Exam 1 Study Guide Flashcards

Question

Nonverbal communication

Answer 1

- 60-75% is done nonverbally - unconsciously motivated (expressions) - nonverbal could tell us something different than their words - saying they aren't in pain when they rlly are

Answer 2

- people often signal readiness to communicate thru eye contact - can have different meanings in different cultures > some might not look you in the eye bc you have such high esteem

Answer 3

- indicate how the person is feeling and if they are ready to communicate

Answer 4

- let you know of the patient is open to communicating and how they feel

Answer 5

- sighs, moans, groans, and sobs - these indicate how the patient is feeling

Answer 6

- conveys caring, empathy, support, reassurance - also conveys anger - influenced by culture so might be inappropriate to some - may or may not be welcomed

Answer 7

- intimate distance: 0-18in (L&D) - personal distance: 18-40in (standing @ bedside)

Answer 8

- not simply what the nurse does but who the nurse is - authenticity - self-awareness: clear understanding of your personal beliefs, values, stereotypes, and personal perspectives - presence: full attention of the nurse being there and being with (eye contact) - empathy (on another card) - appropriate level of involvement (on another card)

Answer 9

- ability to enter into the life of another person and accurately perceive their feelings - communicated understanding - increases the feeling of being connected to another - is NOT sympathy - trying to visualize how they are feeling

Answer 10

- degree of nurse's attachment and active participation in patient's care - fluctuates - maintain professional boundaries

Answer 11

- mutually beneficial - reciprocity - may fulfill mutual needs for pleasure, love, econ security - not the same as therapeutic relationships

Answer 12

- limited perfunctory contacts - minimizing patients suffering - defensive or judgmental communication - neglecting the patient - showing disinterest

Answer 13

- should be limited and only used with the intention of assisting the patient in a pos way - telling info about myself

Answer 14

- should never be secretes btw patient and nurse - if a patient asks if you can keep a secret, you can keep it confidential as long as it is not harming them or anyone else

Answer 15

- no one else can take better care of the patient than me

Answer 16

- providing care that is not given to other patients

Answer 17

- engaging in conduct with a patient that is sexual or may be reasonably interpreted by the patient as sexual - take someone w/ you if you think the patient can interpret it as sexual

Answer 18

- looking at chart before you see the patient - patient does not directly participate - identify professional goals > review available data > talk with other care givers > anticipate health concerns or issues that arise - plan time and space for initial interaction

Answer 19

- when nurse and patient get to know one another - begin to develop trust > give patient basic info about yourself > name, professional status, purpose, nature, and time available of the relationship, when will relationship end - clarify your role and that of patient - assess patient's health status > close ended questions (yes or no) > open ended questions: elicit - patients thoughts and perspectives w/o influencing the direction of acceptable response > focused questions: more specific (can you tell me more...) - begin to identify patient problems and goals

Answer 20

- S: sit at an angle - U: uncross arms and legs - R: relax - E: eye contact - T: touch (or physical proximity) - Y: your intuition

Answer 21

- nurse and patient work tgthr to solve patient problems and achieve patient goals - utilize therapeutic communication skills to facilitate successful interactions

Answer 22

- remind the patient that termination is near - evaluate goal achievement with the patient - transition care to other caregivers as needed - introduce next nurse - talk to the next nurse

Answer 23

- active listening - empathy - minimal cues: brief encouraging phrases and nonverbal prompts - clarification: listening response - ask patient for info or for elaboration of a point (can you tell me what I just said) - restatement: restate parts of the message in the form of a question - paraphrasing: focuses on the cognitive component of the message (so you were confused abt your med schedule) - reflection: focuses on emotional component of the message (so you're feeling sad. can you tell me more?) - summarization and validation: used to pull several ideas and feelings tgthr (so the pain meds are not working. let's try to figure out what we can do diff) - providing info: can decrease anxiety or help w/ decision making - silence - touch - humor

Answer 24

- false reassurance: 007 - giving advice (coersive) - false inferences: making an unsubstantiated assumption about what a patient means w/o asking for validation - over generalizing (it's gonna be fine everyone gets nervous) - changing subject (ignoring what's imp to them) - moralizing (i think it's great you quit smoking) - value judgments/personal opinion: pt shouldn't know if you approve/disapprove their actions - social responses: polite superficial comments that don't focus of what the patient is feeling or trying to see - asking why questions: implies criticism and makes patient feel defensive - being defensive/arguing - bringing up topics best avoided (religion, politics, etc)

Answer 25

- CARE - C: connect w/ pt - A: appreciate the patient's situation and acknowledge their pov - R: respond to their needs - E: empower pts to problem solve w/ u - keep things confidential when appropriate

Answer 26

- promoting health and wellness - preventing illness - restoring health > providing direct care to ill person > performing diagnostic procedures > consulting w/ other health professionals > teaching about recovery activities > rehabilitating pts to optimal fxnal level - caring for the dying

Answer 27

- submit a written application on forms furnished to the applicant - good moral character - completed all education requirements - make statement under oath - Be approved by the board - pass an exam (NCLEX) - pay license fee

Answer 28

- The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, its recovery, or a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help the client gain independence as rapidly as possible.

Answer 29

- Nursing incorporates the art and science of caring and focuses on the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities and populations in recognition of the connection of all humanity

Answer 30

- assessment - diagnosis - outcome identification - planning - implementation > coordination of care > health teaching and health promotion - evaluation

Answer 31

- disciplines are ways of thinking - ways to look at the world

Answer 32

- nurses are not paid for what they do; they are paid for how they think

Answer 33

- strategies used to understand the significance of data, identify real and potential patient problems and choose the best actions to achieve desired outcomes

Answer 34

used when feeding or bathing a patient until the patient can do it on their own

Answer 35

- nurses view a patient as a unique personal system that is constantly interacting/transacting w/ other systems - help patients become active participants in their care by working with them to establish goals for attaining, restoring, or maintaining health

Answer 36

- nurses help a patient cope w/ or adapt to changes in physiological, self-concept, role fxn, and interdependence domains

Answer 37

nurses assist patients w/ 14 activities (breathing, eating, drinking, elimination, movement, positioning, sleep, rest, clothing, body temp, hygiene, safety, communication, play, work, worship, learning) until patients can meet these needs themselves or they help them have a peaceful death

Answer 38

an established nursing theory that emphasizes culture and care as essential concepts in nursing

Answer 39

- elimination - sleep/rest - sensory/perception - sexuality/reproduction - SELF PERCEPTION AND SELF CONCEPT (psychological)

Answer 40

- spiritual

Answer 41

- cultural values, norms and customs

Answer 42

- designer and provider of care - nurse clinician -- ADN, Diploma, BSN - Advanced Practitioner Nurses -- MSN/DNP >NP, Clinical Nurse Specialist, Nurse Midwife, Nurse Anesthetist - manager/coordinator of care -> works w/ IP team - member of a team - negotiating decision making among team is essential - good communication paramount > need to understand Med terms - can be patient educator, politician, consultant, counselor, researcher, client advocate

Answer 43

concern for welfare an well being of others

Answer 44

right to self-determination

Answer 45

respect for inherent worth and uniqueness of populations and individuals

Answer 46

acting in accordance w/ appropriate code of ethics and accepted standards of practice

Answer 47

working to ensure equality in treatment and access

Answer 48

helping clients adapt to internal and external demands

Answer 49

- promoting health and wellness - DIAGNOSING DISEASE - restoring health - caring for the dying

Answer 50

continuing care

Answer 51

- patient centered approach focusing on the patient's needs - requirements: sincerity, listening, presence, respect, acceptance

Answer 52

People, events, projects, and things matter to people. Patients are unique with different backgrounds of experience, values, and cultural perspectives.

Answer 53

Caring is very personal, thus its expression of caring differs for each patient. Expressions, processes, and patters of caring vary among cultures.

Answer 54

Holistic model that supports a nurse's conscious intention to care and promote healing and wholeness. The nurse looks for deep sources of inner healing to protect, enhance, and preserve a person’s dignity, humanity, wholeness, and inner harmony.

Answer 55

Nurturing way of relating to an individual. 1) Knowing 2)Being with 3)Doing for 4)Enabling 5)Maintaining belief

Answer 56

- striving to understand an event as it has meaning in the life of the other - avoiding assumptions; centering on the one cared for; assessing throughly; seeking clues o clarify the event engaging the self or both

Answer 57

- being emotionally present to the other - being there, conveying ability, sharing feelings, not burdening

Answer 58

- doing for the other as one would do for self - comforting, anticipating, performing skillfully, protecting, preserving dignity

Answer 59

- facilitating the other's passage thru life transitions and unfamiliar events - informing/explaining, supporting/allowing, focusing, generating alternatives, validating/giving feedback

Answer 60

- sustaining faith in the other's capacity to get through an event or transition and face a future w/ meaning - believing in/holding in esteem, maintaining a hope filled attitude, offering realistic optimism "going the distance"

Answer 61

- eye contact - body language - voice tone - listening - positive and encouraging attitude

Answer 62

- ask before you touch - Contact touch: skin to skin (task oriented, caring, or protective) ex: holding patient’s hand, giving a massage, gently positioning * Protective touch: protects a nurse or a patient ex: holding patient to prevent from falling or distancing self from patient if there’s tension * Therapeutic touch: holistic intentional and compassionate use of touch to help patients find inner balance * Use touch with discretion as touch can convey many messages

Answer 63

- Engaging with the patient, being present in a non-judgmental and accepting manner * “Taking in” what a patient says + interpreting and understanding what’s said + give back understanding to the patient = listening * Silence yourself and listen with an open mind, concentrate on what the patient is saying, fully focused, observe patients tone of voice, expressions, & body language - paraphrasing and reflecting: i'm hearing ____ is that correct?

Answer 64

- Improves patient satisfaction and patient outcomes * In knowing, nurses are able to identify changes out of the ordinary for the patient which can improve our quality of care * Patients feel valued when nurses take the time to care for them by knowing more about them (favorite drink in the morning, what time they like to bathe, how they like their water, etc)

Answer 65

A caring relationship between patient and nurse help to ... – Mobilize hope for the patient and nurse – Find an understanding of illness, symptoms, or emotions that’s acceptable to the patient – Assist patient in using social, emotional, or spiritual resources – Recognize that caring relationships connect us human to human, spirit to spirit

Answer 66

- Relieving symptoms is more than giving pain meds, repositioning a patient, cleaning a wound, or providing end of life care * Providing comfort, dignity, respect, peace helps to relieve symptoms * Conveying a quiet, caring presence, touching or listening helps you determine the meaning of your patients discomfort and care for them

Answer 67

* Each person experiences life through relationships with others * Caring for an individual includes a person’s family * It is important to know the family as thoroughly as you know the patient

Answer 68

* Compassion fatigue: emotional and physical exhaustion leading to diminished ability to empathize or feel compassion for others * Time constraints reduce the time nurses have to spend quality time with patients * Institutional demands place a strain on the ability to have more time for patient care * Focus on being task-oriented * Short staffed

Answer 69

- learned beliefs, values, norms, traditions of particular group -> guides our thinking, decisions, and actions - constantly changing due to environmental, biological, political, and social influences

Answer 70

* We are unaware of this type of bias, happens outside our control, influenced by personal background, cultural environment, and personal experiences. * One will typically make quick judgements & assessments of people and situations

Answer 71

* Similar to unconscious bias, however, we are aware that the bias is present * We are responsible for this type of bias and must recognize and acknowledge our actions as they impact our behavior, decisions, and patient-centered care - outside of our control

Answer 72

- emphasizes care based on individuals cultural beliefs, practices, and values

Answer 73

- address your own implicit bias - be respectful and responsive to patient preferences, needs, and values - ensure patient's values guide all clinical care decisions (ex: jehovah's witnesses)

Answer 74

- act of being culturally sensitive and appropriate - being culturally competent is a process of continually striving to effectively work within the cultural context of a patient - goal of cultural care: utilize research to provide culturally specific care to meet the needs of each person, family, and community

Answer 75

set of assumptions that develop during childhood - guides how one sees, things, experiences, and interprets the world - creates a lens thru which we view life's experiences - evolves over a lifetime of interacting w/ family, peers, communities, organizations, media, and institutions

Answer 76

- emic worldview - how do i view things - i don't understand that about you

Answer 77

- etic worldview - ask the significance and try to understand

Answer 78

- advocate for patients based on their worldviews - requires ongoing assessment, flexibility, and planning in partnership w/ patient

Answer 79

* Easy to stereotype various cultural groups after reading/hearing general info about their ethnic values, practices, and beliefs * Avoiding stereotypes or unwarranted generalizations about any group * Approach each person individually * Ask questions to gain understanding

Answer 80

- preventative differences in the burden of disease that are closely linked with socially disadvantaged racial, ethnic, and other population groups/communities - example: food desert where they don't have access to foods

Answer 81

- conditions in which people are born, grow, live, work, and age that affect health functioning and quality of life outcomes - examples: age, race, ethnicity, SES, access to nutritious food, transportation resources, religion, sexual orientation, level of education, literacy level, disability, geographic location

Answer 82

1. Economic Stability (wealthy or poor) 2. Education Access and Quality (may not have learned about healthy foods) 3. Health Care Access and Quality 4. Neighborhood and Build Environment 5. Social Community Context

Answer 83

- oppressed or disregarded - LGBTQ+, people of color, physically/mentally challenged, not college educated * Nursing intersects with a variety of people from different cultures, awareness of marginalization is critical

Answer 84

- Inadequate resources, poor patient-provider communication, lack of culturally competent care, inadequate access to language services that lead to poor patient health outcomes * To promote equal treatment we must be deliberate about addressing these issues

Answer 85

- Self examination of own bias toward other cultures and in-depth exploration of one’s cultural and professional background. Being aware of existence of racism and other “isms” in health care delivery - being aware of own bias

Answer 86

HCP seeks & obtains sound education about culturally diverse groups focusing on health-related beliefs/cultural values, care practices, disease incidence and prevalence

Answer 87

- Performing cultural assessment of patient to collect relevant cultural data about a patient’s presenting problem, also accurately conducting a culturally based physical assessment - figuring out what they need and how we can help

Answer 88

Encourages HCP to engage in face-to-face cultural interactions. Encounters aim to modify a HCP's existing belief about a cultural group; prevent possible stereotyping

Answer 89

Motivation of HCP to “want to” (and not have to) engage in process of becoming culturally aware, knowledgeable, and skillful in seeking cultural encounters

Answer 90

- Do not use family members to interpret for you or other healthcare providers. Family can include own perceptions/opinions in translation and reduce accuracy of information translated.

Answer 91

- L: listen to patient's perception of the problem - E: explain your perception of the problem - A: acknowledge both differences and similarities of the problem - R: recommendations must involve the patient - N: negotiate a treatment plan

Answer 92

- avoid conflict or sidestep issues - often reflect feelings of sadness, depression, anxiety, powerlessness and hopelessness

Answer 93

- often consist of "you" statements - goal of dominating while suppressing the other person's rights - often involves loud tone of voice

Answer 94

- indirect expression of hostility - failure to confront the issues or one's real emotions * Common Behaviors * Asking threat-based questions * Making wistful statements * Doling out backhanded compliments * Ignoring or saying nothing * Procrastination * Leaving someone out * Sabotaging someone * Keeping score

Answer 95

- setting goals, acting on those goals in a clear, consistent manner and taking responsibility for the consequences of those actions - uses the direct expression of feeling -- "I" statements - steps in an assertive response - express empathy - describes your feelings or the situation - state expectations - list consequences

Answer 96

therapeutic context of nursing 2

Answer 97

* Derived from federal and state constitutions * Ex: every patient has the right to refuse treatment

Answer 98

* Clearly defines expectations of civil and criminal law. * EX: Nurse practice act states you have a duty to care of your patients (observe, assess, diagnose, plan, intervene, evaluate patient)

Answer 99

* US congress & state legislatures make decisions * Civil- protects rights of individuals. Fair & equitable treatment (Americans with Disabilities Act, Nurse Practice Act) * Criminal-protects society & provides punishment for crimes

Answer 100

if patient or family alleges the nurse knew or should have known their behavior was less than what a reasonably prudent nurse would do under similar circumstances

Answer 101

- civil wrongful acts or omissions of care made against a person or property

Answer 102

- deliberate acts against a person or property - assault: intentional threat placing person in reasonable fear of harmful, imminent, or unwelcome contact. actual contact is not required - battery: intentional offensive touching w/o consent or lawful justification. harmful, causes injury or merely offensive to patient's personal dignity

Answer 103

- receive explanation of procedure or treatment - receive names and qualifications of people performing and assisting in the procedure - receive description of the serious harm, including death, that may occur as result of procedure and anticipated pain and/or discomfort - receive explanation of alternative therapies to the proposed procedure or treatment and the risks of doing nothing - know the right to refuse the procedure or treatment w/o discontinuing other supportive care - know the right to refuse the procedure or treatment even after the procedure has began

Answer 104

- keeping pt who's mentally and physically stable confined

Answer 105

- provides rights to patients to consent to the use and disclosure of protected health information (PHI) - limits who can access patient records - privacy: right of patients to keep personal information from being disclosed - confidentiality: protects private patient info once it is disclosed in health care settings

Answer 106

- intent to harm is not there but harm occurs - invasion of privacy (disclosing confidential info) - defamation of character - false communication resulting in damage to a person's reputation (talking negatively abt someone) - slander (spoken) - libel (written)

Answer 107

- person is harmed and the person inflicting the harm knew, or should have known, that their actions were less than the accepted scope of standard practice - malpractice: negligence by a professional

Answer 108

- act of omission: failing to do something you were supposed to do - act of commission: doing something you aren't supposed to do

Answer 109

- nurse (defendant) had duty to patient - nurse failed to carry out that duty - patient was injured as result of breech in duty - damges to patient

Answer 110

- assessment: The RN collects comprehensive data pertinent to the patient’s health or the situation. - diagnosis: The RN analyzes the assessment data in determining diagnoses or issues. - outcome: The RN identifies expected outcomes for a plan individualized to the patient or the situation. - planning: The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes. - implementation: The RN implements the identified plan. - evaluation: The RN evaluates progress toward attainment of outcomes

Answer 111

* Failure to meet standard of care (Nurse Practice Act, Joint Commission for Accreditation of Health Organizations (JCAHO), American Nurse Association (ANA) * Failure to assess/monitor patient * Failure to make appropriate nursing judgement * Failure to implement appropriate nursing care * Failure to communicate important info with HCP (healthcare professional) * Failure to act as patient advocate * Failure to use equipment in a responsible manner * Inappropriate delegation of nursing tasks

Answer 112

- breach of duty caused injury - foreseeability

Answer 113

- actual injury to client - physical, emotional, financial

Answer 114

- meds error - falls - inadequate assessment/judgment - inadequate communication - burns - mistaken identity of patient - incidents in or - pressure injuries

Answer 115

- document appropriately (chart it or it didn't happen) * Comply with agency policies * Ask for help when necessary * Question orders when * A patient questions * If the patient’s condition has changed * Recording verbal orders to avoid miscommunication * It is illegible, unclear or incomplete * Malpractice insurance

Answer 116

- responsible for their own actions - held to same standard of performance as RN - to reduce liability (be prepared and comply with agency/SON policies - if working as PCA perform task allowed for PCA

Answer 117

- originates from decisions that were made in the absence of law

Answer 118

- describes decisions made in legal cases that were resolved in courts

Answer 119

* Patient’s signed consent necessary for admission to health care agency * Gives permission for invasive procedures and treatments such as IV insertion, surgery, etc)

Answer 120

– State laws to protect citizens, make nurses accountable, ensure consistent care with best practices (within the scope and standards of nursing). – The nursing commission/State board of Nursing: licenses all RN’s in the state in which they practice. Permits offering of special skills to the public – Provides legal guidelines for protection of the public.

Answer 121

- encourages health care professionals to assist in emergencies - limits liability and offers legal immunity if a nurse helps at the scene of an accident - if a patient subsequently develops complications due to your actions, you are immune from liability if you acted without gross negligence - protects nurses from doing what is reasonable to save a life (within nurse's scope of practice)

Answer 122

- Requirements for reporting communicable diseases, school immunizations, other conditions to promote health and reduce health risks in the community - CDC (Center for disease control) & OSHA (Occupational Safety and Health Administration) provide guidelines on national level for safe and healthy communities and work environments.

Answer 123

- Roe v Wade (1973) US Supreme Court ruled for a fundamental right to privacy for a woman’s decision to terminate a pregnancy. - Regulations put forth regarding when an abortion can take place (which trimester can one occur) - Decision has been overturned and now affects nursing practice in a different capacity.

Answer 124

– Competent individuals with terminal disease (incurable or irreversible, that will produce death within 6 months) can request for medication to end their life in a humane and dignified manner – The ANA (American Nurse’s Association) believes nurse’s participation in assisted suicide violates the code of ethics for nurses. – AACN (American association of colleges of nursing) historically has supported to ensure peaceful end of life. – It is important to know your state’s laws and ensure that your practice falls within the law’s requirements.

Answer 125

– Basic definition of the actual point a person is legally dead – Two standards for determination of death * Cardiopulmonary: irreversible cessation of circulatory (heart) and respiratory (lung) functions * Whole Brain: irreversible cessation of all functions of the entire brain

Answer 126

- staffing and nurse to patient ratios - nursing assignments - patient abandonment (refusing to care after relationship has been established) - nurse delegation - nursing students

Answer 127

- study of what's right and wrong

Answer 128

judgment about behavior based on specific beliefs

Answer 129

deeply held personal belief about an idea, custom, or object

Answer 130

- freedom from external control - respect another's right to determine course of action - preeminent principle - informed consent

Answer 131

- taking positive action to help others - doing or promoting good AS THE PATIENT DEFINES IT

Answer 132

avoidance of harm or hurt

Answer 133

faithfulness or the agreement to keep promises

Answer 134

treating all patients equal and fair

Answer 135

truth telling

Answer 136

- practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual - responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy - primary commitment is to the patient - promotes, advocates for, and strives to protect the health, safety, and rights of the patient. - responsible and accountable for individual nursing practice - nurse owes the same duties to self as to others - participates in establishing, maintaining, and improving health care - participates in advancement of the profession - collaborates w/ other health professionals and the public

Answer 137

- two opposing courses of action can both be justified by ethical principles

Answer 138

- (instead of competing options for action) Nurse feels the need to take specific action while believing that action to be wrong

Answer 139

- legal accountability (must be dated, timed, legible, permanent and use acceptable terminology) - report client response to care - quality assurance - research - education - reimbursement | /HJDO DFFRXQWDELOLW\

Answer 140

- interagency accessibility - cost savings - increases access to client info - efficiency an ease of use - enhanced quality of care and communication - safety

Answer 141

- cost - lack of standardization (hospitals systems with different programs) - confidentiality issues > don't share username/password, logout when finished using terminal, HIPAA compliance

Answer 142

- mandates privacy protection of a person's identifiable health info (PHI) - restricts the sharing/disclosure of PHI w/o a person's permission (authorization) - assures individual's basic rights (access, amend, obtain, accounting of disclosures of PHI) - imposes sanctions - civil and/or criminal if Rule is not obeyed

Answer 143

- name, address, social security, dates, medical record numbers, phone number, email, license plate number, full facial photographs, fax numbers, health plan numbers, account numbers, certificate/license numbers, device identifiers, web universal resource locators (URLS), internet protocol address numbers, biometric identifiers, any other unique identifying number, characteristics, or code

Answer 144

- info about the past, present, or future physical or mental health of a person, the provision of health care to a person and payment of care - includes written, electronic, or oral

Answer 145

- identifiable info: PHI rule applies - de-identifiable info: rule doesn't apply

Answer 146

- treatment (not gonna have to go in every time and be like can I read your chart), payment, operations - students do not need specific authorization to look at a pt chart

Answer 147

- state agencies (abuse, neglect or domestic violence reporting) - public health agencies w/ legal authority (covid #s) - legal proceedings (court order, subpoena) and law enforcement - health oversight agencies - required disclosures to FDA - medical examiners for purposes of identification of person or cause of death - cadaveric eye or tissue donation

Answer 148

- psychotherapy notes, some fund raising activities, PHI generated in the context of a research study - opportunity to restrict > patient directories, informing family members

Answer 149

- non-permanent part of patient record - face screen/sheet - includes basic pt info

Answer 150

- comprehensive and give you baseline data - first assessment and condition they came to us in

Answer 151

- description of patients condition - current meds, diet, treatments - activity level - restrictions - referrals - info you need to know before they go home

Answer 152

- standardized plans part of EHR - should be individualized

Answer 153

- used by all members of IP team - nurses notes write down narrative

Answer 154

subjective, objective, assessment, plan, interventions, evaluation

Answer 155

- statement nurse makes regarding particular incident that occurs w/ patient - may refer to: sign or symptom, nursing care measure, client behavior, medication administration, patient teaching

Answer 156

- accurate - clear descriptive objective information about what the nurse observes, hears, palpates and smells - chart data not inferences - avoid seems to, appears to, looks like

Answer 157

- stated, "I feel sick" - vomited 100 ml green-tinged fluid - was tearful during interview wrong - patient is nauseated - disoriented - how do u know

Answer 158

- patient is extremely fearful of this surgery (wrong) - abdomen is distended and hard - stated he is confused about why he needs this medication - respirations are normal (what's normal)

Answer 159

- ambulated to bathroom w/ no c/o dizziness - tolerated clear liquids well (how do you know) - vision is poor (did they tell u) - drinking adequate amounts of fluid (what's adequate)

Answer 160

- U - IU - Q.D., QD, q.d., qd, Q.O.D., QOD, q.o.d., qod - trailing zeros (X.0 mg) - lack of leading zeros (.X mg) - MS

Answer 161

- strike through and sign - use correct spelling - use only approved abbreviations

Answer 162

- thorough (always include how patient was left) - current - organized (military time) - legally prudent (don't throw ppl under the bus) - confidential - signed (signed entry first initial, last name, title)

Answer 163

- assessment, intervention, evaluation - pertinent info only - not housekeeping details - chary is about pt so no need to restate patient or mr x

Answer 164

- handoff > info exchange at critical times such as transitions in care > bedside > transfer knowledge and info about diagnosis, response to treatment, recent changes in condition and circumstances, an the plan (including contingencies) - authority and responsibility transferred

Answer 165

- standardized framework to communicate about a pt's condition - I: introduction -- self, unit, patient, room # - S: situation -- what is happening with the patient - B: background -- what is the clinical background - A: assessment -- what do i think the problem is - R: recommendation -- what would i recommend

Answer 166

- closed loop communication strategy used to verify and validate info exchanged

Answer 167

- wrong: Give furosemide 10 mg PO q. d., give 10U NPH insulin every morning, give MS 10 mg PO PRN - correct: give furosemide 20 mg IV stat, give ibuprofen 400 mg PO at HS

Answer 168

- is angry and inflexible

Answer 169

- crying. states she doesn't want visitors to see her like this

Answer 170

only licensed personnel can accept

Answer 171

- Knock on door * Say hello and goodbye * Address pt by name * Introduce self to all in room

Answer 172

- Introduce self * Give status (RN, student nurse, etc) * Use preferred name * Respect, dignity * Start with last name, clarify * Avoid “honey, sweetie, etc” * Avoid calling pt by room #, diagnosis

Answer 173

- Essential for the nurse/patient relationship * Effective communication essential for trust * Barriers to trust * Withholding important information (okay if not in our scope) * Lying * Distorting truth (unethical and illegal) * Gossip, talking about other pts and coworkers

Answer 174

- communicates self-assurance, respect, responsibility for own decisions

Answer 175

- self-directed, independence, advocacy - advocate for pt autonomy

Answer 176

- language comprehension - variability in word usage, dialects, literacy - nonverbal (personal space, eye contact, touch) - spiritual and religious belief differences within a culture

Answer 177

* Non-English speaking * Hearing and/or visually impaired * Unable to speak clearly, nonverbal * Cognitive impairment * Unresponsive (don't talk over them)

Answer 178

* Personal assessment of own cultural values and biases * Research and learn about different cultures * Identify primary language and English fluency * Interpreter services * Always speak to pt * Written information in preferred language and English * Ensure understanding through teach-back, restating, etc. * Incorporate into plan of care

Answer 179

- Safety is defined as the avoidance, prevention, amelioration of adverse outcomes or injuries stemming from the process of health care itself. (National Patient Safety Foundation) * Foundational for Quality Care

Answer 180

* Medication errors * Falls & trauma * Hospital acquired infections * Pneumonia * DVT * Complications of surgery

Answer 181

* Can impact patient safety * Disagreement arising from differences in attitudes, values, needs, in which the actions of one party frustrate the ability of the other to achieve their expected goals * Results in stress or tension

Answer 182

* A natural part of human relationships * Arises from incompatible goals or needs * A warning that something needs closer attention * Can promote growth * Can be detrimental

Answer 183

* Poor communication * Difference in values * Cultural belief system * Personality clashes * Stress

Answer 184

* Unassertive and uncooperative: Ignores rather than confronts conflict situation * Advantages: * May allow a cooling-off period * Issue may be trivial or potential damage too great * Disadvantages: * Leads to stress, bottle-up of feelings, and further conflict * Important decisions may be made by default * “Kick the can down the road” * I lose-you lose

Answer 185

* Assertive and Uncooperative: Goal oriented * Resolve a struggle by controlling or persuading others * Advantages: * Useful when quick, decisive action is needed * Can challenge participants to make their best efforts * Disadvantages: * More counterproductive than productive * Results in winners and losers * Fails to recognize concerns and needs of others * Can escalate conflict and losers may retaliate * I win now but then both lose-lose the situation

Answer 186

* Unassertive and cooperative * Attends to the needs of others /ignores own needs * Deals with problems by deferring to others * Advantages: * Harmony in the relationship is most important goal * Good will may be earned * Disadvantages: * Accommodator sacrifices values and possible higher- quality decision * Credibility and influence can be lost * I lose-you win

Answer 187

* Degree of Assertiveness and Cooperation * Midway between avoidance and competition * Partially satisfies both parties * Advantages: * Expedites the process * Disadvantages: * Neither side is completely satisfied * May not work if initial demands are too great * I lose-you lose

Answer 188

* Both assertive and cooperative * Attend fully to other’s concerns while not sacrificing or suppressing own * Directly confront the issue, acknowledge feelings, use open communication * Advantages: * Both sides win * Solutions more cost effective in the long run * Disadvantages: * Most difficult to achieve * Demands energy and hard work among participants * I win-you win

Answer 189

* Single coordinated unit of interprofessional providers * Team members have complementary skills or management responsibilities in the delivery of patient care. * Require collaboration

Answer 190

* Express empathy: “I understand that things are difficult at home.” * Describe the behavior: “But you have been coming late to work three times this pay period.” * State expectations: “It is necessary for you to be on time.” * List consequences: “If you are late again, I will have to report you to the personnel department.”

Answer 191

* Listen and paraphrase: “You are saying that being late is not acceptable.” * Acknowledge you are taking suggestions seriously: “I hear what you are saying.” * Give your side by stating supportive facts: “My car would not start.” * Develop a plan for the future: “I will take my car to be repaired tomorrow.”

Answer 192

* Use CUS when you need it * I am Concerned about my patient's condition. * I am Uncomfortable with my patient's condition. * I believe the Safety of the patient is at risk.

Answer 193

* Address the objectionable or disrespectful behavior > Briefly state the behavior and its impact on you * Emphasize the specifics of the putdown behavior > Refer only to the behaviors identified * Prepare a few standard responses > “I think it was out of line for you to criticize me in front of the patient.” * Escalate up the chain of command

Answer 194

* Different expectations * Members of the health care team often look at situations differently * Communication styles may differ * Differences in role hierarchy * Differences in education & experience * Differences in responsibilities and rewards * Value conflicts * End of life care * Moral distress * Disruptive behavior * Known as incivility, lateral violence, bullying

Answer 195

* Situations in which lack of civility or lack of respect occurs within a professional relationship frequently and over time. * May include * Overt behavior (clear) * Covert behavior (subtle)

Answer 196

includes processes involved in nutrition/metabolism, activity/exercise, elimination, sleep/rest, sensory/perception, and sexuality/reproduction.

Answer 197

relates to cognitive, emotional and developmental processes, self-perception and self-concept, coping and stress tolerance, and learning and decision-making

Answer 198

involves values and beliefs regarding the meaning and purpose of life as well as the individual’s relationship to a higher being.

Answer 199

refers to the broader community, cultural, and other groups, the family, health care and other organizations, and support systems for the person. Learned patterns of behavior, cultural values, norms, customs, roles and relationships with others, and health/illness practices are included in this dimension.

Exam 1 Study Guide Flashcards

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