NURS100 / NURS 100 Assessment 2 V2: Fundamentals of Nursing | Latest 2026–2027 Update | Questions with Correct Answers | Grade A – WCU

NURS100 / NURS 100 Assessment 2 V2: Fundamentals of Nursing | Latest 2026–2027 Update | Questions with Correct Answers | Grade A – WCU 2026 / 2027 Academic Year Q: The nurse is caring for a dying patient. Which intervention is considered futile? Answer d. Administering the influenza vaccine Q: A nurse has a duty of nonmaleficence. Which of the following would be considered a contradiction to that duty? Q: A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What crime may the nurse be committing? Answer b. Assault Q: A nurse is experiencing an ethical dilemma with a patient. Which information indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? b. Presence of conflicting values Answer A nurse is tr Q: A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research? Answer d. An article about emotional needs of dying patients and their families Q: Which is the nurse's best legal safeguard? c. Competent practice Q: A nurse is providing client care in a hospital setting. Who has full legal responsibility and accountability for the nurse's actions? Answer a. Nurse Q: Before conducting any study with human subjects, the nurse researcher must obtain informed consent. What must the nurse researcher ensure to obtain informed consent? ( Select all that apply.) a. Understands how confidentiality is maintained b. Ensures that subjects complete the study c. Allows free choice to participate or withdraw d. Identifies risks and benefits of participation e. Gives complete information about the purpose Answer a, c, d, e, Q: Which of the following is the most frequent reason for revocation or suspension of a nurse's license? Answer d. Drugs and alcohol abuse Q: A nurse is concerned about the practice of routinely ordering an extensive series of laboratory tests for clients who are admitted to the hospital from a long-term care facility. An appropriate source in handling this ethical dilemma would be: Answer d. the institutional ethics committee. Q: A nurse uses evidence-based practice (EBP) to provide nursing care. What is the best rationale for the nurse's behavior? Answer c. EBP is a guide for nurses in making clinical decisions. Q: Which organization has established safety standards about the use of electrical equipment, isolation techniques, and toxic chemicals? a. The Centers for Disease Control and Prevention (CDC) b. Equal Employment Opportunity Commission (EEOC) c. The Occupational Safety and Health Administration (OSHA) d. The Nurse Practitioner Data Bank Answer c. The Occupational Safety and Health Administration (OSHA) Q: The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? a. Confidentiality b. Advocacy c. Responsibility d. Accountability Answer c. Responsibility Q: A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the "C"? a. Who listen to music b. After surgery c. Who receive standard nursing care d. Achieve better control of their anxiety and pain Answer c. Who receive standard nursing care Q: One step in implementing evidence-based practice is to ask a question about a clinical area of interest or an intervention. The most common method is the PICO format. Which of the following accurately defines the letters in the PICO acronym? a. population, intervention, compromise, outcome b. population, intervention, comparison, output c. patient, institution, comparison, outcome d. population, intervention, comparison, outcome Answer d. population, intervention, comparison, outcome Q: The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? a. Accountability b. Advocacy c. Confidentiality d. Responsibility Answer b. Advocacy Q: When the nurse inserts an ordered urinary catheter into the client's urethra after the client has refused the procedure, and then the client suffers an injury, the client may sue the nurse for which type of tort? a. Dereliction of duty b. Battery c. Assault d. Invasion of privacy Answer Battery Q: A home care nurse visits a client who is confined to bed and is cared for by a chemically dependence adult child. The home is cluttered and unclean and the nurse notes that the client is wet with urine, has dried feces on the buttocks, and signs of dehydration are present. After caring for the client, the nurse contacts the health care provider and reports the incident to Adult Protective Services. What ethical framework is the nurse practicing? a. Fidelity b. Autonomy c. Nonmalefacence d. Justice Answer Answer Nonmalefacence Q: Which scenarios are examples of a nurse committing a tort? Select all that apply. a. The nurse administered a sedative medication to a sleeping client because the client's child requested the parent receive it. b. The nurse told the client, "The doctor prescribed this medication, and you must take it. I'll force you to take it." c. The nurse is part of a team who forcibly restrained an out-of-control client who was threatening to harm him- or herself. d. The nurse tells another employee, "Everyone knows the previous nurse does not do the job and charts medications not administered." e. The nurse applied a vest restraint to an older adult client who is confused and has an unsteady gait. The client is constantly getting out of the chair. Answer a, b, d Q: A nurse fails to administer a medication that prevents seizures, and the client has a seizure. The nurse is in violation of the Nurse Practice Act. What type of law is the nurse in violation of? a. Supreme b. Criminal c. Civil d. Federal Answer c. Civil Q: A group of nurses working in a long-term care facility fails to keep the narcotic medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in disciplinary action against the: a. Facility's state license b. State regulating body c. Pharmacist's license d. Nurse's license Answer d. Nurse's license Q: QSEN has 6 competencies. Which one of the following is not a QSEN competency? a. Safety b. Patient-centered care c. Care planning d. Teamwork and collaboration Answer c. Care planning Q: A nurse identifies a clinical problem with pressure ulcers. Which step should the nurse take next in the research process? a. Analyze results. b. Conduct the study c. Develop the research question d. Determine method. Answer c. Develop the research question A nurse does not assist with ambulation for a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse? a. Assault b. Fraud c. Battery d. Negligence Answer d. Negligence . A nurse is using the research process. Place in order the sequence that the nurse will follow. 1. Analyze results. 2. Conduct the study. 3. Identify clinical problem. 4. Develop research question. 5. Determine how study will be conducted. Answer 3. Identify clinical problem. 4. Develop research question. 5. Determine how study will be 2. Conduct the study. 1. Analyze results. The patient's son requests to view documentation in the medical record. What is the nurse's best response to this request? a. "I cannot let you see the chart without a doctor's order." b. "I'll be happy to get that for you." c. "You are not allowed to look at it." d. "You will need your mother's permission." Answer d. "You will need your mother's permission." In conducting a research study, the nurse researcher guarantees the subject no information will be reported in any manner that will identify the subject and only the research team will have access to the information. Which concept is the nurse researcher fulfilling? a. Confidentiality b. The research process c. Informed consent d. Bias a. Confidentiality The scope of nursing practice is legally defined by: a. Professional nursing organizations b. Hospital policy and procedure manuals c. Health care providers in the employing institutions d. State Nurse Practice Acts d. State Nurse Practice Acts The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to resolve this ethical dilemma in the correct order. 1. The nurse identifies possible solutions or actions to resolve the dilemma. 2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation. 3. Health care providers use negotiation to redefine the patient's plan of care. 4. The nurse evaluates the plan and revises it with input from other health care providers as necessary. 5. The nurse examines the issue to clarify opinions, values, and facts. 6. The nurse states the problem. 2, 5, 6, 1, 3, 4 A nurse is trying to decrease the rate of falls on the unit. After reviewing the literature, a strategy is implemented on the unit. After 3 months, the nurse finds that the falls have decreased. Which process did the nurse institute? a. Generalized study b. Qualitative research c. Peer-reviewed project d. Performance improvement d. Performance improvement In caring for patients, what must the nurse remember about evidence-based practice (EBP)? a. EBP is the only valid source of knowledge that should be used b. EBP is secondary to traditional or convenient care knowledge c. EBP is dependent on patient values and expectations d. EBP is not shown to provide better patient outcomes. c. EBP is dependent on patient values and expectations An on-duty nurse discovers that a colleague is pilfering medicines. According to the Nurse Practice Acts, what should the nurse do? a. Discuss this incident with the colleague. b. Keep silent and overlook the incident. c. Report the incident to the supervisor. d. Inform the local police station. c. Report the incident to the supervisor The nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the nurse knows that the first step is what? a. Collecting all available information about the situation b. Identifying people who can solve the difficulty c. Clarifying values related to the cause of the dilemma d. Exploring reasonable courses of action a. Collecting all available information about the situation A student nurse employed as a nursing assistant may perform any function that: a. Have been learned in school b. Are expected of a nurse at that level c. Are identified in the position's job description d. Require technical rather than professional skill c. Are identified in the position's job description What is the legal source of rules of conduct for nurses? a. American Nurses Association b. Agency policies and protocols c. Constitution of the United States d. Nurse Practice Acts d.Nurse Practice Acts Learn More You can also click on terms or definitions to blur or reveal them What part of the brain controls sleep? brain stem (hypothalamus) Stage 1 sleep cycle Wake stage (lightest sleep) alert but eyes closed alpha & beta waves normal vital signs Stage 2 sleep cycle deeper sleep heart rate & temp. decrease Stage 3 sleep cycle Deepest sleep immune system strengthens (muscle, tissue, bone, cells) this stage decreases with age Stage 4 REM Dream stage breathing is irregular & erratic heart rate is elevated stress recovery improves memory and fights depression What are methods to promote sleep? avoid stimulants establish a routine (dim lights, reading, tea) no naps after 3pm Insomnia recurring problems in falling or staying asleep hypoapnea excessively slow or shallow breathing decrease in O2 saturation longer than 10 seconds apnea temporary cessation of breathing (10 seconds) Obstructive sleep apnea sleep disorder defined by episodes when breathing stops during sleep as a result of blockage of the airway hypersomnia excessive daytime sleepiness with no improvement after sleep Restless Leg Syndrome Wills Ekbom Disease uncontrollable urge to move the legs during sleep PQRST Provoke Quality Region/Radiate Severity Timing Objective indicators of pain Vital signs initially showing an elevation in blood pressure, heart rate, and respiration Muscle tension or rigidity Pallor When pain becomes more severe, there is a decrease in blood pressure and heart rate Nausea and vomiting Fainting Withdrawal to pain Grimacing Restlessness Guarding the area of pain non-pharmocological interventions positioning heat/cold therapy massage acupuncture hypnosis TENS unit Opioids & Narcotics are prescribed for moderate to severe pain. They are associated with respiratory depression and adverse effects of nausea, vomiting, constipation, itching, urinary retention, and altered mental processes. Morphine, oxycodone, codeine, methadone Nonopiods/NSAIDS Acetaminophen NSAIDs: ibuprofen, naproxen, celecoxib Adjuvant Analgesics Aid in pain relief by working on underlying pain generators, such as antidepressants, corticosteroids, and botulinum toxin. Somatic Pain originates in tendons, ligaments, bones, blood vessels, nerves Strong pressure on a bone or damage to a tissue with a sprain Visceral Pain pain that originates from organs or smooth muscles (by disease) Referred pain pain that is felt in a location other than where the pain originates Assessing is ? the systematic and continuous collection, analysis, validation, and communication of the patient data, or information. Database ? includes all the pertinent patient information collected by the nurse and other health care professionals Assessment and Clinical Reasoning -assessing systematically and comprehensively, using a nursing framework to identify nursing concerns and a body system framework to identify medical concerns focused assessment ? The nurse gathers data about a specific problem that has already been identified. Nursing Assessment should be ? Purposeful, prioritized, complete, systematic, factual and accurate, relevant, recorded in a standard manner Initial Assessment? is preformed shortly after the patient is admitted to a health care facility or service -Purpose of this assessment is to establish a complete database for problem identification and care planning. Emergency Assessment ? When a patients with a physiology or psychological crisis, the nurse performs this assessment to identify life-threatening problems time-lapsed assessment ? scheduled to compare a patients current status to the baseline data obtained earlier Patient-Centered Assessment Method ? a tool health care practitioners can use to assess patient complexity using the social determinants of health; these determinants may explain why some patients engage and respond well in managing their health while others with the same or similar health conditions do not experience the same outcomes Establishing Assessment Priorities? Health orientation, developmental stage, culture, and need for nursing Nursing Assessment? focus on the patient's response to health problems Subjective Data ? Information perceived only by the affected person; these data cannot be perceived or verified by another person. Objective Data? observable and measurable data that can be seen, heard, felt, or measures by someone other than the person experiencing them Sources of Data ? a) Primary = the CLIENT b) Secondary = all other sources which does NOT COME FROM THE client c) the patient record Observation ? conscious and deliberate use of the five senses to gather data Interview ? A face-to-face or telephone questioning of a respondent to obtain desired information. Physical Assessment? systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems Promoting a caring interview -establish rapport -listen -ask questions -observe -interview Problems Related to Data Collection Inappropriate organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data Failure to establish rapport and partnership Recording an interpretation of data rather than observed behavior Failure to update the database Validation ? the act of confirming or verifying Data Validation ? the process of verifying that a program's input data is within the expected range Phase of assessment Assessment-Clinical reasoning-diagnosis Documentation ? the patients initial database is entered into the computer or record in ink, using the designated facility protocol or forms, the same day the patients is admitted to the facility Privacy, Confidentiality, and Professionalism? -one of your primary ethical responsibilities safeguarding the privacy or your patients Health Assessment? nursing health assessment involves gathering information about the health status of the patient. The nurse then evaluated and synthesizes the information. Comprehensive health assessment? is broad and includes a complete health history and physical assessment Ongoing partial health assessment? or follow up assessment: is one that is conducted at regular intervals during care of the patient. focused health assessment? is conducted to assess a specific problem Emergency Health Assessment? is a type of rapid focused assessment conducted when addressing a life threatening or unstable condition Patient Preparation ? when conducting a nursing health assessment, it is important to consider and remain sensitive to the patient's physiologic needs and psychological needs Environmental Preparation? Privacy and respect for the patients are primary concerns when conducting a health assessment equipment for physical exam -thermometer -scale -penlight -stethoscope -metric tape -eye chart Positions Used During a Physical Assessment: standing sitting supine dorsal recumbent sims prone Lithotomy knee-chest Inspection ? is the process of preforming deliberate, purposeful observations in the systematic manner Palpation ? to examine by touch Percussion ? tapping on a surface to determine the difference in the density of the underlying structure Auscultation? Listening with a stethoscope ex: S1 and S2 for heart (adults and S3 is normal for child Conducting a Physical Assessment? Head-to-toe The order to Assess an Abdomen? Inspection, auscultation, palpation, percussion Body Mass Index (BMI) A measure of body fat that is the ratio of the weight of the body in kilograms to the square of its height in meters. skin color assessment observe for tone, consistency, and pigmentation Assessing the Thorax and Lungs - inspect the thorax for color, shape or contour, breathing patterns, and muscle development - palpate anterior and posterior thoracic landmarks for sensitivity, chest expansion during respirations, and vibrations - auscultate airflow within the respiratory tract Assessing the Cardiovascular and Peripheral Vascular Systems ? -assessment of the heart and extremities -Health History adventitious breath sounds? Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles. Assessing Neurologic System? Includes cerebral function, cranial nerve function, cerebellar function, motor and sensory function, and reflexes. Assessing muscle strength? -ask patient to press against resistance -test for drift (pronation of Palm) 5: full strength 4: fair strength 3: sufficient strength to overcome gravity 2: can move but not overcome force of gravity 1: minimal contractile power 0: no movement Documentation of Data ? Immediately give verbal reporting of data whenever a critical change in the patient's health status is assessed. Enter initial database into computer or record in ink on designated forms the same day patient is admitted. Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner. Use good grammar and standard medical abbreviations. Whenever possible, use patient's own words. Avoid nonspecific terms subject to individual interpretation or definition. Factors affecting Safety ? Age and development Lifestyle Mobility and health status Sensory-perceptual alterations Cognitive awareness Emotional state Ability to communicate Safety awareness Environmental factors Fall risk factors ? -Poor Vision -Cognitive dysfunction (confusion, disorientation, impaired memory/judgement) -Impaired gait or balance and difficulty walking b/c of LE dysfunction -Difficulty getting in/out of bed/chair -Orthostatic hypotension -Urinary frequency or receiving diuretics -Weakness from disease process or therapy -Current med regimen that includes sedative, hypnotics, tranquilizers, narcotic analgesics, and diuretics Box 32-2 page 729 Risk for poisoning? ...Accentuated risk of accidental exposure to, or ingestion of, drugs or dangerous products in doses sufficient to cause poisoning. Preventing Accidents and Injuries -Occupational Safety and Health Administration (OSHA) -Division of department of labor -Establishes and enforces safety standards in work place -Occupational Exposures to Hazardous Chemicals -Blood borne Pathogen Standard Restraints ? a device that stops or slows something's motion Preventing Falls ? Steps that must be taken in order to keep residents free from falls; wearing non-skid slippers, cleaning up spills or locking wheelchair brakes Using restraints Must complete a thorough assessment before restraining! The use of restraints MUST be clinically justifiable. The use of restraints may be indicated for risk to self, risk to others, risk for injury, and/or to prevent therapy disruption (pulling out IV's) elbow restraint? A type of restraint that is used in the care of infants or small children to prevent flexing an arm to scratch or touch skin on the face or head, primarily during surgery Wrist Restraints? a physical restraint that limits arm movement chemical emergency ? The release of some hazardous chemical agent either unintentionally, such as through an accidental industrial release, or intentionally, as in a terrorist attack. RACE ? rescue, alarm, contain, extinguish Factors affecting personal Hygiene ? culture, socioeconomics, spiritual practices, developmental level, health state, personal preferences, health literacy Health State ? disease, surgery, injury, weakness, dizziness, fear of falling, pain Oral Cavity ? The part of the mouth behind the gums and teeth that is bounded above by the hard and soft palates and below by the tongue and by the mucous membrane connecting it with the inner part of the mandible. physical assessment of skin? assess for color, texture, turgor, and excretion of wastes Physical assessment of oral cavity ? Observe for oral problems. Dental caries Periodontal disease Other oral problems Identify actual or potential oral problems that nurses can treat. Identify appropriate nursing measures. Carry out the plan of care. Diagnosing for personal hygiene ? problems concerning deficient hygiene are categorized as self-care deficits outcome identification and planning Specification of (1) patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnoses; and (2) related nursing interventions Providing Scheduled Hygiene Care -should be provided with regular intervals -early morning, afternoon care, hour of sleep care, and care as provided Early morning care ? Routine care given before breakfast; AM care Morning care (a.m. care) after breakfast, complete morning care, which includes: bathing, oral care, toileting, mouth care, back massage, special skin care measure (decubitus ulcer or fungal infection), hair care, cosmetics, dressing, and positioning. This is the time to change the bed linens and tidy the bedside area also. Afternoon care (p.m. care) Ensure that the patient is comfortable after lunch and offer assistance with toileting, handwashing, and oral care. Straighten the bed or help someone to reposition for comfort. Hour of sleep care (H.S. care) Before the patient goes to bed, offer to toilet them again, wash face and hands, and oral care. This is also a good time for a back massage as patients find it soothing and may help them to fall asleep. Some patients may also find a bath to be soothing and sleep promoting at this time. At this time it is also important to change soiled linens, position the patient comfortably, and ensure the call be is within reach. As needed care (p.r.n. care) -offer individual hygiene measure as needed -change clothing and bed linens of diaphoretic patients -provide oral care every 2 hours if indicated Assisting with bath and skin care ? -cleans the skin -conditions skin -help relax a person -promoting circulation -helping improve self image -proving sensory output -strengthen nurse to patient relationships Bed baths ? gloves, wheels locked on bed, wash face first, wash one area at a time, perform perineal care with clean water Disposable bath ? -prepackaged products -often microwaved for warm temp Providing vaginal care -using plain soup is effective means to control odor Massaging the back -back rub acts as a general body conditioner and can relieve muscle tension and promote relaxation In providing perineal care on a female, always clean from front and back Assisting with oral hygiene ? -important to promote the patients sense of well being and prevent deterioration of the oral cavity Tooth brushing and flossing What helps reduce plaque Proving eye care -normally eyes are kept clean with lacrimal secreations -during illness the eyes may produce more secretions then normal and may appear glass like Proving ear care ? -clean in and out of the ear -clean hearing aid of patients have them Providing Nose Care -blow both nostrils proving hair care -cultural significance of grooming -shampoo and condition hair shampooing the hair the first step of preliminary grooming is cleansing, this involves: cleaning, bathing, and disinfecting the deceased as well as ___________ ___ _____ Proving fingernail care ? -trim nails straight across -remove hangnails -clean dirt from under nails Proving foot care ? -circulatory care is important for feet -cleaning feet is crucial for immobile patients Evaluating patients hygiene ? -level of patients participation in hygiene program -elimination of, reduction in, or compensation for factors interfering with the patients independent execution What do studies show helps morale and meeting patient outcomes? Good communication skills What do harassment and disruptive communication lead to? Affect the emotional and physical well being of those involved in the abusive behavior Functioning of organization Safety of patient care A person's use of written and spoken language can reveal what? Aspects of the persons intellectual development, educational level, geographic, and cultural origin What are some examples of nurses' use of verbal communication? Verbal interactions with patients and family Giving oral reports to other nurses Writing care plans Recording progress in patient charts Public speaking Writing for publication Composing signals and posters What does non-verbal communication reveal? Subtle and hidden messages in what the patient is saying verbally When there is in-congruency in verbal and non-verbal communication, which usually expresses more of the true meaning of the communication exchange? Nonverbal communication expresses more true meaning How do touch, eye contact, facial expressions, posture, gait, gestures, general physical appearance, mode of dress and grooming, sounds, and silence impact communication? Touch: express feelings of love, comfort, affection, security, anger, frustration, aggression, excitement Eye contact: suggests respect and a willingness to listen and keep communication open Facial expressions: convey joy suspicion sadness fear and contempt Posture: good health=good body alignment depressed= slouched. Gives clues concerning physical health Gait: bouncy walk= well being less purpose= sad or discouraged Gestures: used when 2 people different languages are trying to communicate General physical appearance: changes help detect illness or evaluate effectiveness of therapy Dress/ grooming: healthy= attentive to appearance ill= no care Sounds: crying, moaning, gasping, sighing all forms of nonverbal communication Silence: indicates understanding, thinking, anger What are some instances that the nurse would need to watch his/her facial expressions? Not upset patients Need to control expressions Define intrapersonal and interpersonal communication. Intrapersonal: self-talk, communicating within a person Interpersonal: two or more people with goal to exchange message How do developmental level, gender, sociocultural differences, roles and responsibilities, space, physical, mental, and emotional state, values and environment influence communication? Developmental level: how each age group perceives things helps guide interactions Gender: men and women communicate different Sociocultural differences: recognize how cutler, economic condition, lifestyle influence preferred form of communication Roles and responsibilities: persons occupation might give the nurse generalization of their abilities, talents, interests, economic status Space and territory: people are most comfortable in areas they consider to be their own Physical, mental, emotional: comfortable in these aspects free to engage in interactions and influence communication Values: comm. influenced by how people value themselves and purpose of human interaction Environment: comm. happens best when environment facilitates an easy exchange of needs information . Best comm. when environment is calm and non threatening Compare the helping relationship with the social relationship. Helping:does not occur spontaneously, specific person and purpose, unequal sharing of info, builds on patient needs Social: spontaneous, similar amount of sharing, helping both people, grows out of helping What are the characteristics of the helping relationship? Dynamic. Both the person assisting and person being helped are active participants to extent each is able Purposeful and time limited. Specific goals intended to be met in certain time. Person providing assistance is responsible for outcomes the relationship. Helper provides honesty and no more help than they are capable of giving. What are the phases of the helping relationship? See Box 20-3 Orientation phase Working phase Termination What factors promote effective communication within the helping relationship? Nurses who are competent, honest, skilled communicators Warmth and friendliness Openness and respect Empathy What is rapport and what helps to build it? A feeling of mutual trust experienced by both people in a satis factory relationship, facilitates open communication Specific objectives Comfortable environment Privacy Confidentiality Patient vs. Task focus Using nursing objectives and observations Optimal pacing How do listening skills, silence, touch, and humor increase communication skills? Listening: involves hearing and interpreting what others say Silence: time to reflect on what was shared, and observe patient without concentrating on spoken word Touch: connect people, provide affirmation, reassurance, and stimulation. Decrease loneliness, increases self esteem. Share warmth, intimacy, approval, and emotional support Humor: balances prospective in work and encourages patient to do the same Familiarize yourself with the interviewing techniques. We will use these in class next week. What are open ended and closed ended questions, validating and clarifying questions, reflective and sequencing questions? Open ended: patients express what the understand to be fic enough to not digress from the issue Closed question/ comment: gather specific info from patient and allows focus on a particular area Validating: validates what nurse believes he or she has heard or observed Clarifying: gain understanding of patients comment Reflective: repeating what the person said or describing the persons feelings Sequencing: places events in chronological order to investigate case and effect between events Also know the blocks to communication. Why do nurses avoid clichés, "Why" questions, leading questions, giving advice, judgmental comments, changing the subject, and giving false assurance? Cliches: can cause patient to think the nurses is not sincerely interested in how they feel Why and how questions: intimidating to patient Leading questions: produce anewers that please the nurse but don't encourage patient to respond honestly without feeling intimidated Comments that give advice: implies the nurse knows best and denies patient right to make decisions and have feelings. Increases dependency on care givers Judgmental comments: impose nurses standards on patient Changing the subject: patient may feel ready to talk about something then become frustrated when the subject is changed False assurance: gives patient impression the nurse isn't interested in their problems According to Shelly and Fish (1998), three spiritual needs underlie all religious traditions and are common to all people they are: Need for meaning and purpose Need for love and relatedness Need for forgiveness Although nurses may differ in their beliefs about how involved they should become in meeting patients' spiritual needs, it is impossible to nurse patients well while ignoring the spiritual dimensions of health List three elements of spirituality: Spirituality is experienced as a unifying force, life principle, essence of being. Spirituality is expressed and experienced in and through connectedness with nature, earth, the environment, and the cosmos. People express and experience spirituality in and through connectedness with other people Spirituality shapes the self-becoming and is reflected in one's being, knowing, and doing. Spirituality permeates life; providing purpose, meaning, strength, and guidance; shaping the journey Define Faith: generally refers to a confident belief in something for which there is no proof or material evidence "Although it is impossible for nurses to be knowledgeable about all religions", we are better able to meet the patients' spiritual needs when we understand their religious beliefs and practices. Religious beliefs and practices influence patients' responses to llness and suffering Self-care practices such as diet hygiene birth and death rituals Gender roles Spiritual practices Moral codes Buddhism They believe in Buddha "The Great Physician"- taught 4 noble truths to indicate the range of SUFFERING its ORIGIN its CESSATION and the WAY that leads its cessation. The real cause of human suffering is ignorant craving. The NobleEightfold Path- right views, aspirations, speech, conduct, mode of livelihood, effort, mindfulness, and concentration- leads to cessation of suffering Don't proclaim healing through faith. However, spiritual peace and liberation from anxiety attained through the awakening to Buddhas wisdom may be an important factor in expediting healing and the recovery process. Accepts modern science. The doctrine of avoidance of extremes is applied to the use of drugs, blood, vaccines. Buddhism does not condone taking lives of any form. Check with the patient about special diet restrictions and the observance of holy days. Never, presume to know what a patient's religious beliefs or practices are just because you have learned the patient's faith tradition. Many religious groups ....... In addition, you should not interpret the fact that a patient does not belong to an organized religion to mean that the patient is has no spiritual needs: ........ and people work out their own set of beliefs and practices, which may or may not be compatible with the tradition at large. a person may be deeply spiritual yet not profess to belong to an organized religion. Define Hope: the ingredient in life responsible for a positive outlook, even in life's bleakest moments. Define spiritual health well being is the condition that exists when the person's universal spiritual needs for meaning and purpose, love and belonging, and forgiveness. Three needs being met. Define spiritual healing the movements toward integration, from brokenness to wholeness. Spiritual beliefs are of special importance to nurses because of the many ways they can influence a patient's level of health, sense of well-being, and self-care behaviors. List four ways a person's spirituality can serve them. Give examples: Guide to daily living habits Dietary requirements and restrictions Acceptable birth control practices Types of medical treatment Source of support: this does for the person, spiritually, what protective exercises do for the body Other people in their faith Prayer Devotional Other religions practices Source of strength and healing Religious affiliation and member ship- promote healthy behavior and lifestyles Regular religious fellowship- offering support that buffers effects of stress and isolation Participation in worship and prayer- physiological effect of positive emotions Religious beliefs- health promotion and personality styles Simple faith- thought of hope, optimism, and positive expectations Mystical experiences- activating a healing bioenergy, or life force, or altered states of consciousness Absent prayer- healing by paranormal means or divine intervention Source of conflict Jehovahs witness denying blood transfusion. This would call for alternate care plan. List factors affecting a person's spirituality: Developmental considerations Ethnic background Formal religion Life events How are religious beliefs in conflict with the Law, Ethics, and Medicine? Many religious beliefs clash with what is ethical, lawful, and considered appropriate in medicine. People with strong religious beliefs are asking for their protection to practice individual decisions (medically) that align with their scriptures interpretation. Such practices can result in a person's death. These measures are sometimes taken out upon children with religious parents. Some procedures or beliefs are considered to be child abuse and neglect. How does a Parish Nurse (faith community nurse) help to integrate the healing tradition into the life of faith communities? List four Interpreting the relationship between faith and health Promoting personal responsibility for health and wellness Serving as health counselors and educators Staying aware of available resources and making appropriate referrals Acting as advocated for people who have health needs but limited resources Recruiting and training volunteers Visiting church members Initiating caring relationships with older adults, the chronically ill, and the worried well Complete the Promoting Health Spirituality Assessment Checklist Box 45-1. How well are you meeting your own spiritual needs? List two self-care behaviors you will use to strengthen your spirituality. I am doing fairly well meeting my own spiritual needs. I try my best to take time daily to encounter God and listen to what He wants me to hear Explore more practices that are spiritually supportive Practice loving relationships with self and others On page 1723 please answer question #3 under Developing Clinical Reasoning. There is no right or wrong answer. Just gage where you are in your spiritual journey, and where you would like to be, before you care for patients. I would listen to the patient and what they have to say. Assure them that their thinking is normal and it is a good thing that they are asking tough questions and being curious. Encourage them and offer prayer. Support them in their decision. Explain benefits on pursuing a spiritual life. Explain part of my story and how I encountered God. What it means to me. How my life has been changed. I am not completely where I would want to be, spiritually, in this situation. I would still use what I have to help the patient and meet them where they are spiritually. What are the primary objectives of the nurse as a caregiver? 1. Promote health 2. Prevent illness 3. Restore health What is holistic care? Care that addresses the many dimensions that comprise the whole person What is health? A state if complete physical, mental, and social well-being, not merely the absence of disease or infirmity. What is morbidity? How frequently a disease occurs. What is mortality? The number of deaths resulting from a disease. What is wellness? An active state of being healthy, including living a lifestyle that promotes good physical, mental and emotional health. What are the different human dimensions that makes up a whole person? -Physical -Intellectual -environmental -spiritual -Sociocultural -Emotional What is an illness? A response of the person to a disease; it is an abnormal process in which the person's level of functioning is changed when compared with a previous level What are illnesses classified as? Either acute or chronic Is it possible to have acute and chronic illness at the same time? Yes What is an acute illness? Rapid onset of symptoms and lasts relatively short time. Examples: appendicitis, pneumonia, diarrhea, common cold What is a chronic illness? A broad term that encompasses many different physical and mental alterations in health. -Usually has a slow onset and may have periods of remission and exacerbation Examples: diabetes mellitus, lung disease, arthritis, lupus Which is an example of an acute illness? A. Diabetes B. Rheumatoid arthritis C. Pneumonia D. Osteoporosis Answer: C. Pneumonia Rationale: Pneumonia is an acute illness that has a rapid onset of symptoms and lasts only a relatively short time. Diabetes, rheumatoid arthritis, and osteoporosis are chronic illnesses that cause a permanent change, require special patient education for rehabilitation, and require a long period of care or support. What are some characteristics of a chronic illness? -It is a permanent change. -It causes, or is caused by, irreversible alterations in normal anatomy and physiology. -It requires special patient education for rehabilitation. -It requires a long period of care or support What are the different stages of illness behavior? Stage 1: Experiencing symptoms Stage 2: Assuming the sick role Stage 3: Assuming a dependent role Stage 4: Achieving recovery and rehabilitation Tell whether the following statement is true or false. A person who is experiencing a productive cough and fever takes a sick day to recuperate and decide whether to make an appointment with the doctor. This person is said to be in stage 3 of illness behavior: assuming a dependent role. A. True B. False Answer: B. False Rationale: A person who defines oneself as sick and self-medicates or visits a doctor is said to be in stage 2 of illness behavior: assuming the sick role. What are some influencing factors for health disparities? -Racial and ethnic groups -Poverty -Gender; age -Mental health -Educational level -Disabilities -Sexual orientation -Health insurance and access to health care What are the factors affecting health and illness? -Basic human needs -The human dimensions -Self-concept -Risk factors for illness or injury What are the The Human Dimensions Affecting Health? -Physical dimension -Emotional dimension -Intellectual dimension -Environmental dimension -Sociocultural dimension -Spiritual dimension What is the physical dimension affecting health? genetic inheritance, age, developmental level, race, and gender What is the Emotional dimension affecting health? how the mind affects body function and responds to body conditions What is the Intellectual dimension affecting health? cognitive abilities, educational background, and past experiences What is the environmental dimension affecting health? housing; sanitation; climate; pollution of air, food, and water What is the Sociocultural dimension affecting health? economic level, lifestyle, family, and culture What is the spiritual dimension affecting health? spiritual beliefs and values Tell whether the following statement is true or false. A person who keeps in touch with neighbors in an attempt to foster a "community feeling" is promoting one's emotional human dimension. A. True B. False Answer: B. False Rationale: A person who keeps in touch with neighbors in an attempt to foster a "community feeling" is promoting one's sociocultural human dimension. What are the different types of health promotion and illness prevention? -Primary -Secondary -Tertiary What is the Primary type of health promotion and illness prevention? directed toward promoting health and preventing the development of disease processes or injury. Examples are immunization clinics, family planning services, poison-control information, and accident-prevention education. What is the Secondary type of health promotion and illness prevention? focus on screening for early detection of disease with prompt diagnosis and treatment of any found Examples are assessing children for normal growth and development and encouraging regular medical, dental, and vision examinations. What is the Tertiary type of health promotion and illness prevention? begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning Examples include teaching a patient with diabetes how to recognize and prevent complications, using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury, and referring a woman to a support group after removal of a breast because of cancer. What is an example of a nursing activity that promotes secondary prevention as a level of preventive care? A. Conducting a smoking cessation class B. Performing a blood pressure screening at a local mall C. Performing range-of-motion exercises on a bedridden patient D. Promoting safer sex practices in school settings Answer: B. Performing a blood pressure screening at a local mall Rationale: Secondary preventive care focuses on early detection of disease, such as heart disease in this example. Primary preventive care is directed toward promoting health and preventing diseases. Tertiary care begins after an illness is diagnosed to reduce disability and rehabilitate patients. What are the models of Health and Illness? -The health belief model -The health promotion model -The health-illness continuum -The agent-host-environment model Which model of health and illness views health as a constantly changing state, with high level wellness and death being on opposite ends of a graduated scale? A. Agent-host-environment model B. Health-illness continuum C. Health promotion model D. Health belief model Answer: B. Health-illness continuum Rationale: The health-illness continuum measures a person's level of health on a graduated scale. The agent-host-environment model refers to the interaction of the agent, host, and environment creating risk factors that must be examined. The health promotion model illustrates how people react to their environment as they pursue health. The health belief model is concerned with what people believe to be true about their health. What is the Agent-Host-Environment Model (Leavell and Clark)? -Views the interaction between an external agent, a susceptible host, and the environment as causes of disease in a person. -It is a traditional model that explains how certain factors place some people at risk for an infectious disease. -These three factors are constantly interacting, and a combination of factors may increase the risk of illness. The use of this model is limited when dealing with noninfectious diseases. What is the health illness continuum? -Conceptualizes a person's level of health -Views health as a constantly changing state with high-level wellness and death on opposite sides of a continuum -Illustrates the dynamic (ever-changing) state of health What is the Health Belief model? (Rosenstock) Concerned with what people perceive to be true about themselves in relation to their health Modifying factors for health include demographic, sociopsychological, and structural variables. What are the three components of individual perceptions of threat of a disease for the health belief model? Perceived susceptibility to a disease Perceived seriousness of a disease Perceived benefits of action What is the health promotion model? -Developed to illustrate how people interact with their environment as they pursue health -Incorporates individual characteristics and experiences and behavior-specific knowledge and beliefs -Personal, biologic, psychological, and sociocultural factors are predictive of a certain health-related habit. -Health-related behavior is the outcome of the model and is directed toward attaining positive health outcomes and experiences throughout the lifespan. What are the risk factors for illness? -Age -Genetic factors -Physiologic factors -Health habits -Lifestyle -Environment What is a basic human need? People's behaviors, feelings about self and others, values, and priorities all relate to physiologic and psychosocial needs. -These basic human needs are common to all people; meeting these needs is essential for the health and survival of all people. What is meeting a basic human need? A person can meet some needs independently, but most needs require relationships and interactions with others for partial or complete fulfillment. Satisfying one's needs often depends on the physical and social environment, especially one's family and community. What are the Characteristics of Basic Needs/Maslow -Their lack of fulfillment results in illness. -Their fulfillment helps prevent illness or signals health. -Meeting basic needs restores health. -Fulfillment of basic needs takes priority over other satisfactions when unmet. -A person feels something is missing when a need is unmet. -A person feels satisfaction when a need is met. A nurse who focuses attention on the strengths and abilities of patients rather than their problems is helping them to achieve which of Maslow's basic human needs? A. Self-actualization B. Self-esteem C. Love and belonging D. Safety and security E. Physiologic Answer: A. Self-actualization Rationale: To meet patient self-actualization needs, nurses provide a sense of direction and hope, and maximize patient potential. Self-esteem needs are met by respecting patient values and beliefs and setting attainable goals for them. Love and belonging needs are met by including family and friends and establishing caring relationships with patients. Safety and security needs are met by encouraging spiritual practices and independent decision making. Physiologic needs are needs that must be met to maintain life. What are the Physiologic Needs according to Maslow's Hierarchy of Human Needs -Oxygen: most essential -Water -Food -Elimination -Temperature -Sexuality -Physical activity -Rest What is the Safety and Security Needs according to Maslow's Hierarchy of Human Needs? -Second in priority -Have both physical and emotional components -Being protected from potential or actual harm -Examples of interventions to meet these needs: -Using proper hand hygiene to prevent infection -Using electrical equipment properly -Administering medications knowledgeably What is the Love and Belonging Needs according to Maslow's Hierarchy of Human Needs? -Third priority needs, often called higher-level needs -Understanding and acceptance of others in both giving and receiving love -The feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community. -Unmet needs produce loneliness and isolation -Example of interventions to meet these needs: -Including family and friends in care of a patient -Establishing a trusting nurse-patient relationship What is the Self-Esteem Needs according to Maslow's Hierarchy of Human Needs? -Need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments -Positive self-esteem facilitates the person's confidence and independence. -Factors affecting self-esteem: Role changes Body image changes What is the Self-Actualization Needs Acceptance of self and others as they are Focus of interest on problems outside oneself Ability to be objective Feelings of happiness and affection for others Respect for all people Ability to discriminate between good and evil Creativity as a guideline for solving problems and pursuing interests Which patient need has the highest priority? A. A patient who needs to ambulate to prevent DVT B. A patient who is in isolation and feels lonely C. A patient who recently lost her husband D. An elderly patient who is at risk for falls Answer: A. A patient who needs to ambulate to prevent DVT Rationale: Preventing DVT is a physiologic need and is the highest priority need. A patient in isolation might have unmet love and belonging needs (3rd in priority). A patient who lost a spouse might have unmet self-esteem needs (4th in priority). A patient who is at risk for falls might have unmet safety and security needs (2nd in priority). What are the different kinds of family structures? -Family -Nuclear family -Extended family -Blended family -Single-parent family What is the "Family" family structures? any group of people who live together and depend on one another for physical, emotional, and financial support What is the "Traditional Family" family structure? traditional family; two parents and their children What is the "Blended Family" family structure? two parents and their unrelated children from previous relationships What is the "Extended Family" family structure? includes aunts, uncles, and grandparents What is the "Single-Parent" family structure? may be separated, divorced, widowed, or never married Tell whether the following statement is true or false. A family can be defined as any group of people who live together and depend on one another for physical, emotional, and financial support. A. True B. False Answer: A. True. Rationale: A family can be defined as any group of people who live together and depend on one another for physical, emotional, and financial support. What are the family functions? -Physical -Economic -Reproductive -Affective and coping -Socialization What are the family stages? -Couple and family with children -Family with adolescents and young adults -Family with middle-aged adults - Family with older adults Which of the following family functions is met when the family provides emotional comfort to a child who is ill? A. Physical B. Economic C. Reproductive D. Affective and coping E. Socialization Answer: D. Affective and coping Rationale: The affective and coping function of a family provides emotional comfort to family members. The physical function provides a safe, comfortable environment. Economically, the family provides financial aid to members. The reproductive function pertains to raising children and socialization involves transmitting beliefs, values, attitudes, and coping mechanisms, as well as guiding problem solving. What are the Risk Factors for Altered Family Health? -Lifestyle risk factors -Psychosocial risk factors -Environmental risk factors -Developmental risk factors -Biologic risks Tell whether the following statement is true or false. An example of a developmental risk factor is a family that has inadequate childcare for a preschool child when both parents are working. A. True B. False Answer: B. False Rationale: An example of a psychosocial risk factor is a family that has inadequate childcare for a preschool child when both parents are working. What are the community factors affecting health? -Social support systems -Community health care structure -Economic resources -Environmental factors Tell whether the following statement is true or false. The health care structure of a community has a direct effect on the health of the people living within it. A. True B. False Answer: A. True. Rationale: The health care structure of a community has a direct effect on the health of the people living within it. What are the Characteristics of Community Influences on the Health of a Member? What are the different types of cultural diversity? -Varying cultures -Racial and ethnic origin -Religion -Physical size, age, and gender -Sexual orientation -Disability -Socioeconomic and occupational status -Geographical location What is a culture? -Shared system of beliefs, values, and behavioral expectations -Provides social structure for daily living -Defines roles and interactions with others and in families and communities -Apparent in the attitudes and institutions unique to the culture Tell whether the following statement is true or false. What is a subculture? -Large group of people who are members of a larger cultural group Culture includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one's family. A. True B. False Answer: A. True. Rationale: Culture is defined as a shared system of beliefs, values, and behavioral expectations that provides social structure for daily living. It includes the beliefs, habits, likes and dislikes, and customs and rituals learned from one's family -Members have certain ethnic, occupational, or physical characteristics not common to the larger culture. What are the different groups in society? -Dominant group (usually largest group) -Minority group (smaller group) What is the Dominant group in group societies? Group has the most authority to control values and sanctions of society What is the Minority group in group societies? A physical or cultural characteristic identifies the people as different from dominant group. What is Cultural Assimilation? -Minorities living within a dominant group lose the characteristics that made them different. -Values replaced by those of dominant culture What is Culture Shock? -The feelings a person experiences when placed in a different culture -May result in psychological discomfort or disturbances Which of the following occurs when members of a minority group, living with a dominant group, begins to blend in and lose the characteristics that made them distinct? A. Cultural imposition B. Cultural conflict C. Cultural assimilation D. Cultural shock Answer: C. Cultural Assimilation Rationale: Cultural assimilation occurs when one's values are replaced by the values of the dominant culture. Cultural imposition is the belief that everyone should conform to the majority belief system. Cultural conflict occurs when people become aware of cultural differences, feel threatened, and act negatively. Cultural shock refers to the feelings a person experiences when placed in a different culture. What is Ethnicity? -Sense of identification with a collective cultural group -Largely based on group's common heritage What is race? Typically based on specific characteristics -One can belong to an ethnic group through birth or adoption of characteristics of that group. -Groups share unique cultural and social beliefs and behavior patterns. -Largely develops through day-to-day life with family and friends within the community. Skin pigmentation, body stature, facial features, hair texture Five major categories: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White What is stereotyping? -The assumption that all members of a culture or ethnic group act alike -May be positive or negative -Negative includes racism, ageism, and sexism Tell whether the following statement is true or false. Stereotyping occurs when people ignore differences in the cultures in which they live and proceed as if they do not exist. A. True B. False Answer: B. False Rationale: Cultural blindness occurs when people ignore differences in the cultures in which they live and proceed as if they do not exi