week 2 book ch 7, 8, 9, & pgs 64,65,&67B, 120-127, 383-385, 416, & 448 Flashcards
On an inpatient unit, one patient assaults another patient, resulting in a small laceration. Considering the patients’ right to confidentiality, how will the nurse effectively document this event?
a. Ensure unit safety by documenting the hostile and combative characteristics of the assaulting patient.
b. Document in each patient’s medical record the events and actions taken, using the initials of the other patient involved.
c. Document in both patients’ medical records that an occurrence (incident) report was prepared according to agency policy.
d. Verbally report the events to other team members and minimize written documentation in order to reduce potential legal consequences.
b. Document in each patient’s medical record the events and actions taken, using the initials of the other patient involved.
hallmark of psychiatric disorder in kids
regression
symptoms psychiatric disorders may result in
abdominal pain
headaches
lethargy
insomnia
intense fatigue
Mental Status Examination
collects OBJECTIVE data
*physical behavior
*appearance
*speech
*mood & affect
*thought content
*cognitive ability
*body language
*insight & judgement
Psychosocial Assessment
collect SUBJECTIVE data
**chief complaint
** client’s words
nursing diagnosis is
clinical judgement about a patient’s response, need, mental health, risk, & comorbidities
3 elements of a nursing diagnosis
- problem – unmet need
- etiology – cause
- supporting data – signs & symptoms
A nurse prepares a patient in a rural community for an initial telehealth visit with the health care provider. Select the nurse’s priority action.
a. Ensure that the patient’s rights to privacy are respected.
b. Ask the patient, “How much do you know about the Internet?”
c. Inform the patient, “This experience will be like appearing on television.”
d. Advise the patient, “You will be able to hear, but not see, your health care provider.”
a. Ensure that the patient’s rights to privacy are respected.
4 clarifying techniques
exploring
paraphrasing
reflecting
restating
complementary vs symmetrical relationships
complementary = difference in power (teacher vs student)
symmetrical = equals
6 therapeutic communication techniques
- clarify
- validate
- explore
- open-end question
- observe
- tell me more
7 non-therapeutic techniques
- advice
- close end question
- false reassurance
- asking why
- value judgement
- giving approval
- changing subjects
A neighbor telephones the nurse daily, giving lengthy details about multiple somatic complaints and relationship problems. Which limit-setting strategy should the nurse employ?
a. Suggest the neighbor call other people in the community.
b. Say to the neighbor, “I can talk to you for 15 minutes twice a week.”
c. Use the telephone’s caller identification to screen calls from the neighbor.
d. Tell the neighbor, “You should discuss these concerns with your personal physician rather than me.”
b. Say to the neighbor, “I can talk to you for 15 minutes twice a week.”
A patient has been oppositional, demanding, and resistant to working on goals. A mental health nurse tells the nursing supervisor, “We finally had a serious talk. I let that patient know it’s time to get right with God and stop this behavior.” Recognizing the nurse’s actions were not acceptable, select the supervisor’s responding action.
a. Review the facility policies regarding patient’s rights with the nurse.
b. Ask the nurse about documentation related to this patient interaction.
c. Schedule the nurse for a staff development activity on cultural sensitivity.
d. Work with the nurse to prepare and analyze a process recording of the interaction.
d. Work with the nurse to prepare and analyze a process recording of the interaction.
. A nurse participating in a community health fair interviews an adult who has had no interaction with a health care professional for more than 10 years. The adult says, “I like to keep to myself. Crowds make me nervous.” Which action should the nurse employ?
a. Refer the adult for a full health assessment.
b. Explore the adult’s family and social relationships.
c. Ask the adult, “How do you feel about the quality of your life?”
d. Explain to the adult, “We can help you feel better about yourself.”
c. Ask the adult, “How do you feel about the quality of your life?”
