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104 Cards in this Set

  • Front
  • Back
How frequently should the nurse take vital signs?
As often as needed regardless of doctor's orders that may allow for longer periods.
What is the term the nurse would document of a client who just had a cold or hot liquid?
List the pulse sites and locations...
Apical pulse: Left chest area (From sternum down 5 intercostals, over to the left to center of clavical line.) Use stethoscope.

Radial pulse: Use tips of first two fingers over groove along radial or thumb side of clients inner wrist.
List 4 elements for assessing the pulse...
1) assess for risk factors for pulse alterations
2) assess for signs and symptoms of altered stroke volume and cardiac output such as dyspnea, fatigue, chest pain, orthopnea, cyncope, palpitations, jugular venous distention, edema peripherals, blue/pale skin
3) assess for signs and symptoms of peripheral vascular disease such as pale, cool, extremities (thin, shiny skin w/decreased hair growth), thickened nails
4) Assess for factors that influence pulse rate and rhythm: age, exercise, position changes, fluid balance, medications, temperature, sympathetic stimulation.
What is it called when you encourage a person to talk by waiting for answers? What happens as a result of this communication? Is it Therapeutic Communication or Non?
Using silence. Use this to give a client time to sort out a difficult feelings or decisions or provide time to figure you out and you to figure client out. Method demonstrates respect show understanding, lays foundation for openness. This is Therapeutic Communication.
How would you define the statement: "I wouldn't worry about that." What happens as a result? Is this a THERAPEUTIC Communication Technique or NON?
This would be an example of Automatic response. This is a form of stereotyping, does not show interest in client concern, develops withholding info. This would be NON THERAPEUTIC Communication Technique
How would you define the statement: "I wouldn't even consider buying a motorcycle." What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
This would be an example of Approval/Disapproval. The consequence of this is a judgement statement. This circumvents client's right to make own determinations. Just because you are told a decision is not invitation to judge, usually it is to open dialog regarding feelings. If communicate this way client will stop sharing. This would be NON THERAPEUTIC Communication Technique.
How would you define sitting facing the client and letting the client take the lead. What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
This would be an example of Active listening. Interest is demonstrated. This would be THERAPEUTIC Communication Technique. To implement this use SOLE-R Sit facing, Observe, Lean in; Eye contact; Relax
How would you define the expression: "Tell me something about meal planning regarding your low fat diet?" What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
This would be an example of: Relevant questions. The result of this leads to openness, candor, and more facts for therapeutic decisions. This would be THERAPEUTIC Communication Technique. 3 Types: Open-ended, Focused, Closed-ended. In addition, the use of statements like "tell me about it" is good to make it less of a question/answer routine and more of an active dialog.
How would you define the statement: "Everything will be fine." Is this a THERAPEUTIC Communication Technique or NON?
This would be an example of False reassurance. This would be NON THERAPEUTIC Communication Technique
List all vital signs normal adults limits...
Pain (subjective),
Temperature (96.6-100.4 degrees F, 36-38 C/tympanic-oral/ 99.5 F 37.5 C rectal/97.7 F 36.5 C/axillary),
Pulse (Heart Rate) 60-100/bpm,
Respirations 12-20/bpm (breaths/min),
Blood Pressure >120/80,
Pulse Pressure 30-50 mmHg
What elements define a professional relationship?
Client centered agenda at the core:
1) Introduce yourself
2) Providing privacy/confidentiality
3) Attending to care needs
4) Active listening
5) Observing professional boundaries
6) Goal directed
7) Promoting positive change and growth
What are the phases of a therapeutic relationship?`
1) Pre-interaction phase
2) Orientation phase
3) Working phase
4) Termination phase
What is involved with pre-interaction therapeutic relationship and what is the goal?
Answer needed
Define the elements of the orientation phase of the therapeutic relationship...
Answer needed
What is involved with the working phase of the therapeutic relationship?
Answer needed
Define the termination phase of the therapeutic relationship and what is involved...
Answer needed
What constitutes the verbal form communication and how is meaning delivered via this approach?
Oral and written communication. Oral uses pace, tone, clear/brief, and volume to deliver meaning. Written is clear/brief/concise and organized.
What constitutes the non-verbal form communication and how is meaning delivered via this approach?
Eye contact. body language (actions and cues). Gestures, posture, space and distance, touch all deliver meaning.
When discussing nursing process and communication, in the assessment process what factors influence effective communication?
1) Psychophysiological which includes: cognitive; sensory; physical; psychological (levels of anxiety a) mild b) moderate c) severe 4) panic)
2) Relational
3) Situational
4) Environmental
5) Cultural
In the nursing process and communication, explain the psychophysiological elements that affect assessment...
Psychophysiological is ...
The cognitive part that could influence assessment are the emotional state of the client.
The sensory of a client such as hearing loss could impact assessment.
Physical state such as a broken jaw, shortness of breath, tracheotomy any of which could impede assessment.
The psychological state such as anxiety levels could impact assessment. Whereas mild anxiety can improve alertness and increase assessment success, moderate, severe, and panic states would limit assessment.
Does systolic reflect contraction or relaxation of the ventricle?
Contraction of ventricle
Does diastolic reflect contraction or relaxation of the ventricle?
Relaxation of the ventricle
What is the difference between systolic and diastolic called?
Pulse pressure
Protecting client from aspiration - What are the 12 techniques?
1. Determine their ability to swallow
2. Assess their cough
3. Determine if have gag reflex
4. Prepare oral meds in easiest way to swallow
5. Self-administer if possible
6. Place meds on strongest side of mouth
7. Give meds 1 at a time allowing swallowing of each
8. Use thicker fluids
9. Avoid straws
10. Have client hold cup & drink if possible
11. Time meds.with mealtimes or when client well rested & awake if possible
12. Give meds in different route if risk of aspiration is severe
What kind of factors influence blood pressure measurements?
1) age
2) stress
3) ethnicity
4) gender
5) daily variation
6) medications
7) activity and weight
8) smoking
List 4 errors that can occur when taking a blood pressure?
(see table 32-10)
1) wrong cuff size
2) deflating cuff too fast/slow
3) arm not even with heart
4) stethoscope pressure improper or placement wrong
What does the pulse oximetry measure?
Oxygen saturation, normal 95 to 100%, less than 90% bad. This is the amount of hemoglobin that is bound with oxygen in the arteries. Indicator of how well someone is breathing.
List 4 factors that may interfere with the accuracy of the pulse oximetry assessment...
(see p533 box 32-12)
Interference with light transmission:
1) smoking
2) jaundice
3) nail polish/artificial nails
4) outside light sources
5) dark skin
6) client motion
7) intravascular dyes

Interference with arterial pulsations:
4) atherosclerosis
6) hypothermia
7) vasoconstrictors
8) low cardiac output and hypotension
9) peripheral edema
10) too tight attachment of probe
List the nurses responsibility for monitoring vital signs...
answer needed
What is the two-step method for taking blood pressure?
Step 1: find radial pulse
Step 2: inflate BP cuff until no longer feel pulse
Step 3: raise up 30 mmHg above
Step 4: release as normal to get systolic and diastolic
What are barriers to effective communication?
Speech impairment
Hearing impairment
Vision impairment
Cognitive impairment
Environmental distractions or disruptions

Personal perceptions
Personal prejudices
Fear of person, environment, subject
Lack of interest

Verbal Barriers (Errors in message delivered by nurse):
Giving orders, advice
Threatening client
Criticizing, blaming, shaming
Overly praising
Too much or too little information
How can you improve communication with older adults?
Get the clients attention before speaking?
Check for hearing aids and glasses
Introduce yourself
Be sure your face is visible to the client, and use facial expressions and gestures
Choose a quiet, well-lit environment with minimal distractions
Do not shout, it distorts sounds. Speak clearly at a moderate speed
Allow time for the client to respond. Do not assume the client is being uncooperative if does not reply or takes a long time to reply
Give client a chance to ask questions
Do not talk to the client like a child. Use words appropriate to the client's developmental level
List the 3 elements for assessing the respiratory rate...
(see 530 box 32-3)

1) identify risk factors for respiratory alterations (fever, pain, anxiety, chest wall/muscle disease, constrictive chest/abdominal dressings, gastric distention, COPD, trauma to chest wall/lung tissue, chest tube, respiratory infection, pulmonary edema/emboli, head injury brain stem, anemia);
2) assess for signs and symptoms of respiratory alterations (blue nail beds, lips, mucous membranes and skin; restlessness, irritability, confusion, reduced level of consciousness, pain during inhaling; difficult breathing, breathing problems, sputum thick frothy, blood-tinged)
3) Assess pertinent lab values
H/R > 100 bpm
H/R < 60 bpm
pulse deficit
Difference between apical pulse & radial pulse
The stimulation for contraction of the heart. Starts in SA node.
stroke volume
Amount of blood pumped from ventricle with each heart beat
Cardiac output
amount of blood ventricle pumps out in 1 minute
normal breathing. Respirations 12-20 breaths per minute
Abnormal respiratory pattern with alternating periods of apnea & deep rapid breathing
abnormal condition in which the client must sit to breathe
difficulty in breathing -- labored respirations (increased effort to breathe)
absence of breathing. Absence of spontaneous respirations
What does normal blood pressure mean?
120/80 is the average normal adult blood pressure force that is exerted on the walls of an artery by the pulsing blood under pressure from the heart.
Systolic pressure: the peak of maximum pressure when ejection occurs. Diastolic presssure: the minimal pressure exerted against the arterial walls at all times.
What are the 3 relationships in professional communication?
Collegial (co-workers, student-faculty)
Therapeutic (nurse-patient relationship; focus on client)
What are the 7 elementsof a professional nurse-client relationship?
1. Introduce self
2. Privacy (confidentiality)
3. Attending to basic care needs
4. Active listening
5. Professional boundaries
6. Goal-directed (achieving their goals)
7. Promote positive change & growth
What are 4 phases of a therapeutic (helping) relationship?
1. Pre-interaction phase
2. Orientation phase
3. Working phase
4. termination phase
(box 24-4, pg. 347)
Pre-interaction phase
Before meeting the client:
Gather info from charts, history, info from other caregivers with info re: client, anticipate health concerns or issues that arise.
Select a location & setting (private, comfortable) for meeting with client.
Plan enough time for initial interaction.
Orientation phase
When nurse & client meet to get to know one another.
A statement of relevance telling client who you are & your purpose. "I'm ____ & I'm here to do __________."
Expect client to test nurses' competence & commitment.
assess client's health status
Assess their physical needs (anxiety levels)
Begin to assess & form judgment re: client's messages & behaviors.
Working phase
When nurse & client work together to solve problems & accomplish goals.
Encourage/help client to express feelings re: their health.
Provide info needed to understand & change behavior
Encourage/help client set goals
Take action to help client meet set goals
Use appropriate self-disclosure & confrontation.
Termination phase
Discharge or end of shift
Remind client that termination is near
Evaluate goal achievement with client
Reminisce about relationship with client.
Separate from client by turning responsibility over to them.
Achieve smooth transition for client to other caregivers as needed
Verbal communication
Spoken or written words:
pace/speed of conversation
Non-verbal communication
self expression:
Personal appearance
posture & gait (way of walking)
facial expression
eye contact
sounds (sighs, moans, sobs
territorality & personal space
What are the PHYSICAL Non-verbal barriers (of client or nurse) in effective communication?
table 5.4, page 90
Speech impairment
Hearing impairment
Vision impairment
Cognitive impairment
Environmental distractions or disruptions
What are the Psychological barriers that influence Effective Communication: Non-verbal barriers of client or nurse
Personal perceptions
Personal prejudices
Fear of person/environment, subject
Lack of interest
(table 5.4, page 90
What are Verbal barriers from a nurse that that influence effective communication?
Giving orders, advice
Threatening client
Critcizing, blaming, shaming
Overly praising
too much/too little information
(table 5.4, page 90)
What are the barriers for clients with special needs?
Psychophysiological Barriers:
Cognitive (Alzheimers, language barrier)
Sensory (hearing loss, espressive aphasia (can't talk, but can hear),
Physical (ec:breathing tupe, respiratory problems, dentures)
Psychological (Levels of anxiety)
What are the levels of anxiety in emotional status?
What are the 5 contextual factors influencing communication in the Assessment phase?
Psychophysiological Context
Relational context
Situational context
Environmental context
Cultural context
(box 24-6, pg. 349)
Relational context?
The nature of the relationship
(eg: social, helping or working relationship; level of trust between participants; level of caring expressed; level of self-disclosure between participants; shared history of participants; balance of power & control
(box 24-6, pg. 349)
Situational context?
The reason for the communication
(eg: info exchange, goal exchange, problem resolution, expression of feelings)
box 24-6, pg. 349)
Psychophysiological Context?
The internal factors influencing communication:
physiological status (eg: pain, hunger, weakness, dyspnea)
Emotional status: (eg:, anxiety, anger, hopelessness, euphoria)
Growth & Development status: (eg: age, developmental tasks)
Unmet needs: (eg: safety/security, love/belonging)
Attitudes, values & beliefs (eg: meaning of illness experience)
Perceptions & personality (eg: optimist/pessimist, introvert/extrovert
Self-concept & self-esteem (eg: positive/negative)
(box 24-6, pg. 349)
Environmental Context?
The physical surroundings where the communication takes place:
(level of: privacy, noise, comfort & safety, distraction)
Cultural context?
The sociocultural elements that affect the interaction
(educational levels of participants; language & self-expression patterns; customs & expectations)
(box 24-6, page 349)
Define culture
Dynamic adaptation
A learned way of life that includes interrelated attitudes, morals, beliefs, values, ideals, knowledge, symbols, artifacts, customs, traditions & norms of a particular group that are transmitted intergenerationally; guide behavior & make life meaninfgul
Define ethnicity
A large group of people classified according to common national tribal, linguistic or cultural origin or background & who feel a sense of shared identity
Impact of lack of communication?
Can lead to delay in care & frustration level
2 Coping mechanisms in reaction to psychological stress
Exercise (body produces morphine which reduces stress & anxiety)

Ego-defense mechanism (spontaneous)??
What are the 7ego defense mechanisms used to protect one's self esteem?
Compensation (Making up for deficiency one aspect of self image & emphasizing an asset. Eg: a person who is a poor communicator relies on organizational skills)
Conversion (unconsciously repress emotion & transfer into symptoms: difficulty sleeping, loss of appetite)
Denial (eg: a person refuses to discuss or acknowledge a personal loss)
Displacement (transferring emotions by taking it out on the family)
Identification (assuming another's qualities, characteristics or actions)
Dissociation (sense of numbing & less awareness of their surroundings)
Regression (go back to being a child)
box 31-2, pg. 488
When are the defense mechanisms most often used?
In mild to moderate levels of anxiety
Planning & Collaboration
Goals & Outcomes -specific & measurable
Setting of priorities
Continuity of care - collaboration with other healthcare providers (eg: speech therapist, physician, etc)
Federal regulations
Protect the health of the public by ensuring that meds. are safe & effective.
State & local regulations of medication
State & local med laws must conform to federal legislations. States often have additional control, including control of substances not regulated by fed. govt.
Health care institution
Conform with state & Federal laws. Each hospital has its own policy
Nursing Practice Act
A statutory law. Is in every state. They describe & define the legal boundaries of nursing. Set up black box warning (eg Sleepy tea has valarian root)
Civil/common law
Torts, consent, abortion, nursing students liability
p 333
Classifications - 2 types
Pharmacologic action
Therapeutic use
Therapeutic use
answers why the person is getting the med
-classification: (eg: anticoagulant)
-usefulness: (eg: influence blood clotting)
Another word for "Pharmacological action"
Pharmacological action
Mechanism of action
-classification: (eg:vasodilator)
-mech. of action: (eg: dilates peripheral blood vessels).
Some drugs have several mech. of actions. Eg: aspirin has 4:
Alway below trade name & in lowercase letters
Trade name
Always on top & in capital letters
Site where administer drug
Movement of drug through body
Process of breaking down via liver
Excretion via kidneys
Side effect
Adverse effect
Drug having opposite effect; drug under-reacts on patient; unexpected
Side effect
not life threatening. Mild (eg:nausea,vomit) Sometimes a benefit
Adverse effect
more life threatening; potential to harm
Drug-Drug interactions
Systemic reaction. Life threatening!
How would you define the communication:"Why did you stop taking your medications?" What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
Asking for explanation. This type communication lends the sense of accusation, implies nurse is testing person although knows the answer. The word why can do this so better if question can be re-framed using another word. Leads to resentment and mistrust. This is NON Therapeutic.
How would you define the communication:"I noticed you are biting your nails." What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
Sharing observation is the technique. This is Therapeutic. It leads to starting conversations especially those clients that are withdrawn.
How would you define the communication:"During the past hour you and I have been discussing your post operative care." What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
Paraphrasing/Summarizing. This is Therapeutic. Used in 2 places: at the end of a segment of discussion used to highlight key points and allows for adding other info to them. Second used at the beginning of a new discussion which provides a basis of reminder of the previous discussion and shows that nurse has analyzed the previous dialog.
How would you define the communication:"Client: I would like to die. Nurse: Did you go to your Alcoholics Anonymous like we discussed? " What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
Changing the subject. This is NON Therapeutic. Rude, lacking empathy, blocks future dialog and leads to withholding and ruins trust.
How would you define the communication:"It must be very frustrating to have your surgery postponed." What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
Sharing empathy. This is Therapeutic. Provides basis for trust by not being judgmental and showing care. This is Therapeutic. Useful when client is scared, anxious, terrified, alienated, troubled, confused, having identity crisis.
How would you define the expression: "Would you tell me more about what you just said?" What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
need answer
need answerHow would you define the expression: "No one here is purposely ignoring your call light." What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
need answer
How would you define the expression: "You mentioned your are having a problem with following through with your rehabilitation schedule." What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
need answer
How would you define the expression: "I think you should do something for yourself for a change." What is the result of this communication? Is this a THERAPEUTIC Communication Technique or NON?
need answer