NUR 275 Exam 1 Study Guide
Questions and Answers
Nurse's legal parameters for the State's Nurse Practice Act - -
Nonprofessional involvement occurs when you cross professional boundaries
and establish social, personal, or business ties with a patient
Social talking about the weather or news may put patients at ease in the
beginning, but too much chatting—especially about religion, politics, gossip,
or personal finances—is unprofessional. Some disclosure may help establish
a therapeutic relationship, but you should always present such information in
the context of the patient.
For example, a nurse is working with parents of a child who was recently
diagnosed with asthma. The nurse's son also has asthma. The nurse may use
that information to say, "I have a child with asthma, too. I noticed that the
cough would get worse at night. When is your child's cough noticed?"
In this example, the nurse uses personal information to quickly redirect the
conversation to focus on the patient and the family.
Careful with social media
No sexual contact bc considered sexual misconduct
Visiting patients beyond your role of providing patient care also breaks
professional boundaries.
-Comprehensive, focused, and emergent assessment - -Comprehensive
assessment: are broad and complete. The amount and type of information
vary depending on the patient's needs, purpose of data collection, health
care setting, and the nurse's role.
Focused assessment: based on the patient's health issues. This type of
assessment occurs in all settings. It usually involves one or two body
systems and is smaller in scope than the comprehensive assessment, but
more in depth on the specific issue or issues.
Emergent assessment: involves a life-threatening or unstable situation, such
as a patient who has experienced a critical traumatic injury.
Remember:
A—Airway (with cervical spine protection if an injury is suspected)
B—Breathing—rate and depth, use of accessory muscles
,C—Circulation—pulse rate and rhythm, skin color
D—Disability—level of consciousness, pupils, movement
E—Exposure
-Difference between subjective and objective assessment data - -Subjective
data: are based on patient experiences and perceptions. The individual
describes the feelings, sensations, or expectations; you then document them
as subjective data or put them in quotes.
Objective data: measurable data. You observe the patient's general
appearance; assess vital signs; listen to the heart, lungs, and abdomen; and
assess peripheral circulation.
-What critical thinking skills helps the nurse see relationships among data? -
-clustering related cues and data
includes gathering and clustering data to draw inferences and propose
diagnoses
As a nurse, you use critical thinking to identify patterns and trends, consider
missing or conflicting assessment information, and decide the type and
frequency of future assessments.
Identify strengths and abnormal data.
Cluster data.
Draw inferences.
Propose possible nursing diagnoses.
Check for defining characteristics.
Confirm or rule out diagnoses.
Document conclusions.
-What is the nursing process, understand each of the 5 steps - -1)
Assessment: complete and accurate health assessment to promote health at
the highest level
2) Diagnosing: the clustering of data to make a judgment or statement about
the patient's difficulty or condition.
3) Planning: determining resources; targeting nursing
interventions; writing plan of care
4) Implementing/Intervention: providing treatment or education to the
patient
5) Evaluation: Appraising the effectiveness and appropriateness of
interventions
, ADPIE
-Understand the difference between verbal and non-verbal communication -
-Verbal: speaking with the patient
You learn effective interviewing skills through practice and repetition. Your
speech is of moderate pace and volume with clear articulation. A too-soft
voice may indicate embarrassment or discomfort, whereas a too-loud voice
may seem too powerful and controlling. Speech that is too fast indicates that
you are rushed, whereas speech that is too slow may indicate that you think
the patient is lacking cognitive ability.
Nonverbal: observe the patient's physical appearance, facial expression,
posture and positioning in relation to the patient, gestures, eye contact, tone
of voice, and use of touch.
For example, you should not assume that touch is culturally acceptable to a
patient. Instead, be courteous and ask permission: "Is it OK if I feel your
abdomen?"
-Understand HIPPA regulations - -Regulates the security and privacy of
information.
Confidentiality of documentation is essential, and only information pertinent
to the care of the patient is shared.
The HIPAA Privacy Rule requires an agency to make reasonable efforts to
limit use of, disclosure of, and requests for protected health information to
the minimum necessary to accomplish the intended purpose.
Health care providers who violate HIPAA may face fines of up to $250,000 or
jail time (HIPAA, 1996). Employees have been terminated for breaching
HIPAA laws concerning confidentiality. Nursing students also have
accountability for keeping HIPAA laws.
-Understand the review of systems (ROS) and what it provides - -is a series
of questions about all body systems that helps to reveal concerns as part of
a comprehensive health assessment.
In the review of systems, data collected is subjective information.
Objective data, or that completed in the physical assessment, is documented
separately.