20220422071724_626256846a33d_nur2356__multidimensional_care_i__1_.pdf

Multidimensional Care I Questions With Answers 2023 A+ E. Biofeedback A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, time, and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment.

Multidimensional Care I Questions With Answers 2023 A+ What must be completed before performing first aid? Primary survey Name the nursing interventions for BLEEDING Apply pressure to wound site (home) DO NOT remove impaling objects, stabilize the object (home) IV volume replacement with blood or volume replacement (hospital) The acronym RICE is used to manage sprains, what do the letters stand for? R - Refrain from weight bearing (also known as "rest") I - apply ice to decrease inflammation C - Apply a compression dressing to minimalize swelling E - Elevate the affected limb Name the nursing interventions for BURNS - remove the agent - smooth any flames present - cover the client and maintain NPO status - elevate the extremities

Multidimensional Care I Questions With Answers 2023 A+ Name the nursing interventions of INFANT BURNS - test the temperature of formula and bath water - Place pots on back burner and turn handle away from the front of the stove - supervise the use of faucets - cover electrical outlets - Apply sunblock SPF 30 or higher Name the nursing interventions of INFANT MOTOR VEHICLE INJURY - rear-facing car seat - car seat with 5-point harness - forward facing seat after the age of 2 or when they meet the height/weight requirements Name the nursing interventions of PRESCHOOLERS/SCHOOL AGE CHILDREN AND FIREARMS - keep firearms unloaded, locked up, and out of reach - teach to never touch a gun or stay at a friend's house where a gun is accessible - store bullets in a different location from guns

Multidimensional Care I Questions With Answers 2023 A+ What are the dietary considerations for Mormons? - avoid tobacco, alcohol, caffeine Name the nursing interventions for CULTURALLY RESPONSIVE CARE - provide language assistance - informing clients of language services verbally and in writing - providing competent, trained interpreters - giving the client learning materials A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room. B. Determine client understanding several times during the conversation. C. Look at the interpreter when asking the family questions. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk. A nurse is caring for two clients who report following the same religion. Which of the

Multidimensional Care I Questions With Answers 2023 A+ A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding? A. "I will set my water heater at 130° F." B. "Once my baby can sit up, they should be safe in the bathtub." C. "I will place my baby on their stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib." Name some benefits of bathing patients - cleanse the body - stimulate circulation - provide relaxation - enhance healing

Multidimensional Care I Questions With Answers 2023 A+ environments, drinking alcohol) - avoid activities that could cause injury to the client should they fall asleep (heights, driving) - take naps - Take prescribed simulants Factors that interfere with sleep - Physiologic disorders: can require more sleep or disrupt sleep (sleep apnea, nocturia)

Multidimensional Care I Questions With Answers 2023 A+ A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them. A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply.) A. "Have your working hours changed recently?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?"

Multidimensional Care I Questions With Answers 2023 A+ E. "Tell me about any personal stress you are experiencing." A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.) A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take an afternoon nap. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime. A nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first?

Multidimensional Care I Questions With Answers 2023 A+ A. Rub the client's back for 15 min before bedtime. B. Offer the client warm milk and crackers at 2100. C. Allow the client to take a bath in the evening. D. Ask the provider for a sleeping medication. A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day." Name some nursing actions for immobility - turn patient every 2 hours - ROM exercises - Check for sores (redness)

Multidimensional Care I Questions With Answers 2023 A+ - Pad bony prominences A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

Multidimensional Care I Questions With Answers 2023 A+ When you see indications of skin breakdown, what is your next action? Elevate and use corrective devices (pillows, foot boots, trochanter rolls, splints, wedge pillows) What does PQRST stand for? Palliative/Provoking Quality Region/Radiation Severity Timing What are some nonverbal signs of pain? - grimacing - moaning - flinching - guarding - decreased attention span - Restlessness, pacing

Multidimensional Care I Questions With Answers 2023 A+ What do vital signs look like during acute pain? - BP increased - Pulse increased - RR increased Before nurses give a pain medication, what should they assess? - Drug interactions - Allergies - Vital signs - Side effects What are common side effects to pain medications? - Low BP - Low HR - Sedation - Respiratory depression

Multidimensional Care I Questions With Answers 2023 A+ - Orthostatic hypotension - Urinary retention - Nausea/vomiting - Constipation After administering pain medication, what is the follow up? - reevaluate pain level - If given orally, follow up q 1 hour - If given IV, follow up q 15 min - check vital signs! What are the complications related to pain management? - Anxiety - Fear -depression - Slower healing - Slower recovery

Multidimensional Care I Questions With Answers 2023 A+ Cutaneous pain - superficial pain usually involving the skin or subcutaneous tissue Visceral pain - pain in internal organs (the stomach or intestines). It can cause referred pain in other body locations separate from the stimulus Phantom pain* A type of neuropathic pain - sensation of pain without demonstrable physiologic or pathologic substance; commonly observed after the amputation of a limb Neuropathic pain - Arises from abnormal or damaged pain nerves. It includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy "Pins and needles" - New pain vs. old pain (> 6 months) - Chronic pain effects ADLs - What's the difference between acute and chronic pain?

Multidimensional Care I Questions With Answers 2023 A+ Idiopathic pain - Chronic pain without identifiable physical or psychological cause - Cognitive behavioral measures: changing the way a client perceives pain, and physical approaches to improve comfort - Cutaneous stimulation: cold, heat, therapeutic touch, massage, TENS - Distraction: ambulation, deep breathing, visitors, television, games, prayer, music - Relaxation: yoga, meditation, progressive muscle relaxation - Imagery: pleasant thought, ability to concentrate - Acupuncture/acupressure - Elevation of edematous extremities - Non-Pharmacological Pain Management strategies What does Aloe promote? Wound healing Anti-inflammatory, calming - What does chamomile promote? Enhances immunity - What does echinacea promote?

Multidimensional Care I Questions With Answers 2023 A+ Inhibits platelet aggregation (clumping) - What does garlic promote? Antiemetic (prevents N/V) - What does ginger promote? Improves memory - What does ginko biloba promote? Increases physical endurance - What does ginseng promote? Promotes sleep, reduces anxiety - What does valerian promote? Complementary therapy - A variety of therapeutic or preventive health care practices, such as homeopathy, naturopathy, chiropractic, and herbal medicine, that do not follow generally accepted medical methods and may not have a scientific explanation for their effectiveness. Used in addition to or to enhance conventional medical care

Multidimensional Care I Questions With Answers 2023 A+ Alternative therapy - includes herbs and other "natural" products as often found in ancient records; these products are not controlled or tested by the U.S. Food and Drug Administration and are considered to be dietary supplements; however, they are often the basis for discovery of an active ingredient that is later developed into a regulated medication Treatment approaches that are used in addition to or to enhance conventional medical care A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? A. Chamomile B. Ginseng C. Ginger D. Echinacea A nurse is caring for a client scheduled for abdominal surgery. The client reports being

Multidimensional Care I Questions With Answers 2023 A+ worried. Which of the following actions should the nurse take? A. Offer information on a relaxation technique and ask the client if they are interested in trying it. B. Request a social worker see the client to discuss meditation. C. Attempt to use biofeedback techniques with the client. D. Tell the client many people feel the same way before surgery and to think of something else. UTI patient education - wipe front to back - pee before and after sex - cleanse beneath foreskin - provide catheter care regularly (nurses) A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

Multidimensional Care I Questions With Answers 2023 A+ A. Check to see whether the catheter is patent. B. Reassure the client that it is not possible for them to urinate. C. Recatheterize the bladder with a larger-gauge catheter. D. Collect a urine specimen for analysis. culture - the totality of socially trans-mitted behavior patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristics of a population of people that guides their worldview and decision making **can be taught** Ethnicity - groups whose members share a common social and cultural heritage that is passed down from generation to generation. It is also similar to subculture in that the members of an ethnic group have some characteristics in common (e.g., race, ancestry, physical characteristics, geographic region, lifestyle, religion) that are not shared or understood by outsiders. Stereotype - is a widely held but oversimplified and unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects.

Multidimensional Care I Questions With Answers 2023 A+ Language barriers (to communication) - Not only language itself, but different definitions for the same thing Healthcare jargon Street talk, slang, jargon Lack of knowledge Emotional responses What are some health and illness beliefs among Native Americans? Health means living in harmony with nature. Surviving under difficult circumstances Body treated with respect Illness is associated with disharmony or evil spirits. Illness is caused by an action that should not have been performed

Multidimensional Care I Questions With Answers 2023 A+ What are some health and illness beliefs among Asian/Pacific Islander? Health is a state of physical and spiritual harmony. Illness is disharmony of basic principles: yin and yang What are some health and illness beliefs among Black or African American? Health is harmony with nature (mind, body, and spirit). Illness is the result of disharmony or failure to eat proper foods. What are some health and illness beliefs among Hispanic or Latino? Health is good luck or a reward for good behavior, a gift from God. Illness is body imbalance (hot or cold, wet or dry) or punishment What are some health and illness beliefs among White or European American? Health is a state of physical and emotional well-being. Illness is contagion or contamination that is hereditary, psychosomatic, or supernatural What are some Dominant Values among White or European American? Independence Individuality

Multidimensional Care I Questions With Answers 2023 A+ Wealth Comfort Cleanliness Achievement Youth and beauty What are some Dominant Values among Hispanic or Latino? Extended family Group emphasis Fatalistic Faith and spirituality What are some Dominant Values among Native Americans? Bonding to family or group Acceptance of nature (Mother Earth) Tradition Sharing Belief in a spiritual power

Multidimensional Care I Questions With Answers 2023 A+ Respect of elders What are some Dominant Values among Asian and Pacific Islander? Extended family Respect for elders Group orientation Subordination to authority Conformity Self-respect and self-control Love of the land What are some Dominant values among Black and African Americans? Family bonding Matrifocal Spiritual orientation Present-oriented Name some enhancing nonverbal cues Direct eye contact

Multidimensional Care I Questions With Answers 2023 A+ Concerned facial expression Leaning forward Personal space Professional appearance Sitting down to talk Touch Stages of Therapeutic Communication Pre-interaction Orientation Working Termination Pre-interaction phase - Name this stage of Therapeutic Communication: - Even before you meet the client, this phase is established.

Multidimensional Care I Questions With Answers 2023 A+ - You begin establishing communication by gathering information about the client, but the nurse and client do not have direct communication. Orientation phase - Name this stage of Therapeutic Communication: - The phase begins when you meet the client and introduce yourself and your role in the relationship. - The goal of this phase is to establish rapport and trust through the use of verbal and nonverbal communication. Working phase - Name this stage of Therapeutic Communication: - The bulk of therapeutic communication occurs in this phase - During this phase, the nurse communicates caring, the patient expresses thoughts and feelings, mutual respect is maintained, and honest verbal and nonverbal expression occurs. Termination phase - Name this stage of Therapeutic Communication:

Multidimensional Care I Questions With Answers 2023 A+ - The conclusion of the relationship, whether at the end of the nurse's shift or on the client's discharge from the unit, facility, or service. - Reviewing and summarizing help to bring the relationship to a comfortable conclusion. The 5 key characteristics of therapeutic communication Empathy Respect Genuineness Concreteness Confrontation Name ways to enhance therapeutic communication Active listening Establishing trust Being assertive Restating, clarifying, and validating messages

Multidimensional Care I Questions With Answers 2023 A+ Interpreting body language and sharing observations Exploring issues Using silence Summarizing the conversation Process recordings Name some barriers to therapeutic communication Asking too many questions Asking why Fire-hosing information Changing the subject inappropriately Failing to probe Expressing approval or disapproval Offering advice Providing false reassurance Stereotyping Using patronizing language Name some non-verbal communication

Multidimensional Care I Questions With Answers 2023 A+ Facial expression Posture and gait Personal appearance Gestures Touch What are the 4 types of personal space? Intimate distance (patients) Personal distance (with patients and healthcare team members) Social distance (with a group) Public distance (with a group or community) What factors are a part of verbal communication? Vocabulary Denotative and connotative meaning Pacing Intonation

Multidimensional Care I Questions With Answers 2023 A+ Clarity and brevity Timing and relevance Credibility Humor What does the SPEAKUP acronym stand for? S - Speak up if you have questions of concerns. P - Pay attention to the care you are receiving E - Educate yourself about your diagnosis A - Ask a trusted friend or family member to be your advocate K - Know your medications and why you take them U - Use a hospital, clinic, surgery center, or other type of healthcare organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by The Joint Commission P - Participate in all decisions about your treatment Joint Commission - Who wrote the National Patient Safety Goals? - What is the purpose of the National Patient Safety Goals

Multidimensional Care I Questions With Answers 2023 A+ Never events - serious but preventable errors (that should never occur) Ex: falls, UTIs from catheters, foreign object, air embolism, administering the wrong type of blood, severe pressure ulcers, injuries from burns, restraints, or bed rails, infections with IVs, DVT, etc. National Patient Safety Goals (NPSGs) - Goals issued by the Joint Commission to improve patient safety in healthcare organizations nationwide Occupational Safety and Health Administration - What does OSHA stand for? To ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance. - What is OSHA's purpose?

Multidimensional Care I Questions With Answers 2023 A+ Incident report - a means of documenting problem events within a hospital or other medical facility Read p. 548 in Fundamentals book - POISONING???? ADPIE Assessment Diagnosis Planning Intervention Evaluation - Steps of the Nursing Process What happens during the Assessment phase of the Nursing Process? Systematic collection, organization, validation, and documentation of patient data What happens during the Diagnosis phase of the Nursing Process? The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs What happens during the Planning phase of the Nursing Process?

Multidimensional Care I Questions With Answers 2023 A+ - The nurse sets measurable and achievable short- and long-range goals for this patient. - Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it. What happens during the Intervention phase of the Nursing Process? - Activities or actions that a nurse performs to achieve client goals. - Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. What happens during the Evaluation phase of the Nursing Process? - To determine whether, after application of the nursing process, the client's condition or well-being improves.

Multidimensional Care I Questions With Answers 2023 A+ - The nurse conducts evaluation measures to determine if expected outcomes are met, not the nursing interventions. 12-20 breaths per minute - normal respiratory rate 120/80... Systolic: 90-120 Diastolic: 60-80 - Normal range for BP 96.4 -99.5 degrees Fahrenheit Oral: 98.6 Tympanic: 99.6 Rectal: 99.6 Axillary: 97.6 - Normal range for temperature 60-100 beats per minute - Normal range for pulse/HR 94%-100% - Normal range for O2 Sat % Self-actualization Esteem Love/Belonging

Multidimensional Care I Questions With Answers 2023 A+ Safety Physiological - Maslow's Hierarchy of Needs Assessment Nursing diagnosis Planning Evaluation ****Interventions are the only part of the nursing process that can be delegated. - What parts of the nursing process cannot be delegated to an NAP (nursing assistive personnel such as LPN, CNA)