NURS 323 BLOCK 3 MODULE 1 COMMUNICATION AND INFORMATICS

The nurse observes a surgeon explaining the procedure for an appendectomy to a client and asking the client to sign the consent for surgery. The nurse is aware that the client does not speak the language being used fluently. Which is the best action for the nurse to take to advocate for the client?

Look up basic words in the client's native language and use them when discussing the informed consent.

Suggest that a hospital interpreter explain the procedure to the client before the consent is signed.

Demonstrate the risks and benefits to the client through physical gestures and facial expressions.

Ask the client's spouse to explain the procedure in their native language and to report the client's understanding of it.

b Suggest that a hospital interpreter explain the procedure to the client before the consent is signed.

When entering a client's room, the nurse washes the hands and asks the client for his name. What is the nurse's next best action?

Take the client's vital signs and record them.

Auscultate heart, lungs, and breath sounds.

Prepare medications in front of the client.

Introduce self and explain what will be done.

d Introduce self and explain what will be done.

A parent visits the clinic with her 4-year-old child. While communicating with the child, the nurse should

stand in front of the child so the child can see the nurse.

touch the child gently but frequently during the interview.

use standard medical terminology so the child is not confused.

talk to the child in simple terms at the child’s eye level.

d talk to the child in simple terms at the child’s eye level.

During a health history interview, a nurse asks a client about childhood illnesses, past surgeries, and allergies. The nurse knows that this information will be charted in what section of the initial comprehensive assessment database?

Personal health history

Biographic

Review of systems

Family health history

a Personal health history

A client who is 2 days postoperative reports feeling "hot." The nurse obtains the following vital signs: 100 degrees F, blood pressure 120/80 mmHg, heart rate 82 beats/minute, respirations 18 breaths/minute, oxygen saturation 100% on room air, pain level 7 on a scale of 0 to 10. Which of the following is subjective?

Respirations 18 breaths/minute

Heart rate 82 beats/minute

The statement of feeling "hot"

The fact that the client is 2 days postoperative

c The statement of feeling "hot"

While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer questions than is usual with younger clients. What should the nurse do?

Stop asking questions so as not to confuse the client.

Ask a family member to answer the questions. 

Slow the pace and allow extra time for answers.

Realize that the client has some dementia.

c Slow the pace and allow extra time for answers.

A nurse is providing change-of-shift report to another nurse for a client using the Situation, Background, Assessment, and Recommendation (SBAR) communication tool. Which of the following information should the nurse include as part of the Background component of this communication tool?

"The client was found unconscious on the floor in her home."

"There are no provider’s prescriptions available."

"The client should be seen by a neurologist."

 "The client is disoriented. Pupils are slow to respond to light."

a "The client was found unconscious on the floor in her home."

The nurse knows that when documenting on a client's chart, assessment information must be concise and accurate, and that all descriptions must be as precise as possible. An example of the best documentation of a wound is:

The abdominal wound appears fairly large.

The abdominal wound looks the same as yesterday.

The abdominal wound appears the size of a baseball.

The abdominal wound measures 6 cm by 9 cm with a 1-cm depth.

d The abdominal wound measures 6 cm by 9 cm with a 1-cm depth.

Which question or statement would be an appropriate termination of the health history interview?

“I wish you could have remembered more about your illness.”

“Can you think of anything else you would like to tell me?”

“Perhaps we can talk again sometime. Goodbye.”

“Well, I can't think of anything else to ask you right now.”

b “Can you think of anything else you would like to tell me?”

A nurse is caring for a client with a neurological disorder. The client is having difficulty forming words and his tone is nasal. Which of the following is an effective communication strategy for this client?

Nod continuously when the client is talking.

Encourage the client to speak quickly while talking.

Repeat what the client has said to verify the meaning.

Engage the client in a lengthy discussion to strengthen his voice.

c Repeat what the client has said to verify the meaning.

the nurse is gathering info about a clients habits and lifestyle patterns. which method of collecting data will the nurse use to best obtain this info?

Perform a through health history during the working phase

the nurse is performing a client centered interview, the client reports daytime fatigue. which question would be the most appropriate for the nurse to ask the client about their daytime fatigue?

what do you think is contributing to your fatigue?

the nurse is documenting data in an electronic health record. which actions by the nurse are correct? SATA

record subjective info by using quotation marks whenever possible

enter the assessment findings for another health care provider

wait until the end of the shift to enter all documentation

do not leave the computer unattended while logged in

use complete concise descriptions of assessments and care

a d e

what is subjective data?

sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client****

what is objective data?

physical characteristics, body functions, appearance, behavior, measurements, or results of laboratory testing *******

what are phases of the interview?

§Pre-introductory

§Introductory

§Working

§Summary and closing

what happens during preintroductory phae

•Review medical record

•Gather information that will assist in interview

what

what happens during introductory phase?

•Introduce

•Explain purpose

•Assure client of confidentiality

•Maintain privacy

•Develop trust and rapport

what happens during working phase?

•Obtain biographical data

•Reason for seeking care

•History (present, past and family)

•Review of body systems

•Lifestyle, developmental level

•Listening, observing

•Interpret and validate

•Collaborate with client to identify problems and solutions or goals

what happens during summary and closing?

•Summarize

•Validate concerns

•Identify plan

•Allow time for additional  questions or concerns

what are the guidlines for documentation? (part 1)

documentation part 1

•Keep confidential all documented information in the client record

•Use correct grammar and spelling (Avoid unapproved Abbreviations)

•Use phrases instead of sentences to record data

•Record data findings, not how they were obtained

•Write entries objectively without making premature judgments or diagnoses

what are the guidlines for documentation? (part 2)

documentation part 2

•Record the client’s understanding and perception of problems

•Avoid recording the word “normal” for normal findings

•Record complete information and details

•Support objective data with specific observations obtained during the physical examination

what are some facts about EHR?

EHR facts

§Improves communication among healthcare providers

§

§Records may be accessed by other health care providers—such as dietitians, physical therapists, laboratories, and other specialists

§

§Reduces errors, improves client safety, and supports  better client outcomes

§

§Allows client to have access and become more involved in care

§Chart in “real-time”, up to date documentation

what is sbar?

situation background assessment reccomendation

what is the purpose of ehr documentation

prupose of ehr

•Promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care

•Provides a chronologic source of client assessment data and a progressive record of assessment findings that outline the client’s course of care

•Ensures that information about the client and family is easily accessible to members of the health care team; provides a vehicle for communication; and prevents fragmentation, repetition, and delays in carrying out the plan of care