week 6 sherpath Flashcards by Monica Galvan-Valencia

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

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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

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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

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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

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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

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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

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Which distance range (in feet) is considered social space in proxemics? Record your answer as whole numbers separated by a hyphen.

4-12 feet

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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

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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

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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

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Which impairments may impede communication?

Select all that apply.

Gustatory

Hearing

Visual

Cognitive

Olfactory

Physical

Hearing

Visual

Cognitive

Physical

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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.

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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.

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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

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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

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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.

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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

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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

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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

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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.”

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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.

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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.

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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.”

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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

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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