NUR 215 ATI PDF

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NUR 215 ATI: Nurse's Touch: Professional Communication Module: Therapeutic Communication Active Listening 1. S: sit facing client 2. O: Observe Open Posture 3. L: Lean toward Client 4. E: Establish, Maintain eye contact 5. R: Relax Silence 1. Let’s clients organize thoughts, consider topics, think through points 2. Demonstrates patience and willingness to wait for client Provide Leads 1. Help client verbalize, steers conversation and indicated interests 2. Develops trust and repor Focused Questions 1. Clarify message 2. Collect data 3. Encourage feedback 4. Confirm clients’ ideas and beliefs Open ended Questions 1. Client takes lead 2. Client explores ideas, feelings 3. Expands conversations Exploration 1. Useful when client remains vague, superficial Clarifying 1. Facilitates understanding, restates basic message or acknowledge misunderstanding 2. Confirms mutual interpretation of message Paraphrasing/Restating Clarifying Concerns 1. Restates concerns to make sure message was interpreted correctly Reflection 1. Validates communication 2. Directs Questions, feelings back to client 3. Conveys what you understand Touch 1. Conveys caring, sympathy Offering Presence 1. Shows interest, provides comfort 2. Unconditional, free from demands Reflecting Questions back to the Clients Refocusing Summarizing

Refocusing the Discussion Nontherapeutic Communication 1. Closed ended questions 2. Why questions 3. Giving common advice/ personal opinion 4. Automatic response 5. False reassurance 6. Arguing/disagreeing 7. Giving false reassurance 8. Defensive responses 9. Minimizing clients’ feelings 10. Changing subject 11. Focusing on self, rather than client 12. Failing to remain client-centered Setting Boundaries 1. Using self-disclosure appropriately 2. Developing rapport with a client 3. Building trust 4. Using therapeutic techniques appropriately 5. Respect for clients’ beliefs and values 6. Demonstrating empathy a. Perceive, understand meaning of client's thoughts

7. Empathy vs sympathy 8. Caring attitude 9. Using humor when appropriate 10. Maintain confidentiality Post test 1. A nurse is caring for a client who states, "I would like to go out on a date with you." Which of the following is an appropriate response by the nurse? a. Inform the client that is an inappropriate statement. 2. A client presents at a community shelter after surviving the destruction of her home by a fire. Which of the following questions should the nurse ask to determine the client's ability to cope? a. "Who do you talk to when you have the feeling of being overwhelmed?" 3. A nurse is caring for an older client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life." Which of the following responses is appropriate? a. "This must be a difficult time for you." 4. A nurse is caring for a client who has depression. The client states, "Things are always going to be bad for me. I wish I could just go to sleep and forget about all my problems." Which of the following is an appropriate response by the nurse? a. "It seems as though you're expressing feelings of hopelessness."

5. A nurse is implementing therapeutic communication techniques with a client in an outpatient mental health facility. Which of the following actions allows the client an opportunity to organize thoughts, consider a topic, or think through a point? a. Use of silence 6. Which of the following is an example of the nurse using clarification to facilitate communication? (Select all that apply) a. "What would you say is the main point of what you are saying?" "I am not sure I am following you." 7. A nurse is admitting a client who has schizophrenia. The client states, "The FBI has bugged the phone and is monitoring my calls." Which of the following responses by the nurse is appropriate? a. "I understand that you believe this is true, and it must be very frightening for you." 8. Which of the following are examples of nurse using non therapeutic communication techniques? (Select all that apply.) a. Focusing on the nurse rather than the client is correct. , Changing the subject., Making value judgments., Giving advice. 9. Which of the following statements is an example of a therapeutic communication technique? a. "Tell me about your relationship with your wife." 10. Which of the following is an example of closed-ended questioning? (Select all that apply.) a. "Are you going to group therapy tomorrow?" b. "How long have you been depressed?" c. "Do you not want to take your medication?" d. "Do you have a family history of depression?"

Nurse's Touch: Becoming a Professional Nurse Module: Profession and Professional Identity Characteristics of a Professional 1. 2. 3. 4. 5.

Technical competence Interpersonal skills Work ethic Moral standards Concern for the welfare of others

ANA Code of Ethics for Nurses - Part 2   

Non-negotiable ethical standard Commitment to society Guidance regarding legal, ethical responsibilities

Outcomes Defined by NAPNES   

Professional behaviors Communication Assessment

  

Planning Caring interventions Managing

Post test

1. Which of the following resources provides guidance on the legal responsibilities of nurses to clients and society? a. Code of Ethics for Nurses 2. Which of the following are characteristics exhibited by a professional? a. Technical competence, concern for others, and interpersonal skills. 3. Which profession organizations provides specific guidance to licensed practical nurses? a. NAPNES 4. A nurse who displays a selfless concern for others is exhibiting what? a. altruism 5. what organization is responsible for authorizing the practice of nursing? a. state board of nursing 6. Which of the following provisions in the ANA code of ethics for nurses with interpretive statements describes the duty of nurses to develop collaborative solutions to broad health issues? a. Provision 8. Nurse has responsibility to be aware of and collaborative with other health professionals and community members in order to address and intervene in broad health concerns, such as hunger, pollution, and lack of access to health care. 7. Which of the following professional associations advances the nursing profession by creating high standards for nursing practice? a. The American Nurses Association (ANA) 8. Which of the following is one of the foundations of the Nursing profession? a. Professional values 9. what are the formal expectations of the nursing profession first learned? a. through classroom and clinical experiences in nursing school 10. Which of the following tenets in the ANA resource Scope and Standards of Practice describes the use of evidence-based knowledge in the provision of nursing care? a. Tenet 4

NurseLogic 2.0 Module: Priority Setting Frameworks 1. Priority Setting Frameworks Aid Decision Making 2. Maslow’s Hierarchy of Needs : Priority bottom to top

3. ABC’s : priority of initial assessment i. 1. Airway 2. Breathing 3. Circulation 4. Safety and Risk Reduction i. Assigns priority to the factor or situation posing the greatest: ii. Safety risk to the client iii. Greatest risk to the client's physical or psychological well-being iv. Multiple risks may require another priority setting framework to identify risk posing greatest threat. 5. Risk Reduction i. Types of risk i. External – Risks in client’s environment 

Complete risk assessment

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Integrate interventions Assistive devices

ii. Internal – Laboratory values and vital signs outside expected

reference range 

ABC combined with safety and risk reduction

ii. Maslow’s Hierarchy or ABC priority setting framework to determine

alteration posing greatest risk iii. Risk posing immediate threat usually becomes the highest priority

6. Least restrictive interventions i. ii. iii. iv. v.

7. Least i. ii. iii.

Close and constant supervision Assessing medications Bed and wheelchair alarms Mattress on floor next to client's bed Physical restraints used when client or staff safety is at risk invasive interventions Incontinent clients on bladder routine Incentive spirometers/inhalation treatments Oral or rectal administration of medications

8. Survival Potential i. 1. Emergent: Class 1- life threatening injuries, immediate treatment= chance of survival ii. 2. Urgent: Class II- Serious and extensive injuries, have chance of survival with delayed treatment iii. 3. Nonurgent: Class III: less serious and less extensive, do not pose treat to life iv. 4. Expectant: Class IV: injuries not compatible for life, given comfort measures 9. Acute Vs Chronic i. Acute is higher priority 10. Urgent Vs Nonurgent i. Urgent is higher priority 11. Unstable Vs Stable i. Unstable is higher priority Post test: Beginner 1. A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider? a. Digoxin 3.0ng/mL 2. A nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? a. Move the client to room near the nurses station 3. A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? a. Place the infant in a supine position when sleeping

4. A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? a. Obtain an ECG 5. A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? a. Place the client in the orthopneic position 6. A nurse is collecting data on four clients. Which of the following findings is the most urgent? a. Warmth and pain in the calf 7. A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? a. Assist client to cough effectively 8. A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? a. Determine the mobility status of each patient 9. A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention? a. Platelets 95,000 mm3 10. A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? a. Check on the client 11. A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action? a. Maintaining a patent airway 12. newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster? a. Immediate 13. A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? a. A client who is having a nosebleed associated with hypertension 14. A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit? a. Check the heart rate and blood pressure 15. A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? a. Check the leg for warmth and edema 16. A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? a. Hypoxic 17. A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? a. Diarrhea

18. A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? a. A client who had abdominal surgery 10 days ago and reports feeling his incision pop 19. A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? a. Creating meaningful social relationships 20. A nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? a. Have the client position the head with the chin down while swallowing...