NUR 3306 FINAL STUDY GUIDE: QUIZZES 1-4 2023/2024 100% CORRECTLY ANSWERED

NUR 3306 FINAL STUDY GUIDE: QUIZZES 1-4 2023/2024 100% CORRECTLY ANSWERED The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. The instructor explains that SBAR charting is based on? - CORRECT ANSWER-A. The client's background B. Information that the nurse obtains from the family Correct. C Complete and accurate assessment findings D. Data in old medical records What does the nurse knows about normal blood pressure? - CORRECT ANSWER-A. Stays level throughout the day CorrectB. Follows a diurnal rhythm C. Rises with the early morning fall of blood glucose D. Follows the same cycle as the sun Response Feedback: A daily, circadian (diurnal) cycle of blood pressure occurs, with it increasing late in the afternoon and decreasing in the early morning. Blood pressure does not stay level throughout the day. Blood pressure does not rise with the early morning fall of blood glucose. Blood pressure does not follow the same cycle as the sun. What tool does the nurse use to auscultate the client's abdomen? - CORRECT ANSWER-A. None B. Fetoscope CorrectC. Stethoscope D. Sonoscope A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? - CORRECT ANSWER-A. To establish rapport with the client and family. B. To gather information for specialists to whom the client might be referred. CorrectC. To establish a database against which subsequent assessments can be measured. D. To quantify the degree of pain a client may be experiencing. A nurse, who suffers from a respiratory infection is preparing to perform a shift assessment on a client when she feels the urge to cough. What is the nurse's best action? - CORRECT ANSWER-A. Perform hand hygiene before coughing into hands B. Cover the mouth and nose with her hands while coughing C. Cough into the air away from the client toward the hallway CorrectD. Cough into the inner aspect of the elbow As part of the general survey, the nurse should shake hands with the client when first meeting him or her as long as doing so in culturally appropriate. Why is this action so important? - CORRECT ANSWER-CorrectA. The handshake portrays caring B. The handshake shows how professional the nurse is C. The handshake allows the nurse to get physically close to the client in a nonthreatening way D. The handshake allows the nurse to assess how nervous the client is To make a legal entry into the medical record, the nurse must document what? - CORRECT ANSWER-A. Laboratory tests ordered B. Attending physician CorrectC. Time of the assessment D. Nature of the assessment Response Feedback: The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment. While assessing a new client, the nurse asks about a family history of genetic illnesses The client states that her mother has diabetes. For which of the following is the patient at increased risk? - CORRECT ANSWER-CorrectA. Diabetes B. Hypertension C. Cancer D. Seizures Nursing students are learning about different methods of charting in clinical. What method is the model for improving communication between and among clinicians? - CORRECT ANSWER-CorrectA. SBAR B. CBE C. SOAP D. PIE How does the nurse use critical thinking when accurately assessing vital signs? - CORRECT ANSWER-A. Evaluating assessment techniques CorrectB. Developing nursing diagnoses C. Monitoring evaluations D. Planning assessment techniques HIPAA gives clients greater control over their medical records. What else does HIPAA provide? - CORRECT ANSWER-A. Copying of medical records B. Education of lay people about medical records CorrectC. Client recourse if privacy protections are violated D. Legal use of medical records Response Feedback: HIPAA provides for client education on privacy protection, client access to medical records, client consent prior to disclosing information from the record, and client recourse if privacy protections are violated. HIPAA does not address copying of medical records, education of lay people about medical records, or legal use of medical records. When caring for clients in any health care environment, what is the most important technique for preventing infection? - CORRECT ANSWER-A. Sterile technique B. Standard precautions CorrectC. Hand hygiene D. Use of gloves Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit? - CORRECT ANSWER-A. The evaluation of financial reimbursement B. The evaluation of client nutrition CorrectC. The evaluation of care for continual improvement D. The evaluation of timely documentation of pain Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding? - CORRECT ANSWER-CorrectA. Systolic pressure 180 mm Hg B. Apical pulse 70 beats/minute C. Respirations 12 breaths/minute D. Oxygen saturation 95% on room air The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students knows that this type of information is assessed in what type of assessment? - CORRECT ANSWER-A. Comprehensive CorrectB. Functional C. Head to toe D. Body systems The nursing instructor is discussing the different types of pain with the nursing class. What type of pain would the instructor explain originates from a specific site, yet the client feels the pain at another site? - CORRECT ANSWER-A. Chronic pain B. Cutaneous pain CorrectC. Referred pain D. Somatic pain Response Feedback: Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve. Chronic pain is pain referred to as persistent. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues and is felt at its origination. Somatic painoriginates from skin, muscles, bones, and joints and is felt at its origination. When using Gordon's framework for a functional health assessment, the nurse asks a client, "Have you made any changes in your environment because of vision, hearing, or memory decrease?" What functional health pattern is the nurse assessing? - CORRECT ANSWER-A. Vision B. Hearing C. Coping CorrectD. Cognition Response Feedback: A question to include in review of cognition and perception is whether the client has made any environmental changes because of vision, hearing, or memory decrease. The options of vision or hearing individually would not be complete as a response. The option of coping is not addressed in the question posed by the nurse. An adult comes to the clinic reporting pain in the right lower quadrant. When assessing the client's pain, what elements would the nurse include? (Mark all that apply.) - CORRECT ANSWER-A. Aggressiveness CorrectB. Intensity CorrectC. Quality CorrectD. Functional goal E. Quantity Response Feedback: In addition to pain intensity, other basic elements of a pain assessment are location, duration, intensity, quality/description, alleviating/aggravating factors, pain management goal, and functional goal. Aggressiveness and quantity are distracters for this question. The nursing instructor is explaining to students the difference between the language used when a nurse talks to the client and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record? - CORRECT ANSWER-A. Document according to the orders of the physician B. Talk to the client and document exactly the same CorrectC. Use medical terminology when documenting in the medical record D. Document exactly as the client talks Response Feedback: The nurse documents in the medical record using appropriate medical terminology. When speaking with clients, the nurse uses common lay language so the client better understands the questions. The nurse would not document according to the orders of the physician, nor would the nurse document exactly as speaking to the client. The nurse would not document exactly as the client talks, as this could be incorrect information to include in the medical record. A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows clients to what? - CORRECT ANSWER-A. Rest and improve health CorrectB. Provide accurate answers C. Talk about their feelings D. Communicate verbal concern Response Feedback: The nurse uses silence purposefully during the interview to allow clients time to gather their thoughts and provide accurate answers. The nurse also uses silence therapeutically to communicate nonverbal concern. Silence also gives clients a chance to decide how much information to disclose. Silence is not used to rest and improve the client's health, have the client talk about their feelings, or communicate verbal concern. A clinical instructor is discussing with a clinical group how to take a history of the client's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer? - CORRECT ANSWER-CorrectA. Follow the cues of the client during the interview B. Use a written checklist to make sure you cover all necessary areas C. Use a head-to-toe approach to make sure you do not miss anything D. Use a focused approach, asking only about symptoms of the present illness Response Feedback: Regardless of the order of data, the nurse guides the conversation following the cues of the client and uses a mental checklist to ensure that he or she has assessed all categories before the end of history taking. The nurse would not use a written checklist during the interview, and the nurse would not use a head-to-toe approach when eliciting information about the present illness. The nurse also would not focus only on the symptoms of the present illness. The nursing instructor is discussing with the nursing students different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor's best answer? (Select all that apply.) - CORRECT ANSWER-CorrectA. During a hospital admission B. At a clinic visit for a fall C. In the emergency department after a car accident CorrectD.