NUR 2090 - FINAL EXAM QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
delegation: nurses cannot delegate to whom and which actions?
-LPNs, CNAs, other ancillaries (misc.)
-anything that requires an assessment/significant procedure
delegation: pt needs ambulating, but if suffering from orthostatic hypotension.
what can the CNA and nurse do?
-CNA can ambulate the pt
-nurse can assess for orthostatic hypotension
prioritizing care: case study: what to prioritize?
-BP 145/92
-RR 24
-Temp. 104.2º
-HR 102
address situation that is most dire at the time
-in this case: temp. (104.2º)
normal/average vital signs
-BP: 120/80
-RR: 12-20
-Temp.: 97-99º F (36.1-37.2º C)
-HR: 60-100 bpm
,components of subjective data assessment
-pt feelings and statements about health
-data that cannot be directly observed
*performed during interview portion of assessment
components of objective data assessment
-observable and measurable data
-can be directly observed through sight/hearing/touch/smell
*performed during physical assessment portion of assessment
components of therapeutic communication (PHETS)
-positive regard: assumption that pt is worth dignity; avoids any unnecessary labeling
-honesty: open, direct, sincere
-empathy: ability to look at things from a different perspective
-trust: demonstrate ability to rely on nurses without doubt/question/judgement
-self-awareness/self-reflection: being aware of one's bias; taking responsibility for one's
actions
examples of non-therapeutic responses
-rescue feelings
-false reassurance: "everything will be okay-"
-giving advice: "i think you should-"
-changing the subject: "well look at this-"
-being moralistic: "you should-"
,-nonprofessional involvement: "check out my business-"
communication: opening remarks
general statements based on observations/assessments
-e.g., "where would you like to begin?", "you seem to be feeling better today"
communication: reflection
identifying main emotional themes and deflecting back to pt
-e.g., "what do you think you should do?", "you do not like the way the medicine
tastes?"
communication: focusing
goal-directed questions to help pt focus on key concerns
-e.g., "tell me a little about your children", "give me an example of what you mean"
communication: giving information
sharing with pt relevant information for their well-being
-e.g., "i'm in here today for-", "we could talk about relevant strategies to-"
communication: silence
allow time for a pause; permits nurse and pt to think/reflect
-e.g., "take your time", [don't speak] (with children)
transmission-based precautions: airborne: equipment
-private AIIR; negative pressure
-respirator for nurse
-mask worn by pt outside of room
transmission-based precautions: airborne: disease examples
via small-particle droplets
, -measles, TB, varicella (chicken pox, herpes zoster, shingles)
*think "MTV"
transmission-based precautions: droplet: equipment
-private room or with pt of same disease
-mask within 3 feet of pt
-mask worn by pt outside of room
transmission-based precautions: droplet: disease examples
via large droplets by sneezing/coughing/talking
-influenza
-diphtheria
-rubella
-pertussis
-common resp. viruses
transmission-based precautions: contact: equipment
-private room or with pt of same disease
-gloves at all times; change when moving from soiled contact to cleaner
-hand hygiene immediately after glove/gown removal
-daily cleaning of area
-pt-dedicated equipment
-terminal disinfection charge at end
transmission-based precautions: contact: disease examples
multi-drug-resistant organisms; infectious diarrhea
-C. difficile
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
delegation: nurses cannot delegate to whom and which actions?
-LPNs, CNAs, other ancillaries (misc.)
-anything that requires an assessment/significant procedure
delegation: pt needs ambulating, but if suffering from orthostatic hypotension.
what can the CNA and nurse do?
-CNA can ambulate the pt
-nurse can assess for orthostatic hypotension
prioritizing care: case study: what to prioritize?
-BP 145/92
-RR 24
-Temp. 104.2º
-HR 102
address situation that is most dire at the time
-in this case: temp. (104.2º)
normal/average vital signs
-BP: 120/80
-RR: 12-20
-Temp.: 97-99º F (36.1-37.2º C)
-HR: 60-100 bpm
,components of subjective data assessment
-pt feelings and statements about health
-data that cannot be directly observed
*performed during interview portion of assessment
components of objective data assessment
-observable and measurable data
-can be directly observed through sight/hearing/touch/smell
*performed during physical assessment portion of assessment
components of therapeutic communication (PHETS)
-positive regard: assumption that pt is worth dignity; avoids any unnecessary labeling
-honesty: open, direct, sincere
-empathy: ability to look at things from a different perspective
-trust: demonstrate ability to rely on nurses without doubt/question/judgement
-self-awareness/self-reflection: being aware of one's bias; taking responsibility for one's
actions
examples of non-therapeutic responses
-rescue feelings
-false reassurance: "everything will be okay-"
-giving advice: "i think you should-"
-changing the subject: "well look at this-"
-being moralistic: "you should-"
,-nonprofessional involvement: "check out my business-"
communication: opening remarks
general statements based on observations/assessments
-e.g., "where would you like to begin?", "you seem to be feeling better today"
communication: reflection
identifying main emotional themes and deflecting back to pt
-e.g., "what do you think you should do?", "you do not like the way the medicine
tastes?"
communication: focusing
goal-directed questions to help pt focus on key concerns
-e.g., "tell me a little about your children", "give me an example of what you mean"
communication: giving information
sharing with pt relevant information for their well-being
-e.g., "i'm in here today for-", "we could talk about relevant strategies to-"
communication: silence
allow time for a pause; permits nurse and pt to think/reflect
-e.g., "take your time", [don't speak] (with children)
transmission-based precautions: airborne: equipment
-private AIIR; negative pressure
-respirator for nurse
-mask worn by pt outside of room
transmission-based precautions: airborne: disease examples
via small-particle droplets
, -measles, TB, varicella (chicken pox, herpes zoster, shingles)
*think "MTV"
transmission-based precautions: droplet: equipment
-private room or with pt of same disease
-mask within 3 feet of pt
-mask worn by pt outside of room
transmission-based precautions: droplet: disease examples
via large droplets by sneezing/coughing/talking
-influenza
-diphtheria
-rubella
-pertussis
-common resp. viruses
transmission-based precautions: contact: equipment
-private room or with pt of same disease
-gloves at all times; change when moving from soiled contact to cleaner
-hand hygiene immediately after glove/gown removal
-daily cleaning of area
-pt-dedicated equipment
-terminal disinfection charge at end
transmission-based precautions: contact: disease examples
multi-drug-resistant organisms; infectious diarrhea
-C. difficile
