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NUR 275 Exam 1 Study Guide questions well answered

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NUR 275

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Rasmussen College

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NUR 275 Exam 1 Study Guide questions
well answered

Nurse's legal parameters for the State's Nurse Practice Act - correct answer ✔✔Nonprofessional
involvement occurs when you cross professional boundaries and establish social, personal, or business
ties with a patient

Social talking about the weather or news may put patients at ease in the beginning, but too much
chatting—especially about religion, politics, gossip, or personal finances—is unprofessional. Some
disclosure may help establish a therapeutic relationship, but you should always present such information
in the context of the patient.

For example, a nurse is working with parents of a child who was recently diagnosed with asthma. The
nurse's son also has asthma. The nurse may use that information to say, "I have a child with asthma, too.
I noticed that the cough would get worse at night. When is your child's cough noticed?"

In this example, the nurse uses personal information to quickly redirect the conversation to focus on the
patient and the family.

Careful with social media

No sexual contact bc considered sexual misconduct

Visiting patients beyond your role of providing patient care also breaks professional boundaries.

Comprehensive, focused, and emergent assessment - correct answer ✔✔Comprehensive assessment:
are broad and complete. The amount and type of information vary depending on the patient's needs,
purpose of data collection, health care setting, and the nurse's role.

Focused assessment: based on the patient's health issues. This type of assessment occurs in all settings.
It usually involves one or two body systems and is smaller in scope than the comprehensive assessment,
but more in depth on the specific issue or issues.

,Emergent assessment: involves a life-threatening or unstable situation, such as a patient who has
experienced a critical traumatic injury.

Remember:

A—Airway (with cervical spine protection if an injury is suspected)

B—Breathing—rate and depth, use of accessory muscles

C—Circulation—pulse rate and rhythm, skin color

D—Disability—level of consciousness, pupils, movement

E—Exposure

Difference between subjective and objective assessment data - correct answer ✔✔Subjective data: are
based on patient experiences and perceptions. The individual describes the feelings, sensations, or
expectations; you then document them as subjective data or put them in quotes.

Objective data: measurable data. You observe the patient's general appearance; assess vital signs; listen
to the heart, lungs, and abdomen; and assess peripheral circulation.

What critical thinking skills helps the nurse see relationships among data? - correct answer ✔✔clustering
related cues and data

includes gathering and clustering data to draw inferences and propose diagnoses

As a nurse, you use critical thinking to identify patterns and trends, consider missing or conflicting
assessment information, and decide the type and frequency of future assessments.

Identify strengths and abnormal data.

Cluster data.

Draw inferences.

Propose possible nursing diagnoses.

Check for defining characteristics.

,Confirm or rule out diagnoses.

Document conclusions.

What is the nursing process, understand each of the 5 steps - correct answer ✔✔1) Assessment:
complete and accurate health assessment to promote health at the highest level

2) Diagnosing: the clustering of data to make a judgment or statement about the patient's difficulty or
condition.

3) Planning: determining resources; targeting nursing

interventions; writing plan of care

4) Implementing/Intervention: providing treatment or education to the patient

5) Evaluation: Appraising the effectiveness and appropriateness of interventions

ADPIE

Understand the difference between verbal and non-verbal communication - correct answer ✔✔Verbal:
speaking with the patient

You learn effective interviewing skills through practice and repetition. Your speech is of moderate pace
and volume with clear articulation. A too-soft voice may indicate embarrassment or discomfort, whereas
a too-loud voice may seem too powerful and controlling. Speech that is too fast indicates that you are
rushed, whereas speech that is too slow may indicate that you think the patient is lacking cognitive
ability.

Nonverbal: observe the patient's physical appearance, facial expression, posture and positioning in
relation to the patient, gestures, eye contact, tone of voice, and use of touch.

, For example, you should not assume that touch is culturally acceptable to a patient. Instead, be
courteous and ask permission: "Is it OK if I feel your abdomen?"

Understand HIPPA regulations - correct answer ✔✔Regulates the security and privacy of information.

Confidentiality of documentation is essential, and only information pertinent to the care of the patient is
shared.

The HIPAA Privacy Rule requires an agency to make reasonable efforts to limit use of, disclosure of, and
requests for protected health information to the minimum necessary to accomplish the intended
purpose.

Health care providers who violate HIPAA may face fines of up to $250,000 or jail time (HIPAA, 1996).
Employees have been terminated for breaching HIPAA laws concerning confidentiality. Nursing students
also have accountability for keeping HIPAA laws.

Understand the review of systems (ROS) and what it provides - correct answer ✔✔is a series of
questions about all body systems that helps to reveal concerns as part of a comprehensive health
assessment.

In the review of systems, data collected is subjective information.

Objective data, or that completed in the physical assessment, is documented separately.

A complete review of systems assesses the history of all body systems, including nutrition/hydration,
skin/hair/nails, head/neck, eyes/ears, heart, peripheral, vascular, breasts, abdominal, musculoskeletal,
neurological, genitalia, rectum, and endocrine/hematological.

Any follow-up to problems or results to tests are included.

Understand level of consciousness: semi altered, stuporous, lethargic, obtunded - correct answer
✔✔Semi altered: is a very mild form of altered mental status in which the patient has inattention and
reduced wakefulness.

Stuporous: Patient is unresponsive and can be aroused only briefly by vigorous, repeated stimulation.

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