Multidimensional Care: Nursing Communication and Safety Practices, Exams of Nursing

Download Multidimensional Care: Nursing Communication and Safety Practices and more Exams Nursing in PDF only on Docsity! Multidimensional Care 1 Exam 1 What does Maslow believe about the hierarchy of needs? - correct answer a person could not meet the needs of love and belonging and self-esteem without meeting basic physiological needs . herbal supplements & their usage - correct answer Ginko Biloba: Depression, memory Ginseng: depression Kava: Depression, anxiety Echinacea: common cold Chamomile: calming and soothing properties. Goldenseal: Stimulates immune system and bile secretion Melatonin: sleep Kava - correct answer Herbal Antianxiety Agent and Depression Name the pain scales - correct answer 1-10 FACES FLACC CRIES FLACC pain scale - correct answer F:face L:legs A:activity C:cry C:consolability Things to know about pain assessment - correct answer PQRST If treatment works It's subjective Ginko Biloba - correct answer Depression and memory (dementia) Ginseng - correct answer fatigue and depression Echinacea - correct answer common cold Goldenseal - correct answer Stimulates immune system and bile secretion Chamomile - correct answer calming and soothing properties. Multidimensional Care 1 Exam 1 Melatonin - correct answer sleep When dealing with maslow hierarchy of needs, what is done first? - correct answer ABCs!! Maslow Hierarchy of needs - correct answer Self-Actulaization, Esteem, Safety & Security, Love & Belonging, & physiological SelfActualization - correct answer Met when the person reaches maximum potential and acts in an unselfish manner. Examples of self actualization - correct answer (e.g., extent to which goals are achieved, role performance, Personal growth, reaching one's highest potential) Catholic End-of-Life indviduals may be - correct answer brought to hospitalized patients by a priest, deacon, or designated lay Eucharis- tic minister A Roman Catholic who is seriously ill might - correct answer wish to receive the sacrament of anointing the sick. (last rites) Last Rites - correct answer Anointing of the Sick (Catholic) Mormons follow a strict - correct answer health code, known as the Word of Wisdom Word of Wisdom (Mormon Culture) - correct answer advises healthful living and pro- hibits the use of tea, coffee, alcohol, and tobacco Mormons believe in - correct answer life before and after death; thus, death repre- sents the passage into another life phrase (Mormon) Nurses may remove garments - correct answer before surgery, but it must at all times be considered intensely private and be treated with respect Mormons wear garments at all times except for - correct answer hygiene, elimination, or being intimate in marriage Nursing Interventions to achieve self actualization - correct answer Provide art supplies Esteem - correct answer Met when a person feels a sense of accomplishment and are recognized by others for that achievement. Esteem tier consists of? (Maslow Hierarchy of needs) - correct answer 1. Feeling of accomplishment 2. Body image 3. Pride in achievements 4. Admiration from others Multidimensional Care 1 Exam 1 Hypothermia: - correct answer temperature below the normal range that may be related to exposure to a cold environment -Temp lower than 95 Hypothermia Preventions - correct answer ii. Cover the pt with blankets iii. Use heating devices iv. Increase room temp v. Infuse warm solutions vi. Remove wet clothing Hyperthermia - correct answer temperature above the normal range that may be related to exercise or exposure to an abnormally hot environment -Temp is greather than 104 degrees What is perfusion? - correct answer Adequate arterial blood flow to the peripheral tissue. What does peripheral and central perfusion relate to? - correct answer Peripheral=peripheral tissue Central=major organs Definition of pulse? - correct answer rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart. Bradycardia pulse rate - correct answer less than 60 bpm Tachycardia pulse rate - correct answer beats higher than 100/min Influences for pulses? - correct answer o Exercise o Age o Gender o Anxiety o Pain Documentation for pulse? - correct answer o Rhythm - even tempo o Strength (0-4+, absent, weak or thready, normal, strong, bounding) o Regular rhythm: 30 seconds x 2- or 15-seconds x 4o Irregular rhythm (regular/irregular); full minute; apical. o •Amplitude is what is measured o •Rate, rhythm (regular or irregular), and quality (strong, weak or bounding) Multidimensional Care 1 Exam 1 Quality of pulse - correct answer strong, weak or bounding Strength of pulse - correct answer 0 = absent 1+ = thready or weak 2+ = normal 3+ = strong 4+ = bounding Rhythm of pulse - correct answer regular or irregular Peripheral pulses (Normal, bradycardia, tachycardia) - correct answer - Normal= 60-100 beats per minute o Bradycardia = beats below 60/min o Tachycardia= beats higher than 100/min rhythm of respiration - correct answer even, regular Depth of respiration - correct answer deep, moderate, shallow Inspiration - correct answer drawing air into the lungs (diaphragm contracts > lungs expand); Breathing in expiration - correct answer expulsion of air from the lungs (diaphragm relaxes > lungs recoil); breathing out systolic blood pressure - correct answer ventricles contract, 90-120, maximum pressure on the arteries Pain assessment before and after treatment - correct answer Scale of 0-10(0 being no pain 10 being the worst pain you have ever felt) Assessment of pain history - correct answer · P: Provocation and Palliati o no What causes it? o What makes it better? o What makes it worse? · Q: Quality and Quantity o How does it feel, look, or sound? o How much of it is there? · R: Region and Radiationo Where is it? Multidimensional Care 1 Exam 1 o Does it spread? · S: Severity and Scale o Does it interfere with activities? o How does it rate on a severity scale of 1-10? · T: Timing and Type of Onseto When did it begin? o How often does it occur? o Is it sudden or gradual? What is communication? - correct answer Two-way process of sending & receiving messages Diastolic Blood Pressure (DBP) - correct answer ventricles relax, 60-80, minimum pressure on the arteries Hyperthermia Preventions - correct answer ii. Wear lightweight, loose-fitting clothing. iii. Avoid excessive sun exposure. iv. Stay indoors with fans or air conditioning when outside v. temperatures are elevated. vi. Limit consumption of alcohol and caffeine. vii. Apply sunscreen of at least 30 SPF. viii. If overheated, take a cool water shower or bath. Pulse - correct answer Pulse allows the nurse to assess the how adequate the heart is pumping the blood to the body Normal Pulse Values - correct answer 60 to 100 beats per minute Pulse points - correct answer carotid radial femoral popliteal posterior tibial dorsalis pedis arteries Rate of pulse - correct answer number of times the heart beats per minute; varies person to person Multidimensional Care 1 Exam 1 Cyanosis/blue-tinged lips or oral cavity Anxiety Restlessness Confusion Drowsiness Hypoxia Interventions - correct answer · Oxygen therapy (O2 delivery methods, amount of O2 delivered per device, safety education) · Incentive spirometry · Turn, Cough and Deep Breath · Pursed lip breathing · Collecting a sputum specimen as examples who is the most reliable source of pain? - correct answer Patient Non verbal cues for pain - correct answer Grimacing, guarding, and holding or touching the affected area Verbal cues for pain - correct answer describing quality -sharp, dull, aching, mild, constant Pharmacological Interventions - correct answer i. Analgesics are the mainstay for relieving pain. ii.NSAIDs iii.Opioids 1.PCA 2.IM 3.Transdermal 4.Epidural Non pharmacological interventions - correct answer i. Mind-body practices (yoga,chiropractic manipulation) ii. Cognitive approaches (meditation, distraction) iii. Natural products (herbs, oils) iv. Exercise Multidimensional Care 1 Exam 1 v. Relaxation techniques vi. Cutaneous Stimulation vii. Warm and colf therapies How to do pain assessment - correct answer PQRST - Pain rating scales 0-10 - reassess pain after interventions given to reduce pain (eg. Analgesia) have had time to work - Assessment of pain history Types of pain - correct answer Acute Cutaneous Visceral Phantom Somatic Radiating Referred Neuropathic Chronic Fall safety - correct answer Lighting Visualize patient Orient to enviornment 2 bed rails Fire safety - correct answer Oxygen RACE PASS Smoke detectors Code Red Priority safety for different age groups - correct answer Middle age drugs Adolescent suicide Multidimensional Care 1 Exam 1 Elderly falls Infant Suffocation Sentinel Event - correct answer an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof within hospital Examples of Sentinel Events - correct answer Suicide Death during/after labor Wrong place surgery Surgical error Infant abduction in hospital Medication errors Safe patient transfer techniques - correct answer Use mechanical lift Nonslip shoes/socks Don't twist back Don't pull on neck Priority hygiene practices - correct answer Dry skin folds Moisturized skin promote venous retour Oral hygiene principles - correct answer Encourage pt assist HOB (Head of bed) elevated Unconscious-suction NPO-Oral care q2hrs Perineal Care Principles - correct answer Wipe front to back Clean rag and water Away urethral meatus Cutaneous pain - correct answer Arises from burning your skin like on a hot iron or from touching a hot pan on the stove. Visceral pain - correct answer Caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections. Multidimensional Care 1 Exam 1 Barriers of communication will - correct answer discourage the client from sharing information openly with the nurse. Barriers of communication - correct answer a. Asking too many questions b. Offering advice c. Changing the subject d. Expressing approval or disapproval e. Providing false reassurance f. Stereotyping g. Using patronizing language Communication with visual, hearing, speech and cognitive patients - correct answer a. Be positive and patient b. Provide forms of nonverbal communication c. Use gestures d. Use short sentences when communicating e. Be concrete and specific f. Call client by name g. Minimize environmental noise h. Face the client when speaking Communication with hearing impaired patients - correct answer o Inquire about possible hearing aid devices o Talk slowly, and enunciate o Avoid slang words or complex jargon Communication with visual impaired patients - correct answer -Guide dogs -Braille -Auditory communication -Assisted devices such as walking sticks Communication with speech impaired patients - correct answer o Nonverbal communication is key (hand gestures, picture board) Multidimensional Care 1 Exam 1 o Family assistance o Provide comfortable environment that allows pt to practice speaking o Possible refer to speech pathologist Communication for cognitive impaired patients - correct answer o Do not use in-room intercom to speak to pt o Reduce environmental distractions o Approach patient directly o Don't rush the client Nursing actions/interventions for communication - correct answer o Be positive and patient o Call client by their preferred nameo Minimize environmental noise o Provide forms of nonverbal communication o Use gestures o Be concrete and specific o Keep eye contact (hearing impaired patients will read your lips) What is socialization? - correct answer learning how to become a member of a society or a group. What is acculturation? - correct answer an individual assumes the characteristics of a culture they just immigrated too What is assimilation? - correct answer a new member will learn and eventually take essential values, beliefs, and behaviors of the dominant culture gradually. What are stereotypes? - correct answer considers everyone are the same (ex. Cultural practices, health treatments, illnesses) under their racial or ethnic group What are the phases of therapeutic relationships? - correct answer Pre-interaction Orientation Working phase Termination phase Pre interaction phase - correct answer gathering info about client before meeting client Orientation phase - correct answer begins when you meet the client and Multidimensional Care 1 Exam 1 introduce yourself and role in the relationship ● Build rapport and trust Working phase - correct answer the bulk of the therapeutic communication; the active part of the relationship ● Nurse communicates caring, the patient expresses thoughts and feelings, and mutual respect is maintained Termination phase - correct answer conclusion of the relationship ● Ex: end of shift; client is discharged Personal space is - correct answer boundary lines that determine how close another person can come Intimate Distance is - correct answer the area immediately surround- ing people that they define as their "private space." Personal Distance - correct answer 18 inches to 4 feet. Social Distance - correct answer 4 to 12 feet. It is used in more formal interaction or when communicating with a group of individuals at the same time. Public Distance - correct answer > 12 feet. This distance requires loud and clear enunciation for communication. An interpreter is specially trained to - correct answer provide the meaning behind the words Serve as a cultural broker by conveying the client's responses to questions and by providing general information about the client's culture. Recognize empathy by - correct answer a. Adapt to different styles, tone, vocabulary and behavior b. Place yourself in the patients situation c. Understand the needs (be sensitive) Is silence a communication barrier? - correct answer No, Remaining attentive and waiting for the client to compose the next statement in the conversation enhances therapeutic communication. What does the acronym stand for (SBAR)? - correct answer Situation, Background, Assessment, Recommendation-Readback Multidimensional Care 1 Exam 1 3. Biofeedback 4. Exercise & Fitness 5. Nutritional Supplements 6. Health-Focused TV 7. Music Therapy 8. Acupuncture 9. Acupressure 10. Disease Management 11. Aromatherapy Cultures that refuse blood? - correct answer Jehovah witness Jehovah witness refuse - correct answer Transplants & blood transfusions Do NOT self donate blood Prioritization and Maslow's Hiearchy - correct answer ABCs 1ST!! Phsyiological Safety & Security (In that order) Prioritization of abnormal vital signs - correct answer ABCs then physiologic Airway Breathing Circulation/Cardiac Techniques to promote/help therapeutic nurse patient relationships - correct answer Respect Individualized care Assertiveness Define empathy in 1-3 words - correct answer Caring Self in patients place Compassion Understanding Listening Multidimensional Care 1 Exam 1 Communicatio with patients with aphasia - correct answer Practice patience Speak clearly Closed ended questions What would be the proper follow up for cultures that refuse blood? - correct answer ● Never force ● Educate the patient on why you would give blood ● Document why the reason the patient refused ● Try to find alternatives Cultures that refuse medications? - correct answer Christian Scientists What would be the proper follow up for cultures that refuse medication? - correct answer - Documentation why they refused - Never Force - Explain/Educate to the patient why you are giving them the medication - Try to find alternatives What are the risk factors for people with narcolepsy? - correct answer a. Driving, working, or operating machinery Promote and prevent skin injuries - correct answer turn patient every 2 hours, keep clean and dry Promote & prevent shearing injuries? - correct answer use lift and not drawsheet What does bathing promote? - correct answer a. Hygiene and circulation Different types of bathing - correct answer Assist Bath Partial Bath Bed Bath Towel Bath Bag bath Basin & Water bath Shower Assist Bath - correct answer Nurse helps the patient with areas that may be difficult to reach Multidimensional Care 1 Exam 1 Partial Bath - correct answer Cleanse only the areas that may cause odor or discomfort Bed Bath - correct answer For patients who must remain in bed but who are able to bathe themselves. - You will assist by placing the bath supplies on the bedside stand or overbed table. Towel Bath - correct answer Type of bed bath in which you place a large towel and a bath blanket in a plastic bag, saturate them with a warmed, commercially prepared mixture, and use them to bathe the patient. - No need to towel-dry the patient due to solution drying quickly Bag Bath: - correct answer Modification of the towel bath, in which you use 8 to 10 washcloths instead of a towel and bath blanket. Basin and Water Bath - correct answer Type of bed bath, you use a disposable basin with water; washcloths; lotion; and a pH-balanced, no-rinse soap or a chlorhexidine and water solution. Shower - correct answer Most ambulatory patients prefer a shower. It is a time- saver and refreshing as well as cleansing. Order of bed bath - correct answer ● Use prepackaged bathing products. ● Check the temperature of the packaged bath wipes after microwaving. ● Avoid chilling or tiring the patient. ● Bathe the patient following the principles of "head to toe" and "clean to dirty." ● For extremities, cleanse from distal to proximal. ● Use a new wipe for cleansing the perineum and whenever the wipe becomes soiled. ● Perform hand hygiene when moving from a contaminated body part to cleanse a clean body part. Priority assessments (think ABC's, who would you see first) - correct answer a. A: Airway b. B: Breathing c. C: Cardiac Know delegation to other staff, like Nurse Assistants - correct answer No assessments, double check if they find a critical finding Skin integrity (how to prevent pressure ulcers) - correct answer a. Turn every 2 hours b. keep area dry Multidimensional Care 1 Exam 1 what is the American Nurses Association (ANA) goal? - correct answer Their goal is to foster high-standards of the nursing practices, promoting a safe and ethical work environment, bolstering nursing health and wellness, and advocate for healthcare issues that affect the nurses and public. What are some education points to teach parents with school age children on how to prevent injuries at home? - correct answer .... Never Events - Senital Events - correct answer Serious injuries or death to a patient that should have never happened in a hospital. (Ex. Air embolism, wrong transfusion, falls, and trauma or injuries) a. These mistakes may have been prevented with proper surveillance by the health care professionals involved in the event. Examples of never events - correct answer - air embolism - wrong transfusion - Labor Death - Wrong site surgery - falls - trauma or injuries -DVT or PE after knee surgery - CAUTIs - CLABSIs - HAPIs, etc. Preventing falls at home - correct answer o Exercise regularly o Take your time o Lighten loads/brighten paths Storms (Community Safety) - correct answer · Deaths caused by lighting strikes is the lead cause of fatalities due to weather conditions. · The second leading cause is flooding · Education about outdoor activities during a storm is important to reduce the incidents. Motor vehicle accidents (Community Safety) - correct answer · Failure to use seat belts and proper child car seats are the main factor of deadly accidents Multidimensional Care 1 Exam 1 · Use of cellphones while driving increases the risk of accidents · Motor vehicle accidents are the leading cause of accidental deaths in the U.S. Radiation injury (Occupational safety) - correct answer - Avoid excess radiation - Use protective equipment - TIME: limit time of exposure - DISTANCE: only perform care of patient near the patient when its essential - SHIELDING: wear protective shielding Needle stick (Occupational safety) - correct answer -26% of nurses even with osha regulation - Increased risk when (stress, +12hr shifts, low skill level, lack of protective devices) Back injury (Occupational safety) - correct answer - 52% nurse report back pain - Causes include transferring, repositioning, changing bed linens, & weighing patients - Preventative measures includes, using sage handling equipment, report hazards, incidents and injuries Increased risk of needlestick due to - correct answer stress, +12hr shifts, low skill level, lack of protective devices Healthcare Falls - correct answer a. Complete a comprehensive fall risk assessment. b. Keep the bed in the lowest position. c. Lock wheels on the bed and wheelchair if transferring the client. d. Place call light within reach. e. Keep floors dry and free of clutter. 3. Equipment related accidents a. Related to malfunction or improper use. b. Get familiar with the equipment before using it on the patient. c. Contact Biomed if the equipment is faulty and DO NOT use it Steps for fire safety in healthcare - correct answer a. Know where emergency equipment is located b. Know the types of extinguishers appropriate for different types of fires c. Know how to use a fire extinguisher Multidimensional Care 1 Exam 1 d. Know the location of fire alarms and the procedure for calling in a fire alarm e. Know what to do to ensure the safety of clients in the immediate area of the fire f. Know the code name for "fire" in your facility's public address system Healthcare Biological hazards - correct answer a. Review the hospital policy and procedure regarding proper management of spills. Healthcare Violence - correct answer a. Treat underlying medical conditions, i.e. anxiety. b. Use a calm approach. c. Do no wear anything that dangles around your neck. d. Do not go into a room alone with an angry patient. e. If there is an active shooter event, the best action is to leave the building. What is the most reported incident in healthcare settings? - correct answer Falls Pathogenic causes (Community Safety) - correct answer · Food-borne: Food poisoning; eggs, fish, uncooked meats, poultry, raw fruits & vegetables, milk, etc .· Water-borne: poor sanitation; Giardia lamblia, Cryptosporidium, Escherichia coli · Vector borne illnesses: Mosquitoes = West Nile, Malaria; flies, fleas, ticks, cockroaches, rodents, bird droppings, mice, etc. Air Pollution (Community Safety) - correct answer outdoor or indoor. Outdoor - car, factories, power plants.Indoors - carbon monoxide, mites, smoke, mold, rodent, pets, noise. Maintenance regarding nutrition - correct answer -Monitor for signs and symptoms of fluid and electrolyte imbalances -Assess skin -Urine incontinence: Teach the patient about bladder training, the patient might need an intermittent catheter or a Foley catheter -Diarrhea: provide fluid-balanced, administered medications as needed, keep accurate track of I&O. If severe diarrhea, keep patient NPO but provide IV fluids -Constipation: Encourage a high-fiber diet, use medications as needed, increase activity, increase fluid intake. Prevention regarding nutrition - correct answer -Proper nutrition and hydration -Diet high in fiber (reduces the risk of colon cancer) Multidimensional Care 1 Exam 1 ● Drowning ● Fires, flames, and smoke Safety measures for fall - correct answer a. Do one thing at a time. b. Change positions slowly to avoid dizziness. c. Be sure pathways are well lit. d. Have your eyes checked at least once a year. e. Wear shoes with non-skid soles. f. Avoid clutter Who is at risk for falls? - correct answer h. Everyone but older adults are more at risk How do we prevent falls at home? - correct answer a. Exercise regularly b. Take your time c. Lighten loads- brighten paths d. use caution on stairs e. minimize bathroom hazards f. Childproof the home g. Don't trip yourself up How do we prevent falls at home for Older adults - correct answer ii. Use beds that are low to the floor iii. Keep a cordless phone near by iv. ask doctor to review medicines v. get treatment for postural hypotension and cardiovascular disorders How do we prevent falls in healthcare facilities? - correct answer a. Lock the bed b. Safety locks on wheelchairs c. Apply nonskid slippers d. Keep water, urinal, bedpan, and tissues within easy reach of the patient. e. Place the call light within reach. Have the patient demonstrate the ability to call for the nurse. f. Provide a night light. Multidimensional Care 1 Exam 1 g. Keep floors dry and free of clutter. h. For patients at risk for falls, place a warning sticker on the chart or door. i. Place patient in a room next to the nurse's station j. Stay with patient in bathroom k. Keep bed at lowest level l. Place overbed table across wheelchair m. Offer regular opportunities to toilet n. Provide back rubs and distractions What are our assessment priorities if falls are unwitnessed? (ex. Patient hits head) - correct answer a. Neuro assessment Know interventions if you have a patient falling and you are with them - correct answer a. accompany client during ambulation utilizing a transfer safety belt if he/she is weak or dizzy b. encourage client to request assistance whenever needed c. provide ambulatory aids (e.g. walker, cane) if client is weak or unsteady on feet d. Do not rush client e. instruct and assist client to rise and change positions slowly f. perform actions to increase strength and activity tolerance g. Best interventions with a client who has dementia - correct answer a. Orient client b. Observe closely c. Avoid cultivation of false ideas d. Discourage suspiciousness e. Use simple explanations f. Positive feedback when thinking and behavior is appropriate What is OSHA's primary purpose? - correct answer i. Defines types of personal protective equipment and situations in which you are required to wear it E. Community Safety Motor Vehicle accidents - correct answer a. Leading cause of accidental death Multidimensional Care 1 Exam 1 b. Not wearing seat belt Pathogenic causes - correct answer (foodborne, Water-borne, or vector-borne illnesses) Pollution - correct answer a. Contact local agencies to inquire about proper disposal of paint, tires, etc. b. Use local public transportation to reduce air pollution. Storms - correct answer a. Seek shelter inside a building when there is a storm. b. Avoid riding/driving open vehicles such as bicycles or motorcycles. c. Do not seek shelter under a tree. Poisoning - correct answer i. Have the poison control 800 number posted so it is easily accessible. ii. Keep all chemicals and medications in a locked cabinet. iii. Dispose of unused medication by mixing it with cat litter or take it to a community disposal center. Carbon Monoxide - correct answer i. Have a functioning CO2 monitor in the home. ii. Ensure all gas and wood burning devices are vented to the outside. iii. Be sure vehicles do not allow exhaust fumes to enter the passenger area. iv. Never use a kerosene heater, gas stove, or gas oven to heat the home. v. Never burn charcoal inside the home. Burns - correct answer i. Turn pot handles toward the back of the stove. ii. Never warm infant formula or food for a young child in a microwave. iii. Always check the temperature of bath water for young children prior to placing them in the tub. iv. Wear sunscreen and protective clothing when out in the sun. Fires - correct answer i. Have a smoke alarm system. ii. Have an escape plan. iii. Never leave candles burning unattended. iv. Do not smoke in bed, especially in a home where oxygen is in use. v. Never use an open flame when oxygen is in use. Multidimensional Care 1 Exam 1 Ethnicity - correct answer Member share a common social & cultural heritage (race, physical characteristics) Social organization of the culture - correct answer Family composition or units (single-parent, extended family), and wider organizations (community, religion) that the individual or family identifies. • Close Social Organization Examples • Most common: Middle Eastern and Latinos the man is the dominant family member and the woman is the housemaker • Many African American household the female is the leader and decision maker (Matriarchal) Social Organization related to birth, death, illness, grieving & mourning • Patient who does not believe in the healthcare institutions will delay treatment and will use home remedies instead. Kinship and Social Ties • VIP care for famous celebrities compared to a poor individual or homeless. Using rails to restrict the patient's independence is considered - correct answer a restraint and can cause more harm. DO NOT use this method of restraint. Elderly are at high risk for - correct answer injury;primarily from falls Elderly are primarily at high risk for? - correct answer falls How often do you assess the patient when they're in restraints? - correct answer Every 30 minutes Falls are the most? - correct answer Reported incidents When do falls frequently occur? - correct answer during night time, weekends and holidays The morse scale is used to assess? - correct answer patient's likelihood of falling Remove patient restraints every? - correct answer 2 hours What are common code names for fire? - correct answer "Mr. Red," "Dr. Red," and "code red" are common NCLEX STYLE PRACTICE:Connor's elderly patient becomes disoriented as the day wears on and starts to wander in the hall and go into other patient's rooms. Connor persuades him to get Multidimensional Care 1 Exam 1 back to bed four separate times. The nurse understands that to avoid using patient restraints, they should: • Select All That Apply • ❑ Orient patient to the environment • ❑ Get a sitter • ❑ Do not encourage family to stay • ❑ Use consistent scheduling of patient activities • ❑ Place the patient away from the nurses' station, so they are not disturbed • ❑ Ask for medication from the primary care provider - correct answer ❑ Orient patient to the environment- Yes • ❑ Get a sitter-Yes • ❑ Do not encourage family to stay—No, it is safer if they stay • ❑ Use consistent scheduling of patient activities—YES • ❑ Place the patient away from the nurses' station, so they are not disturbed—No, place the patient by the nurses' station • ❑ Ask for medication from the primary care provider—No, often increasing medications makes patients more confused NCLEX STYLE PRACTICE:The nurse understands that if a restraint is needed, it should be: A. released once a day B. Tied to itself, so the patient cannot get out C. Be the least restrictive as possible D. Unpadded, so it does not become loose - correct answer A. released once a day—No, they should be released every 2 hours B. Tied to itself, so the patient cannot get out—No, they should be slipped knotted to the bed C. Be the least restrictive as possible—YES D. Unpadded, so it does not become loose—No, padding should be used RACE is an acronym used to - correct answer prioritize order of procedures for a fire Meaning of RACE acronym - correct answer R : Rescue: Multidimensional Care 1 Exam 1 • Remove clients from the general area A: Alert/Alarm: • Sound alarm C :Confine: • Contain fire (close doors and windows, make sure fire doors close) E : Extinguish fire PASS - correct answer • Pull the pin; • Aim the nozzle; • Squeeze the handle • Sweep at the base of the fire. NCLEX STYLE PRACTICE: A patient who is cognitively impaired is admitted to the hospital for pneumonia. The patient has a history of wandering at night. What should the nurse do to ensure the safety of this patient? *Encourage a family member to remain with the patient every night. *Obtain a sedative to be administered to the patient at bedtime. *Apply a vest restraint when the patient plans to go to sleep. *Activate the bed alarm on the patient's bed. - correct answer Encourage a family member to remain with the patient every night. - NO unrealistic to have family EVERY single night Obtain a sedative to be administered to the patient at bedtime. NO- it's a chemical restraint Apply a vest restraint when the patient plans to go to sleep. - NO, too restrictive; less restrictive method must be tried first Activate the bed alarm on the patient's bed. YES- Will alert the nurse NCLEX STYLE PRACTICE:Which is an important step when transferring a patient using a mechanical lift? • Position the chair as close as possible to the bed. • Remove the sling after the patient is moved to the chair. • Position the sling at the middle of the patient's back to the ankles. • Attach the longer belts to the lower grommets on each side of the sling. - correct answer Position the chair as close as possible to the bed. Multidimensional Care 1 Exam 1 1. Material in a garbage can usually is paper or textiles; these items are extinguished with a type A or type ABC fire extinguisher. 2. A maintenance closet commonly contains flammable liquids; flammable materials are extinguished with a type B or type ABC fire extinguisher. 3. A mattress consists of cloth covered in plastic; these materials are extinguished with a type A or type ABC fire extinguisher. • 4. A toaster is an electrical appliance; fire involving live electrical wires or equipment is extinguished with a type C or type ABC fire extinguisher. NCLEX STYLE:What nursing intervention can give a patient a sense of control regarding personal safety? Select all that apply. 1. Inform the patient why an identification band should be worn. 2.Instruct the patient how to lock the wheels on a wheel chair. 3. Keep the patient's bed in the lowest position. 4. Teach the patient how to use the call bell. 5.Orient the patient to the environment. - correct answer 1. Although wearing an identification band will provide for patient safety, it does not give the patient a sense of control. • 2. This information allows the patient to ensure that the wheels of a wheel chair are locked. 3. Keeping the patient's bed in the lowest position will not give the patient a sense of control. • 4. The ability to call for help when needed gives the patient a sense of control. • 5. Having an understanding of the environment (e.g., how to use a call bell, how to raise and lower the bed, and how to use the side rails when turning or transferring) gives the patient a sense of control. NCLEX STYLE: A nurse is caring for a 60yo pt in rehab recovering from right sided CVA. The pt has orders for OOB ambulation with assistance as tolerated. Which intervention is most important? 1. Assessing balance 2. Using a bed alarm 3. Encouraging the use of a walker 4. Teaching to rise slowly from a lying to a sitting position - correct answer • 1. Assessment is the first step of the nursing process. The nurse must first assess the patient for the presence of Multidimensional Care 1 Exam 1 problems with strength and balance before moving a pa- tient out of bed. People with problems with balance may not be able to maintain the sitting position while sitting on the side of the bed. 2. A bed alarm is unnecessary. There is no information in the stem that indicates that the patient is confused or unwilling to call for assistance when getting out of bed. 3. This is implementing an intervention before the patient's needs are assessed. 4. Although this should be done, it is not as critical as another option. Even though a patient may become dizzy when moving from a lying to sitting position, the patient is in bed and has little risk of falling out of bed. The upper rails should be raised to provide for the patient's safety. • TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority. Identify the option that is unique. Option 1 is the only option that is an assess Healthcare Worker risks - correct answer • Back Injury • Needle stick Injury • Radiation Injury High Risk factors for falls - correct answer • Poor vision • Cognitive impaired • Weakness • Dizziness • Drowsiness Dominant culture in the U.S. - correct answer Anglo-Saxon Christian of European descent Dominant culture - correct answer the group that has the most authority or power to control values and rewards or punish behaviors ○ Usually but not always the largest group Ethnocentrism - correct answer the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened ○ This exists in all groups, not just the dominant group* Multidimensional Care 1 Exam 1 Intimate distance - correct answer <18 inches Personal distance - correct answer 18 inches to 4 feet Social distance - correct answer 4 to 12 feet Public distance - correct answer >12 feet Health disparities among race and ethnicity - correct answer ○ Health status ○ Quality of care ○ Access to care Race - correct answer strictly related to biology ○ Skin color, blood type, bone structure Bicultural - correct answer describes who identifies with two cultures and integrates some of the values and lifestyles of each into his life ○ Will use one more than the other during certain situations ○ May feel divided or may enjoy the best of both worlds Rest - the body being in a decreased state of activity. Sleep - a state of rest accompanied by an alteration of consciousness and inactivity. Why sleep is necessary for the body's normal function? - correct answer is an important regulator of energy metabolism may improve learning and adaptation affects almost every tissue in our bodies reduce stress and anxiety Nourishes health Growth hormone is released during sleep Important for mental health Multidimensional Care 1 Exam 1 • Solid food intake will be determined as percentage % • Example: Patient ate 55% of dinner Output - correct answer elimination • Emesis (vomit)=Oral, Bleeding, Urine, Feces = Diarrhea • Solid feces are counted per how many • Example: Patient had 1 solid BMs at 1300 • Liquid stools will be measured using mLs. Maintenance for respiratory illnesses - correct answer -Determine the underlying cause -Requires Immediate Attention (emergent) -Administer oxygen-Monitor pulse oximetry. -Medications will be needed (antihistamine, decongestants, glucocorticoids, bronchodilators, mucolytics, & antimicrobials) -Reposition patient in Semi-Fowlers -Teach about deep breathing (use an incentive spirometer) -Coughing exercise -Deep Breathing Techniques Prevention for sensory disabilities - correct answer -Interventions will be primary (prevent) and secondary (maintain) interventions. -Encourage the use of protective devices to minimize risk (ex. Safety goggles, ear plugs, etc) -Perform annual screening diagnosis. Maintenance for sensory disabilities - correct answer -Encourage compliance with medication treatments -Use corrective devices -Complete visual impairment will need resources (guide dogs and learn braille language) -Complete hear impairment will need resources (closed-captions, assistance hearing devices, and learn sign language) Prevention for sexual illnesses - correct answer -Perform STI screening and physical examination -Determine patients' self-knowledge Multidimensional Care 1 Exam 1 -Educate about risk factors and protection Maintenance for sexual illnesses - correct answer -Will depend on the cause -Determine the root-cause -Referred to correct healthcare provider Chemical Agents - correct answer contact with acids, alkali and other organic compounds Contact burns - correct answer Direct contact with a hot surface, such, as metals, vinyl, etc. Sunburn - correct answer excess unprotected exposure to sun. Causes 1st & 2nd degree burns Warming food or formula - correct answer Using a microwave causes the food or formula to become hotter than intended. -Leads to infant and young children injuries Scald injury - correct answer Hot water, steam, grease, cigarettes. The first 3 are the most common burn injuries in children younger than 3. Two-challenge rule - correct answer State a concern twice as needed; if ignored, follow the chain of command to get the concern addressed. Call outs - correct answer Shout out important information (such as vital signs) for all team members to hear at one time Check backs - correct answer Restate what a person said to verify understanding by all team members. CUS words - correct answer State "I'm concerned; I'm uncomfortable; I don't feel like this is safe" What are the steps to validate the message by using therapeutic communication? - correct answer -Restating: using your own words to summarize the message -Clarifying: ensure you have decoded the message correctly -Validate: confirms you have made the correct interpretation What are the physiological consequences for electrolyte excess? - correct answer -Cardiac Dysrhythmias -Muscle Spasms -Kidney stones (nephrolithiasis) Prevention for respiratory illnesses - correct answer -Proper hand washing to avoid respiratory illness. Multidimensional Care 1 Exam 1 -Smoking Cessation (prevents COPD and emphysema) -Teach about exposure to TB or FLU -Vaccinations (prevents flu, pneumonia, etc.) -Turn, Cough and use deep breath techniques. What are the physiological consequences for electrolyte deficit? - correct answer -Cardiac dysrhythmias (<K+) -Muscle weakness (< K+) -Mental Status Change (< Na+) -Generalized Weakness (< Na+) What are the physiological consequences for fluid excess? - correct answer -Hypertension -Strong & Bounding peripheral pulses -Edema What are the physiological consequences for fluid deficit? - correct answer -Hypotension -Tachycardia -Weak peripheral pulses -Dehydration -Reduced kidney function -Decrease urine output (less than 30mL/hr) Interventions promoting normal bowel elimination patterns - correct answer • Encouraging pt to have diet high in fiber • Create meal plan • Keep track of stools everyday and how it appears • Make sure they use the toilet when they need to Diarrhea Nursing interventions - correct answer • Protect the perineal and buttock area with zinc oxide or other barrier cream to prevent skin irritation and excoriation, especially for patients who are incontinent. • Wash and dry skin where stool and urine have made contact, especially for patients who are incontinent. Multidimensional Care 1 Exam 1 B. Slumping while talking to patients C. Folding arms while talking to patients D. Leaning slightly forward toward patients - correct answer D. Leaning slightly forward toward patients 7. A patient who appears to be in pain does not ask the nurse for pain medication because he feels it would upset the nurse. The style of communication that the patient is demonstrating is A. Passive B. Assertive C. Aggressive D. Demeaning - correct answer A. Passive 8. A patient throws his urinal at the nurse and tells the nurse that he thinks she is a terrible nurse. The nurse informs the patient that his behavior is inappropriate. The style of communication that the nurse is demonstrating is A. Passive B. Assertive C. Aggressive D. Demeaning - correct answer B. Assertive 9. When the nurse educates a patient about his medications, the patient tells the nurse that she should go back to nursing school because she doesn't know very much about medications. The style of communication that the patient is demonstrating is A. Passive B. Avoidant C. Assertive D. Aggressive - correct answer D. Aggressive 10. A nursing instructor teaches a class of student nurses that the most effective Multidimensional Care 1 Exam 1 communication style for nurses to practice is: A. Passive B. Avoidant C. Assertive D. Aggressive - correct answer C. Assertive 11. A nurse is caring for a patient who has end stage renal disease and will require dialysis three times per week. The patient states, "I'm upset that I didn't visit all the places I'd like to see. Now that I'm on dialysis I won't be able to." The most therapeutic response by the nurse is: A. "You are upset that it's too late to visit places that you would like to see?" B. "There are many people who feel exactly the same as you do." C. "Don't worry. You can still visit all of the places hat you would like to see." D. "I think you should visit the places you would like to see before it's too late." - correct answer A. "You are upset that it's too late to visit places that you would like to see?" 12. The nurse is caring for a patient who has just been diagnosed with a brain tumor. The patient asks the nurse if he should choose to have surgery. The Nurse's most therapeutic response is: A. "Tell me what you know about surgery." B. "I would never decide against having surgery." C. "If I were you, I would definitely have the surgery." D. "Don't worry. You will be fine if you don't have surgery." - correct answer A. "Tell me what you know about surgery." 13. The nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the patient's primary health care provider. This type of communication is called A. Upward: Escalating to a person of authority B. Bilateral: someone on the same level C. Horizontal Multidimensional Care 1 Exam 1 D. Downward: delegating to someone you're in charge of - correct answer A. Upward: Escalating to a person of authority 14. The nurse is caring for a patient who requires assistance with feeding. The nurse delegates this task to the certified nursing assistant (CNA). This type of communication is called: A. Upward B. Bilateral C. Horizontal D. Downward - correct answer D. Downward 15. The nurse observes a student nurse caring for a hearing impaired patient. The nurse would intervene if the student nurse: A. Speaks clearly without shouting. B. Speaks directly to the patients interpreter. C. Positions himself or herself in front of the patient when speaking. D. Turns down the radio volume when speaking to a patient. - correct answer B. Speaks directly to the patients interpreter. 16. The nurse is caring for a patient who was admitted to the hospital for a cerebrovascular accident (CVA) resulting in difficulty understanding speech. The nurse recognizes that the patient is experiencing: A. Receptive aphasia B. Expressive aphasia C. Receptive dysphagia D. Expressive dysphagia - correct answer A. Receptive aphasia Select All that Apply 1. A nursing instructor is educating a class of nursing students about effective communication. The nursing instructor teaches that effective communication: A. Is essential in proper documentation practices B. Is the foundation of nurse patient relationships