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Nursing 200 Exam 1 Questions With Complete Solutions situation the "s" in SBAR, a concise statement of the problem the "b" in SBAR background, pertinent and brief information related to the situation the "a" in SBAR assessment, analysis and considerations of options — what you found/think recommendation the "r" in SBAR, action requested/recommended — what you want incivility rude or disruptive behavior that may result in psychological or physiological distress for the people involved and, if left unaddressed, may progress into threatening situations lateral violence physical, verbal, or emotional abuse and aggression directed at RN coworkers at the same organizational level student nurses (!)
a group particularly vulnerable to lateral violence bullying repeated, unreasonable actions of individuals (or a group) directed towards an employee (or group of employees), which is intended to intimidate, degrade, undermine, humiliate, or create a health risk to the employee(s) communication/clinical (fill in the blank) nurses must be as proficient in _______________ skills as they are in _________________ skills assertive communication honest, direct, and appropriate communication while being open to ideas and respecting the rights of others/minimizes miscommunication submissive communication allowing your rights to be violated by others/meeting demands and requests without regard for your own feelings or needs aggressive communication communication directed toward what one wants without considering the feelings of others using silence
client: i couldn't eat dinner last night nurse: you had difficulty eating yesterday. client: yes, I was upset after my family left seeking clarification a method of making the client's broad overall meaning of the message more understandable/used when paraphrasing is difficult or when communication is confused or garbled, ex. "I'm not sure I understand that" perception checking similar to clarifying, verifying the meaning of specific words rather than the overall meaning of a message, ex. client: my husband never gets me presents nurse: you mean no gifts on Christmas? client: well...not never. he gets me gifts for Christmas but never any other time offering self suggesting one's presence, interest, or wish to understand the client without making any demands or attaching conditions to receive attention, ex. "I'll stay with you until your daughter arrives" giving information
providing specific factual information in a simple and direct manner that the client may/may not request, ex. "your surgery is scheduled at 11a tomorrow" the nurse will obtain it (fill in the blank) when information is not known, the nurse states this and indicates who has it or when
acknowledging giving recognition, in a non judgmental way, of a change in behavior, an effort the client has made, or a contribution to communication/can be with or without understanding and verbal/nonverbal, ex. "you walked twice as far today without your walker" clarifying time or sequence helping the client clarify an event, situation, or happening in relationship to time, ex. client: I've been asleep for weeks nurse: you had your operation on Monday and today is tuesday presenting reality helping the client differentiate the real from the unreal, ex. "your magazine is in the drawer, it has not been stolen" focusing
offering generalized and oversimplified benefits about groups of people that are based on experiences too limited to be valid. these responses categorize clients and negate their uniqueness as individuals agreeing and disagreeing similar to judgement responses, agreeing and disagreeing imply that the client is either right or wrong and that the nurse is in a position to judge this. these responses deter clients from thinking through their position and may cause a client to become defensive being defensive attempting to protect a person or health care services from negative comments. these responses prevent the client from expressing true concerns. the nurse is saying, "you have no right to complain." defensive responses protect the nurse from admitting weaknesses in the health care services, including personal weaknesses challenging giving a response that makes clients prove their statement or point of view. these responses indicate that the nurse is failing to consider the clients feelings, making the client feel it necessary to defend a position probing
asking for information chiefly out of curiosity rather than with the intent to assist the client. these responses are considered prying and violate the clients privacy. asking "why" is often probing and places the client in a defensive position testing asking questions that make the client admit to something. these responses permit the client only limited answers and often meet the nurses need rather than the clients rejecting refusing to discuss certain topics with the client. these responses often make clients feel that the nurse is rejecting not only their communication but also the clients themselves changing topics and subjects directing the communication into areas of self-interest rather than considering the clients concerns is often a self-protective response to a topic that causes anxiety. these responses imply that what the nurse considers important will be discussed and that the clients should no discuss certain topics unwarranted reassurance using cliches or comforting statements of advice as a means to reassure the client. these responses block the fears, feelings and other thoughts of the client passing judgement
3rd phase of a helping relationship Termination 4th phase of a helping relationship preinteraction phase nurse gets information on client prior to face-to-face introductory phase orientation phase; sets tone for relationship; goal is to develop trust and security working phase nurse and client begin caring about each other; 2 phases: exploring and understanding thoughts/feelings & facilitating and taking action Exploring and Understanding thoughts and feelings 1 phase of the working phase; skills needed: empathetic listening and responding Facilitating and Taking Action 2nd phase of Working Phase; client must make decisions for self with support from nurse Termination Phase
last phase, patient will have a general good attitude if who interaction was positive; summarize the goals/steps; express feelings; check in on client List some ways to develop helping relationships:
- Listen actively
- Help identify what the client is feeling
- Put yourself in the other person's shoes (empathize)
- Be honest
- Ge genuine and credible
- Use your ingenuity- there are many courses of action to handle a problem
- Be aware of culture differences
- Maintain confidentiality
- Know your role and limitations report oral, written or computer-based communication intended to convey information to others record formal, legal document that provides evidence of a client's care and can be written or computer based charting (recording, documenting) process of making an entry on a client record source-oriented record
plan the "p" in SOAP, plan of care designed to resolved the stated problem PIE documentation model that groups information into three categories: problems, interventions and evaluation of nursing care flow sheet uses specific assessment criteria in a particular format, such as human needs or functional health patterns focus charting intended to make the client and client concerns and strengths the focus of care time, focus, and progress notes 3 columns used in focus charting charting by exception a documentation system in which only abnormal or significant findings or exceptions to norms are recorded variance
deviation from what was planned on the critical pathway, unexpected occurrences that affect the planned care or the client's response to care BP Measure of pressure exerted by blood as it flows through the arteries. Discuss when it is appropriate and when it is not appropriate to delegate vital signs to an unlicensed assistant and provide rationale. -UAP's may take BP, temp, pulse, respirations, and o saturation. -The results should be provided to the RN and the interpretation of those results should be done by the RN to determine if any abnormal values are present. -Report of any abnormal values should result in reassessment by the RN. -It is NOT appropriate for the UAP to perform any type of assessment on the patient, this is out of their scope of practice. Pulse A wave of blood created by contraction of the left ventricle of the heart.
Dorsalis pedis-determine circulation to foot. What is an endogenous infection? An endogenous infection is an infection where the microorganism that causes the disease originates from the patients themselves. -Most HAI's appear to have endogenous source- Identify the chain of infection and discuss the components of each factor. The chain of infection starts with etiologic agent or the microorganism > The reservoir or placed where the organism naturally resides. (Examples of reservoir include respiratory tract, GI tract, Urinary tract, Blood, and tissue) ===> the portal of exit from the reservoir (Nose, mouth, urethral meatus, vagina, wound) ===> a mode of transmission. (cough, sneeze, breathing, salvia, blood, discharge) ====> a portal of entry into a new host
====> the susceptibility of a new host Name at least 4 portals of exit for microorganisms Mouth, nose, anus, ostomies, urethral meatus, vagina, open wounds What is a susceptible host and who is most at risk? A susceptible host is an individual who is at increased risk for infection. Including the very young or very old, patients who are receiving immunosuppressant therapies for cancer, chronic illness, or organ transplant, and those who have immune deficiency conditions What are some defenses against infection? Defenses against infection include intact skin and mucous membranes. Each orifice has protective mechanisms like salvia and the shedding of epithelial cells in the mouth. The nasal passages use cilia to trap organisms. The eyes use tears as a line of defense. The vagina has a ph of 3.5to 4.5 to inhibit the growth of many
- Environmental Management - discussing injury proofing house, controlling environmental temperature, describe ways to manipulate the bed, room, and other facilities to prevent injury
- Infection control - teach proper hand hygiene to patient and family, promote nail care, instruct not to share toothbrushes, washcloths, towels, discuss proper use of gloves and other barriers, instruct about proper medication administrations, and about cleaning reusable medical equipment
- Infection Prevention - Teach about signs and symptoms of infections and when to contact aa health care provider, teach how to avoid infections, instruct on the importance of adequate nutrition to support the body, remind to avoid coughing, sneezing, and breathing directly on other. Empathize the need for proper immunizations for family.
- Wound Care - teach client and family about the signs of wound healing and wound infection and why monitoring the wound is important. Delineate factors that promote wound healing, explain proper technique for changes the dressing and disposing of the soiled one. List at least 5 ways in which nursing interventions can break the chain of infection.
Nursing interventions that can break the chain of infection include proper hand hygiene, change dressings, dispose of soiled linens, feces, and urine in the proper areas, avoid talking, coughing, or sneezing over open wounds or sterile fields, wear gloves or gowns if warranted, provide clients with their own person care items, use aseptic technique when completing invasive procedures, use sterile technique when exposing wounds or completing dressings, maintain integrity of patients skin and mucous membranes, ensure a proper diet, encourage ambulation and movement Explain medical asepsis versus surgical asepsis. Medical asepsis is when the intent is to confine an organism to a specific area limiting the growth, number, and transmission of the microorganism. In medical asepsis objects are referred to as CLEAN. Surgical asepsis, also known as sterile technique, is when objects are kept free of all microorganisms. It includes all practices that destroy all microorganisms or spores. Surgical asepsis is used for sterile procedures. Describe seizure precautions and how they are implemented? Can this skill be delegated by the nurse? Seizure precautions are safety measures taken by the nurse to protect the clients from injury should they have a seizure.
