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NSG 121 Exam 1/52 Questions with Solutions
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NSG 121 Exam 1/52 Questions with Solutions
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NSG 121 Exam 1/52 Questions withSolutions
SBAR - -S: Situation (why you are communicating)
B: Background (describe circumstances leading up to the current situation)
A: Assessment (give obj. and subj. data pertinent to the situation)
R: Recommendation (make suggestions for what needs to be done to
manage the difficulty)
- Orientation Phase - -when the nurse and the patient meet and get to know
each other
- Working Phase - -- Highly individualized
- The longest and most productive phase for the nursing- pt. relationship.
- Tasks include planning and implementation
- Major task is identification and resolution of the pts. problems.
- Termination Phase - -- Summarize goals and objectives achieved
- Discuss ways for pt. to incorporate new coping strategies learned
- Review situations of relationship
- Exploring the need for referrals post-discharge
- Establish plans for long-term post discharge functioning.
- Therapeutic Communication Includes: - -- Active Listening
- Show Empathy
- Ask pt. to elaborate by asking "Tell me what you mean by you do not
believe."
- Therapeutic Communication Techniques - -Interviews
Offering Self
Using Empathy
Closed vs. Open Ended Questions
Use of Silence
Clarification
Reflection/Repeating/Parroting
Paraphrasing
Summarizing
Using Unfinished Statements
Giving Information
Stating Implied Thoughts & Feelings
- Technique for Measuring Orthostatic BP - -- Use the same arm
- Wait at least 5 minutes btwn. measurements
- Lying, sitting, standing
, - Orthostatic Hypotension If: - -Fall of SBP ≥ 20 mmHg
Fall of DBP ≥ 10 mmHg
- Pulse 4-Point Scale - -0 absent
1+ palpable, but thready and weak; easily obliterated
2+ normal, easily identified; not easily obliterated
3+ increased pulse; moderate pressure for obliteration
4+ full, bounding; cannot obliterate
- Counting respirations - --Stay in pulse measuring position
-Watch the chest rise and fall.
-Determine quality- Depth (deep or shallow)
-Rhythm (regular or irregular)
- Count each inspiration and expiration as a part for 30 seconds and multiply
by 2.
Let the pt. think you are still taking the pulse while counting.
Example recording: Date, Time, R 18 deep and regular, Your signature and
title.
- Children Vital Sign - --HR is usually faster in children.
- If over 104 retake using the apical pulse.
- Pain Assessment - -- Point to location of pain
- Use the pain scale by asking "On a scale from 1-10 how bad is the pain
now."
- How often fo you get the pain?- frequency.
-What does it feel like?- assessing quality
-What makes it better or worse?
-How much pain are you having now?
- Pain Assessment Model - -OLDCARTS
O- Onset (when did the pain begin)
L- Location (where does it hurt?)
D- Duration (when did you first notice the pain?)
C- Character (dull, sharp, throbbing)
A- Aggravating factors (what makes it worse?)
R- Relieving factors (what make sit better)
T- Timing
S- Severity (pain score)
- Gate Control of Theory - -the theory that the spinal cord contains a
neurological "gate" that blocks pain signals or allows them to pass on to the
brain. The "gate" is opened by the activity of pain signals traveling up small
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