問題一覧
1
Documentation; what should the nurse include w/
Subjective data
2
The medical record able to be released to ___?
the court
3
Select all that apply: QSEN competencies all healthcare must
safety & informatics (2, 4????????? quality improvement
4
If pt. refuses med, how to document
pt. refused meds. physicians notified
5
Language
Call interpreter
6
if a child refuses meds, and a nurse mixes it in pudding, gives to child w/o knowing, what did she violate?
Autonomy (= Respecting the rights of others to make their own decisions)
7
Pt is belligerent, yelling upset, treaenting to sue what should the nurse do?
Continue to establish a rapport
8
Pt, comes in admit to nurse they just sexually assaulted baby before coming, what do to?
Report and contact authorities
9
taking benzo’s
no wine no pain pills, habit forming
10
What are down sides to questioning
Pt can shut down, discourage or from talking
11
pt admitted for OD is upset says I’m so stupid wish family would come see me. Maslow
love and belonging
12
unintentional torts
negligence and malpractice
13
Akathisia
inability to sit still, restlessness
14
Involuntary (emergency)
Up to 72 hours
15
pt ask about side effects nurse says no
veracity (withholding truth)
16
Anticonvulsants, off label use, pt Rx but no Hx of seizures
Mood stabilizer
17
Countertransference
Drug addict came in, how does the nurse show ___ A (obvious)
18
Pt,. family member goes to the unit, nurse observed the other nurse checking visitor bag, what example of?
must be done, apart of protocol
19
How does the nurse have culturally competent care?
-
20
Nurses says to a client, how would u like to begin? What relationship is that?
Collaborative
21
recidivism
reoffendor
22
Typical antipsyhotics
not being able to speak Eps
23
Pt is doing crazy shit in day room
Remove the other client out of the room (safety)
24
Select all that apply: Malpractice
○ Duty ○ Cause in fact ○ Damages (2,3,4) breach of duty proximate cause
25
Lithium
Call PCP if vomiting diarrhea
26
What not to take with benzos, incorrect answer
The pt said they should avoid tyramine
27
There was a question which VS to check first
120 pulse
28
Restraints
Not as needed/PRN
29
Check what lab values go with valproate
low Platelet count (WBC)causes thrombocytopenia check platelet, ast, alt, lipase (10-140)
30
What you're going to do when walking into the room and the patient can't hear you b/c tv is too loud (sensory & motor?
Turn down the volume
31
negligence
don't prevent selfharm, don’t question dr order
32
Lithium: range = 0.5 – 1.5 (salt = stabilize mood)
o Greater than 1.5 = toxic o No excessive water drinking after taking med
33
Definition of pepalu
Shift from what nurses “do to” patients to “do with” patients
34
intentional tort
assault, battery and false imprisonment
35
Discharge, from voluntary hold, are they allowed to?
yes
36
1:1, what right is taken away from them?
Right to privacy
37
violation of pt rights
not allowing them to see the chaplain
38
what right does nurse have to stop pt from doing
right to participate in group therapy
39
Involuntary movement (Dystonia)
Antipsychotics Contact md & report asap if experience, congentin will help, if not taken anything to helps sx, will permanently have eps sx
40
A patient states he doesn’t see his spouse making it, and the nurse says “that’s hard to believe.” What therapeutic approach?
Applying self to show interest in pts, needs
41
Erikson’s
Single adult- I won’t find a life partner, other says he will ■ Intimacy vs. isolation ○ Teenager ■ Identify vs. role confusion ○ School aged child ■ Industry vs. inferiority
42
What are the parameters for patients rights to refuse meds
If Pt grants harmful to themself
43
Adolescent asks you not to tell anyone, what's the response?
Notify the tx team
44
my kid only wants to play with friend
this is normal
45
Restraints, list of orders:
Question the order
46
Trazodone
rarely given as antidepressant, more of sedative
47
If you threaten to seclude a patient is it assault or battery
Assault
48
The nurse is assessing stress. What criteria for them being dx, what is a resilience trait?
Person is expressing unrealistic factors about going to school
49
MAOIs
-don’t take with antidepressants (SSIR) no tyramine (aged cheese)
50
Advanced directive unsigned for pt in psychosis
call family
51
nurse locks pt in after interview
false imprisonment
52
which of would you assess first b/c Maslow is at risk, experiencing depression and thoughts of scuicide
Physiological
53
Buspirone
○ Not addictive as benzo, diazepam benzos end in Pam or lam
54
Newly hired nurse, when should nurse preceptor intervent
○ Refrain from placing the client between the door and the nurse ○ Piece of furniture between them ○ 30-45 degree angle to eliminate anxiousness from interveiqw
55
peplau’s
○ Orientation phase ■ Nurse saying what should i call u ○ Working phase ■ Review meds/ educate ○ Termination phase ■ Nurse says i'll call u in a week to follow up and see how your doing (wrong) if you feel you need help again go to the ER ( correct)