessment, and plan
Summary, objective data, assessment, and plan
Subjective data, objective data, assessment, and plan
Which characteristic distinguishes the Charting by Exception documentation format?
Documentation of clinically significant findings
Inclusion of all past data, but no present data
Documentation of all care
Documentation of only expected findings
Documentation of clinically significant findings
Decision-making in health care is facilitated using clinical decision support systems (CDSSs). Which descriptions pertain to specific CDSSs?
Select all that apply.
Eases the ability to schedule patient care needs
Provides health care information on patient allergies
Allows nurses to develop patient care plans
Provides electronic medication administration record (eMAR) information to caregivers
Allows nurses to document patient needs in rows and columns
Eases the ability to schedule patient care needs
Provides health care information on patient allergies
Allows nurses to develop patient care plans
Which are primary functions of the electronic health record?
Select all that apply.
Provides evidence of health care provider opinions
Allows the use of shared passwords for ease of use
Provides patient information for planning care
Provides interdisciplinary documentation review
Allows access to decision support tools for ease of care
Provides patient information for planning care
Provides interdisciplinary documentation review
Allows access to decision support tools for ease of care
The new nurse is learning to use the electronic health record (EHR). Which knowledge and skills must nurses have to effectively use the EHR?
Select all that apply.
Computer literacy
Password protection and security
Communication management
Database programming
Timed use of the system
Computer literacy
Password protection and security
Communication management
The nurse is caring for a patient admitted with opioid use disorder. Match the electronic health record benefit with the step used in patient care.
Assessing opioid blood level
Determining health care needs
Providing external provider support
Using CPOE to manage prescriptions
Answer choices
Remote access
Point-of-care information
System connectivity
System integration
Assessing opioid blood level
System connectivity
Determining health care needs
Point-of-care information
Providing external provider support
Remote access
Using CPOE to manage prescriptions
System integration
The nurse made an error in documenting a patient’s care. Which method would the nurse use for correcting a documentation error in a paper chart?
Add the patient’s initials beside the error, and draw a line through the error.
Completely black out the error and the nurse’s signature.
Place the nurse’s initials beside the error, and draw a line through the error.
Completely black out the error, and do not add a signature.
Place the nurse’s initials beside the error, and draw a line through the error.
The nurse is caring for a patient transferred from the intensive care unit to the unit. In which ways would the use of standardized nursing language contribute to more favorable patient outcomes?
Select all that apply.
Provides documentation consistency
Facilitates timely documentation
Facilitates communication
Enables data trending across units
Protects patient privacy
Provides documentation consistency
Facilitates communication
Enables data trending across units
Nursing documentation is both a patient care and legal process. Which actions would indicate that the nurse requires further education on the legal implications of documentation?
Select all that apply.
Documenting patient data in front of other colleagues
Using white correction fluid to correct an error on a paper chart
Completing documentation at the end of shift
Including the date and time of any documentation corrections
Including the date, time, and electronic signature on all electronic health record entries
Documenting patient data in front of other colleagues
Using white correction fluid to correct an error on a paper chart
Completing documentation at the end of shift
Match the documentation type to its description.
Includes rows and columns for assessments and outcomes
Is the most used problem-oriented method
Requires evaluation of nursing intervention
Incorporates established best practices for patient outcomes
Answer choices
Clinical pathway
PIE
SOAP
Flowsheet
Includes rows and columns for assessments and outcomes
Flowsheet
Is the most used problem-oriented method
SOAP
Requires evaluation of nursing intervention
PIE
Incorporates established best practices for patient outcomes
Clinical pathway
The nurse is documenting patient care using a non–problem-oriented team approach. Which type of documentation is the nurse using?
Flowsheet documentation
PIE documentation
SOAP documentation
Source documentation
Flowsheet documentation
Which standard electronic health record (EHR) component is required for patient care?
Bar-coding system
Electronic medication system
Flowsheet charting
Workflow support system
Electronic medication system
Which description best characterizes the hand-off process?
Transfer and acceptance of patient responsibility
Transfer of nursing notes from one nurse to another
Acceptance of responsibility for patient documentation
Transfer and acceptance of patient assignment
Transfer and acceptance of patient responsibility
Which is an accurate representation of all elements contained in “SBAR?”
Summary, Basic needs, Acuity, and Response
Summary, Baseline, Acuity, and Recommendation
Subjective data, Background, Assessment, and Response
Situation, Background, Assessment, and Recommendation
Situation, Background, Assessment, and Recommendation
Which components comprise the I-PASS hand-off process?
Select all that apply.
Identifying patient acuity
Time for the receiving nurse to ask question
Identifying the next required medication
Patient treatment plan
Providing time for health care provider discussion
Identifying patient acuity
Time for the receiving nurse to ask question
Patient treatment plan
Which phrase describes the main purpose of completing an incident report?
Records the incident for legal purposes
Ensures that the patient’s record contains all information regarding the incident
Records details of an incident and begins the process of a quality improvement investigation
Ensures that all staff members are aware of the incident
Records details of an incident and begins the process of a quality improvement investigation
Which statements exemplify the core principles of incident reporting?
Select all that apply.
Incident reporting provides an opportunity to learn from errors.
Incident reporting is a punitive process.
All individuals must be able to report an incident without blame.
Incident reporting should result in positive changes related to patient care and safety.
Incident reporting should be done at the end of the shift so that the response to the - incident can be included.
Incident reporting provides an opportunity to learn from errors.
All individuals must be able to report an incident without blame.
Incident reporting should result in positive changes related to patient care and safety.
Match the documentation needs to the type of incident.
Patient name, outcome, labeling, written prescription, responsible person
Location, date and time, fall circumstances, injury level
Location, date and time, event description, injuries, harm level
Date and time, chronology, witness names, injury severity, person disposition
Answer choices
Patient fall
Staff injury
Medication error
Equipment malfunction
Patient name, outcome, labeling, written prescription, responsible person
Medication error
Location, date and time, fall circumstances, injury level
Patient fall
Location, date and time, event description, injuries, harm level
Equipment malfunction
Date and time, chronology, witness names, injury severity, person disposition
Staff injury
In which way can nurses perform effective hand-off reporting?
Ensure that the hand-off report is performed quickly.
Include the minimum amount of information necessary.
Ensure that complete and accurate information is conveyed.
Include all information about the patient’s past hospitalizations and treatments.
Ensure that complete and accurate information is conveyed.
Which information should be included in an ANTICipate hand-off report?
Select all that apply.
Previous patient hospitalizations
Details about the patient’s intubation procedure
Planned treatment if the patient’s condition worsens
Change in the patient’s status from “critical” to “serious”
Information about the patient’s next of kin
Details about the patient’s intubation procedure
Planned treatment if the patient’s condition worsens
Change in the patient’s status from “critical” to “serious”
Which hand-off processes could reduce the potential of a sentinel event?
Select all that apply.
Standardization of critical data
Taped shift hand-offs
Increased communication between shifts
Provision of health care provider contact information
Accurate and up-to-date patient summaries
Standardization of critical data
Increased communication between shifts
Accurate and up-to-date patient summaries
The nurse is caring for a postoperative patient. Which documentation would be needed when an unexpected opioid-related event requires the completion of an incident report?
Select all that apply.
Original pain medication prescription
Nurse’s suspicion that the patient provided false statements to obtain a different medication
Date and time of the incident
Name of the nurse who administered the medication
Nurse’s note related to the incident report in the patient’s record
Original pain medication prescription
Date and time of the incident
Name of the nurse who administered the medication
Which rationales explain how an incident report is used for constructive analysis?
Select all that apply.
To punish the responsible person
To document the incident report in the patient’s record
To provide a framework for implementing change
To provide information to guide solutions
To disseminate information regarding the incident
To provide a framework for implementing change
To provide information to guide solutions
To disseminate information regarding the incident
Which situations require an incident report?
Select all that apply.
Respiratory distress caused by ventilator malfunction
Cardiac arrest of a patient in the emergency department
Nurse slips and falls on a wet floor
Adult patient expires while on life support
Incorrect opioid dosage administration
Respiratory distress caused by ventilator malfunction
Nurse slips and falls on a wet floor
Incorrect opioid dosage administration
