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for Clinical Judgment and Collaborative Care 11th
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Edition (Donna d. Ignatavicius)
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All Chapters Completed cf c m c f c m
,Chapter 01: Overview of Professional Nursing Concepts for cfcm c fcm c fc m c fc m cf cm c f cm c fc m
Medical-SurgicalNursing cfm
MULTIPLE CHOICE c f c m
1. A nurse wishes to provide client-centered care in all interactions. Whichaction by
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cfcm the nurse best demonstrates this concept?
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a. Assesses for cultural influences affecting health care cfcm cfcm cfcm cfcm cfcm cfcm
b. Ensures that all the clients basic needs are met cfcm c fc m c f cm cfcm c fcm c fc m cfcm c f cm
c. Tells the client and family about all upcoming tests
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d. Thoroughly orients the client and family to the room cfcm c fc m cfcm c fc m cfcm c fcm cfcm c fcm
ANSWER: A c f c m
Competency in client-focused care is demonstrated when the nurse focuses on communication, cfcm cfcm cfcm cfcm cfcm cfcm cfcm cfcm cfcm cfcm cfcm
cfcm culture, respect compassion, client education, and empowerment. By assessing the effect of the
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cfcm clients culture on health care, this nurse is practicing client-focused care. Providing for basic needs
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cfcm does not demonstrate this competence. Simplytelling the client about all upcoming tests is not
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cfcm providing empowering education. cfcm cfcm
Orienting the client and family to the room is an important safety measure, but notdirectly related to
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cfcm demonstrating client-centered care. cfcm cfcm
DIF: Understanding/Comprehension REF: 3
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KEY: Patient-centered care| culture MSC: IntegratedProcess:
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Caring NOT: Client Needs Category: cfc m cfc m c fcm cfcm
Psychosocial Integrity c fc m
2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was
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cfcm 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What actionby the nurse is best?
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a. Call the Rapid Response Team.cfcm cf cm c f cm c fc m
b. Document and continue to monitor. c fcm cfcm c fc m c fc m
,c. Notify the primary care provider. cfcm cfcm cfcm c f cm
d. Repeat blood pressure measurement in 15 minutes. cfcm c fc m c fc m c fc m c fcm c fcm
ANSWER: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they
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cfcm suffer either respiratory or cardiac arrest. Since the client hasmanifested a significant change, the nurse
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cfcm should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly
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cfcm significant.
Documentation is vital, but the nurse must do cfcm cfcm cfcm cfcm cfcm cfcm cfcm c f c m more c f c m than document. The primary care provider
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cfcm should be notified, but this is not the priority over calling the RRT. The clients
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cfcm should c f c m be reassessed cfcm c f c m frequently, but the priority cfcm cfcm c f c m c f c m is getting the rapid care to the client.
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DIF: Applying/Application REF: 3
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KEY: Rapid Response Team (RRT)| medical
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cfcm emergencies MSC: Integrated Process: cfcm cfcm cfcm
Communication and Documentation c f cm c fcm
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. A nurse is orienting a new client and family to the inpatient unit. What informationdoes the
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cfcm nurse provide to help the client promote his or her own safety?
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a. Encourage the client and family to be active partners. cfcm cfcm c fc m cfcm c fc m c fc m cfcm c f cm
b. Have the client monitor hand hygiene in caregivers. cfcm cfcm c fc m c fc m c fc m c f cm c fc m
c. Offer the family the opportunity to stay with the client.
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d. Tell the client to always wear his or her armband.
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ANSWER: A
Each action could be important for the client or family to perform. However, encouraging the client
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cfcm to be active in his or her health care as a partner is the mostcritical. The other actions are very
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cfcm limited in scope and do not provide the broad protection that being active and involved does.
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DIF:
, Understanding/ComprehensionREF:
3KEY: Patient safety
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