Exam 2 Study Guide

What Therapeutic Communication Is

Communication is a complex interactive process of sending and receiving messages, influenced by illness, culture and age. Therapeutic communication narrows that: the interaction focuses on the patient and the patient's concerns, it is caring and empathetic, and it is a skill — it takes practice. The slide's last line is the one students skip: the nurse should be comfortable with her self-concept and aware of her own biases, values, culture and communication style. You cannot manage your effect on a patient without that.

Nonverbal communication — as important as the words

The deck lists nine channels: physical appearance, facial expressions, sounds (gasps), silence, posture and positioning, gait, gestures, eye contact, and touch.

Eight factors influencing communication

The slide's own eight: developmental level · gender · sociocultural differences · roles and responsibilities · space / personal territory · physical, mental and emotional state · values · environment.

Building the skill

Therapeutic vs Nontherapeutic Techniques

The ten therapeutic techniques are boxed at the front of this guide, because the deck's notes name them as tested content. Their counterparts matter just as much — most application questions are built by putting a nontherapeutic response in the answer options and seeing whether you pick it.

From the ATI Communication modules — techniques the deck does not name

The blueprint tells you to complete the ATI Communication assignments, so ATI’s own list is fair game. It overlaps the deck’s ten but is not identical. Where the two ever disagree, the deck wins — these are additions, not replacements.

ATI names eight more that the deck leaves out. They are worth knowing as a set, because they are all failures of the same kind — in every one of them the nurse’s comfort, opinion or convenience quietly takes the place of the patient’s.

Assertive vs aggressive

Assertiveness is the professional standard — on an exam, the assertive option is nearly always correct. Note that assertiveness includes standing up for others, not only for yourself, and that accepting help is on the assertive side rather than a weakness.

The deck contrasts two. ATI names four types, and the two extra ones are where most real workplace conflict actually lives.

Interviewing, and the Data It Produces

The techniques above are how you talk to a patient. This section is how you ask, and what you have once they answer. It sits in the communication part rather than in assessment because the distinctions below are made with your mouth, not with your hands — but they reappear in every part of this guide: the skin history in Part 3, and the pain interview in Part 4 are both this same machinery pointed at a different body system. Learn it once here.

Open-ended, closed-ended and focused questions

The Week 3 prep worksheet asks you to write three open-ended and three closed-ended questions and say when each is used, so this is assigned work as well as textbook content. Taylor adds a third type.

The data you collect, and where it came from

Two classifications run underneath every assessment in this course, and they are independent of each other — students collapse them into one, which is exactly what an exam item is built to catch.

Professional Behavior, Culture, and Special Situations

Three subjects sit under this heading and they share one question: whose needs is this conversation serving? Boundaries are that question asked about the nurse. Culture and language are it asked about the gap between two people who do not share a frame of reference. The phases of the relationship are it asked over time. The interpreter material is the part the blueprint names outright, and it is the densest few inches in Part 1.

Professional boundaries

• Non-professional involvement — a little social chatting can build rapport, but watch the drift. The deck's two examples: discussing your own family member with the same illness, and discussing how much you need a day off. Both move the focus from patient to nurse.
• Sexual boundary violation; visiting patients beyond the role of nurse.
• Do not confuse privileged intimacy with friendship. This is the line the deck draws explicitly — the nurse–patient relationship grants access no friendship does, and that access is not friendship.

Intercultural communication

The blueprint names “language barrier strategies and laws related to interpreter use” by name. The deck states the rule; ATI supplies the specifics below. Nothing here contradicts the slide — it fills it in.

Other points: use tools such as picture boards and common-phrase lists; be aware of gender roles in a culture and of societal biases around gender and sexual orientation; notice that routine questions often assume a heterosexual patient.

The phases of the therapeutic relationship — three or four, depending who is asking

From Taylor Ch 8. Not on the slides, and the two sources you have been pointed at do not agree on the count — see the box below the table. Included because it is the structure the whole chapter is organised around, and it survives into every later course.

Length and depth vary enormously — a few minutes in acute care, or weeks across a long admission. The phases overlap in practice rather than running cleanly one after another.

Adapting technique to special situations

Hearing impairment · visual impairment · semi-consciousness · cognitive impairment · mental health illness · crying · anger · alcohol or drug use · the patient asking the nurse personal questions · sexual aggression (inappropriate jokes, flirtation).

The Teach-Back Method

Everything so far has been about getting information out of a patient. Teach-back is the reverse — it is how you find out whether anything you said got in. One technique, performed in one sentence, and the most reliable way there is to discover that a patient who nodded all the way through your explanation understood none of it.

Teach-back should occur with every interaction — it is not a one-time event, and it is practised in chunks, checking each time new information is presented.

Focus on need-to-know and need-to-do. The patient wants to know: What is my main problem? What do I need to do? Why is it important to me to do this? Teach-back is documented in the EHR patient education screen, with teach-back selected as the teaching method.

Health literacy — from the ATI Client Education module

ATI defines literacy as the “ability to read, understand and interpret information written at an 8th grade level or higher.” The clues to low literacy are behavioural, not stated: anxiety and avoidance — the patient who keeps deferring the handout, or who says they will read it later. Strategies: simplified written materials · one step at a time · methods that appeal to several senses · teach-back and repetition, inside a trusting, nonjudgmental relationship.

ATI names exactly two evaluation strategies for patient teaching: questioning (asking for information, which it notes does not threaten the client) and return demonstration for psychomotor skills. It places teach-back inside return demonstration, as the version that adds the cognitive domain — you demonstrate a skill back, or you explain understanding back.

The Medical Record

Documentation is only two questions of the forty, which makes it tempting to skim. Resist that: both of the topics the blueprint names are in this part, and both are procedures rather than facts — things you do in an order, which is exactly the shape a question can be built on. Start with what the record is for, because every rule that follows is downstream of one of these six purposes.

The record is multipurpose. Six purposes:

1. Legal document
2. Communication and planning care
3. Quality assurance — chart audits
4. Financial reimbursement
5. Education — unique case studies
6. Research

The deck notes students most often underestimate legal document and financial reimbursement — which is exactly why they make good exam questions.

Four terms the prep worksheet asks you to define

The Joint Commission "Do Not Use" list

From Taylor Ch 20. Not on the slides, but the clinical objectives name documentation with approved abbreviations, and this is the short memorizable list — the minimum every organisation must prohibit. It applies to handwritten orders and medication documentation, including free-text computer entry.

What goes in, and when

Flow sheets and progress notes are where most day-to-day nursing documentation happens.

Principles and Formats of Documentation

The last section was what the record is for. This is what a nurse actually puts in it: five principles that govern every entry ever written, and five formats that arrange the same information differently. Learn the principles properly and the formats reduce to a matching exercise.

The five principles

The formats

Reporting Care and ISBARR

Documenting is what you write down. Reporting is what you say out loud — and the risk is completely different, because speech leaves no trail. Everything in this section is a structure for making spoken communication as reliable as written communication: a standard format so nothing is left out, and a read-back so nothing is misheard. The second of those is where the verbal-order procedure lives.

A 2009 TJC safety goal required agencies to develop a standardized approach for handoff communications. Written and verbal handoffs are complementary, not alternatives — verbal is best supplemented with written.

Taking a verbal or telephone order

The second R is the only one of the six letters that is a physical act rather than a piece of speech, and it belongs to a larger procedure the deck does not spell out. The blueprint names this topic outright, and the Documentation section of the exam is only two questions — so the odds that one of them lands here are high. There are two halves to it: how you receive the order, and how you document it.

Strategies for effective handoff

Organized, complete, accurate, concise, respectful · standard format (ISBAR) · face-to-face verbal update with interactive questioning · limit interruptions · use read-back policies · cross-monitor the handoffs of others. The two highest-yield habits per the deck: read-back and limiting interruptions.

Bedside shift report — the evidence-based standard

• What it is: handoff conducted at the bedside with the patient and family present and participating; outgoing and oncoming nurses verify information together, in view of the patient.
• Why: endorsed by AHRQ — the Agency for Healthcare Research and Quality, the federal agency that studies how care is delivered and publishes evidence-based bedside tools — and supported by TJC handoff safety goals. Associated with fewer handoff errors, falls and preventable adverse events, and better patient engagement, satisfaction and nurse accountability.
• In practice: introduce the oncoming nurse; invite patient and family in; use a standard format such as ISBAR; do a visual safety check; move sensitive details outside the room when privacy requires it.

What a complete change-of-shift report contains

Nine categories, and they run roughly in the order you would say them — who the patient is, how they are now, what has changed, and what is planned.

Incident Reports, Family Reporting, and Incivility

Three topics that do not obviously belong together, joined by one thread: each is a situation in which a nurse is tempted not to say something. A mistake that could be quietly absorbed. A family asking for information. A colleague behaving badly. In all three the answer is that it gets reported — and in none of them is the report a punishment.

Incident / occurrence reports

• Anything out of the ordinary that can potentially cause harm to a patient, employee or family.
• Purpose is quality improvement and risk identification — not punishment.
• Do not ignore mistakes. The provider must be told, for example, if an incorrect medication dose was given.
• The agency keeps the report as factual reference in the event of litigation.
• Complete only the facts of the occurrence — no opinions.

Reporting to family and significant others

Follow HIPAA. Nurses keep families updated, and confidentiality is protected by using a code. Be careful about what is yours to share: a new diagnosis such as a malignancy is the provider's to deliver — the nurse provides support and explains what it means for care.

Incivility and bullying

Organizations address it with: accountability for all staff · education on professional, respectful behavior · zero-tolerance policies and whistleblower protection · leadership training · accessible reporting systems · documentation of bullying behavior.

Integumentary Terminology

The lab lists terminology as a topic in its own right, alongside wound documentation, drainage types, staging and edema. These are the words you are expected to use rather than describe — most of them appear again in context later, but this is the one place they sit together.

Skin, Hair, Nails and Glands

Those terms describe changes in a structure. This is the structure. Learn the three layers in order of depth, because every pressure injury stage is named for how far down the damage has reached — Stage 2 stops within the dermis, Stage 3 is through it into fat, Stage 4 is down to the things the body was not built to expose.

Hair — an appendage of skin: protects against invasion, insulates, aids sensory stimulation and gender identification. Changes with disease: alopecia; dry brittle hair raises a question about nutritional status. Nails — epidermal appendage, nail bed highly vascular; changes with disease — the deck's example is clubbing in chronic hypoxia.

Older Adults, Turgor and Culture

Normal is not one thing. The same finding means something different on an eighty-year-old than on a thirty-year-old, and something different again on darkly pigmented skin. This section is the set of adjustments you make before interpreting anything you have just inspected — and every one of them is a way of being wrong that an exam item can be built out of.

Older adults: thinner skin · more prone to bruising (ecchymosis) and shearing injury · decreased turgor.

Cultural considerations: consider beliefs and practices; a patient may refuse to remove head dress or refuse skin-to-skin contact (wear gloves); ask about cultural practices. Cupping and coining are common in Southeast Asia — rubbing a coin across the skin in a specific manner to treat health concerns. The marks can be mistaken for abuse. More than half of all patients are likely to self-treat a skin lesion with what is culturally familiar before seeking professional help.

Subjective and Objective Skin Data

Both axes from Part 1 apply here. What the patient tells you about their skin and what you can see of it are different kinds of evidence, and a stem will make you sort them. Subjective comes first for a practical reason: the history tells you what to look for, and an inspection without one is just looking.

Subjective — risk factors

• Family history — irregular moles, melanoma (strong familial risk)
• Past medical history — irregular moles, severe sunburn as a child, skin cancers, PVD, diabetes, HIV. Diabetes and PVD mean decreased blood flow → impaired wound healing, and neuropathy means decreased sensation. Sensory loss = cannot sense the need to change position = risk for pressure injury. HIV/AIDS and chemo/radiation = weakened immune system
• Allergies — medications, insects, nuts, bees, and the reaction
• Medications — photosensitivity, allergies, chemo/radiation, OTC, supplements. Corticosteroids risk thinning of the skin and edema
• Lifestyle / occupational / behavioral — nutrition, activity, wheelchair-bound, weight
• Focus is on risk of melanoma and pressure-related skin breakdown; teach self skin assessment

Symptoms to ask about: pruritus (where, how long, remedies tried); rash (add recent allergen exposure — new meds, yard work, unusual foods — and recent illness, fever, chills, headache, which could indicate an infectious skin disorder); single lesion or wound (acute or chronic? medical, surgical or traumatic? any factors delaying healing — diabetes, impaired circulation, immune suppression, obesity, smoking).

Skin Lesions — Macules, Papules, Plaques and Pustules

A lesion is any change in the skin, and the classification is almost entirely mechanical: is it flat or raised, is it bigger or smaller than a centimetre, and what is inside it. Four of these are named in the blueprint by name. The rest are here because the deck displays the full chart and the distractors are drawn from it — you need to recognise them, not recite them.

How a Wound Heals, and What Goes Wrong

Everything up to here has been about describing skin. From this point the guide is about repair — and the rest of Part 3 only makes sense on top of it. The order below is deliberate: the principles that govern every wound, then the four phases the tissue actually goes through, then the three intentions, which are a statement about how the edges meet and are far easier to hold onto once you know what granulation tissue is. Classification and the five complications close it out.

Two sources, one subject. The deck gives the three intentions (a starred slide) but not the four phases, and names no complications — those come from Taylor Ch 33. They are taught together here because they are one topic, whichever source each piece comes from.

Principles

• Intact skin is the first line of defense against microorganisms.
• Use surgical asepsis in caring for a wound; sterile technique with open wounds.
• The body responds systemically to trauma.
• Adequate perfusion is essential for a normal body response to injury.
• Normal healing is promoted when the wound is clean and free of foreign material.
• The extent of damage and the person's state of health affect healing.
• Response to a wound is more effective if proper nutrition is maintained.

From Taylor Ch 33. The deck gives the three intentions but not the four phases, and names no wound complications. Both are standard chapter content.

Classifying a wound

That last row is the same distinction the staging system uses: Stage 2 is partial thickness; Stages 3 and 4 are full thickness.

Nutrition and Wound Healing

Nutrition runs through this deck at six separate points — it is a factor affecting the skin, a factor affecting healing, a pressure-injury risk factor, a Braden subscale, a lab value, and a prevention intervention. Collected here because it is easy to meet six times and learn zero times. Two of the six — the Braden subscale and the prevention bundle — you meet properly in the sections that follow. This is the one place where all six are in view at once, which is why it sits here rather than at the end.

Pressure Injury — Definition, Mechanism, Risk

This is the centre of Part 3, and Part 3 is nearly half the exam. One sentence runs underneath all of it: pressure over a bony prominence cuts off blood supply, and tissue that is not perfused dies. Everything that follows — the risk factors, the scoring tools, the stages, the prevention bundle — is that sentence turned into either a prediction or a description.

Because of CMS (Centers for Medicare and Medicaid Services) — this is the reimbursement mechanism set out in Part 2, arriving here as a change in what nurses actually do — practice changed: an occurrence report is filed for any pressure injury present on admission, plus staff in-services, policy and procedural changes, documentation guidelines. Many facilities require nurses to photograph pressure injuries on admission and place the photo in the chart.

Problem naming: Risk for pressure injury = potential · Pressure injury = actual.

The Braden Scale and UPMC SKIN

The risk factors in the last section are the ones a nurse notices. Braden is those same factors turned into a number, so that a care plan is triggered by a score rather than by judgment — and so that two nurses assessing the same patient reach the same conclusion. Read the scale first; the argument about where its cut-off sits comes after, and it will make more sense once you know which direction is bad.

Notice SKIN is the Braden subscales minus friction/shear and activity — same concepts, fewer letters. If you remember one, you can reconstruct the other. One thing the table above leaves unsettled: the cut-off. The slide, the handout and the textbook do not agree, and the trap below is the whole argument.

Staging Pressure Injuries

Everything so far has been about the skin staying intact. This section is what you say once it has not. Staging is a statement about depth of tissue loss — nothing else, and that single idea explains every rule below, including the two students get wrong: why the number never comes back down, and why a wound you cannot see into cannot be staged at all.

With those two rules in place, the stages themselves are readable. Read the table downward as a single descent through the tissue — epidermis, dermis, fat, and then the structures underneath — rather than as five separate definitions to memorise. The two entries that are not part of that descent, deep tissue injury at the top and unstageable at the bottom, are both the same situation: damage you cannot see the extent of, once because the skin is still closed over it and once because something is lying on top of it.

Two traps down, and both were about reading a wound that already exists. The rest of this section turns around to face the other direction: where these injuries happen, and how often you have to move someone to stop them. The link between the two halves is the same mechanism as always — every site below is a place where bone presses skin against a mattress, and every interval below is an estimate of how long tissue tolerates that before it dies.

Classifying, Treating, Documenting and Preventing

Staging says how deep the damage goes. This section is everything you do once you have said it, in the order you do it: classify the wound by the colour of its bed, treat it accordingly, document it in the elements a chart requires, and prevent the next one. That order is not decorative — the colour rule chooses the treatment, which is why the debridement tables sit directly underneath it.

Caring for a wound that already exists

The colour rule above says what to do to a wound. This is how you do it. Beyond the deck, which covers classification and prevention but not wound care itself.

Wound vac (negative pressure): promotes healing of open wounds — they heal inside-out. It removes drainage, reduces edema and draws the wound edges together. The seal must be airtight or the device does nothing, and a canister filling with fresh blood is reported, not reset.

Labs and diagnostics

Scraping · culture and sensitivity (C&S) · biopsy · nutrition labs: albumin, prealbumin, total protein.

Problems / hypotheses

Prevention — nursing actions

• Maintain clean, dry, wrinkle-free linens
• Perform a daily pressure injury risk assessment
• Clean and dry skin following incontinence; apply moisture barrier creams
• Use tepid water, pat skin dry
• Reposition in bed at least every 2 hours, in a chair every 1 hour
• Lift — don't pull — the patient up in bed
• Maintain heels off the bed surface (float the heels)
• Ambulate as soon as possible and frequently; assist with ROM while in bed
• Prohibit massage over bony prominences
• Provide adequate hydration (2–3 L/day) and meet protein and caloric needs

Pain — the Six Rules Everything Else Applies

Pain is ten of the forty questions, and almost none of them will ask you to recite a definition. They will give you a patient and ask what you do, or what you do first. That makes this part unusual: the physiology, the scales and the drug classes are all in service of a small number of decisions, and it is worth seeing those decisions before the material that supports them.

What Pain Is

Rule 1 of the six is that the patient’s report is the gold standard. This section is why that is a definition rather than a courtesy: pain is defined — by the IASP, and by ATI in almost the same words — as an experience. An experience has no external instrument, so there is nothing to check the patient’s report against, and the exam will punish any option that tries.

Threshold is physiological and remarkably similar across people; tolerance is personal and varies enormously. Mixing the two up is the classic error.

The Joint Commission standard (2016–present): "The hospital assesses and manages the patient's pain." Nurses must assess and reassess pain regularly; organizations set their own policy for which patients and how often — commonly every 4–6 hours. TJC's 2022 clarification: it does not require treatment until pain scores reach zero, and does not push opioid prescribing.

Under-treatment has physical and psychological consequences — anxiety, fear, depression. Challenges include looking for nonverbal signs where there is cognitive impairment or a communication barrier such as language or mechanical ventilation.

Neuroanatomy, Nociception and the Gate

You will not be asked to draw a pain pathway. You will be asked why rubbing a sore back helps, why one patient’s pain is sharp and another’s is a deep ache, and why a drug developed for seizures treats nerve pain. All three answers are in this section, and each is a single step of the pathway seen from the bedside.

Glutamate is the neurotransmitter responsible for communication between the peripheral and central nervous systems. Pain travels via the lateral spinothalamic tracts → thalamus → limbic system (where the emotions controlling pain are produced) → cerebral cortex, where the sensation is recognised as pain.

Categories of Pain

Pain is categorized two ways: by duration (acute or chronic) and by origin (nociceptive or neuropathic).

Neuronal windup — repeated assaults on the neurons produce an enhanced response.

Dimensions of pain, and what shapes the experience

Dimensions: physical · sensory · behavioral · sociocultural · cognitive · affective · spiritual.

Factors affecting the experience: age · fatigue · culture · ethnic variables · family, genetic sensitivity, gender · religious beliefs · environment and support people · anxiety, fear and other stressors · past pain experience.

Assessing Pain and the Assessment Tools

Rules 1, 4, 5 and 6 are worked out here. Assessment is largely a matter of asking the right questions in the right order and then choosing a scale the patient can actually use — which means the hardest assessments are the ones where the patient cannot tell you anything, and those are the ones most likely to be tested.

On the Q of OPQRST the deck adds a warning: let the patient describe the pain — if you supply the words, they may say what they think you want to hear. The same caution appears in the tips list as "do not put words in the client's mouth."

Two behavioural scales the deck does not list, worth recognising by name so they do not throw you: PAINAD (Pain Assessment in Advanced Dementia) for patients who can no longer self-report, and CRIES for neonates. Beyond the deck — the deck’s own answer for a nonverbal or cognitively impaired patient is FLACC, and for young children FACES. Answer with those unless a stem names one of these directly.

Patients unable to report pain — the sequence

1. Attempt a self-report anyway
2. Identify potential causes for pain
3. Observe patient behaviors
4. Ask family or caregivers about changes in behavior
5. Attempt an analgesic trial

Lifespan

Older adults: pain is NOT a normal consequence of aging · may be stoic and conceal pain · at risk for under-treatment · ask about effects on diet, sleep and mood · consider comorbidities such as arthritis · assess current medications and how they are taken. Newborns, infants and children: challenging, and also at risk for under-treatment — use FLACC, or FACES for ages 2–7.

Pharmacologic and Non-Pharmacologic Management

Assessment produces a number. This section is what you do with it: three drug classes, one safety scale that outranks all of them, and one device whose entire safety rests on a single assumption. Rules 2 and 3 from the head of this part are both worked out here, and rule 3 is the one that decides whether the rest of it is safe to give.

Three classes, and the exam’s interest in them is almost entirely about what each one is for rather than about doses. The pattern worth carrying away: non-opioids treat the tissue, opioids treat the signal, and adjuvants treat the nerve — which is why a burning, shooting pain that shrugs off morphine responds to a drug developed for seizures. Everything after this table is about giving them safely.

The drug classes tell you what exists; the sedation scale tells you when to stop. What is still missing is the join between them — how the number a patient gives you chooses which of the three you reach for. That is the step-up below, and it is the most application-shaped idea in this part: the blueprint asks for it in those words.

Non-pharmacologic measures (Taylor Ch 29)

Distraction · humor · music · imagery · relaxation · cutaneous stimulation · acupuncture and acupressure · hypnosis · biofeedback · therapeutic touch · position.

Cutaneous stimulation, massage and warm compresses are the gate control theory in practice — they stimulate large-diameter fibers to close the gate.

Other routes

PCA (set out in full above — it is listed here only because the deck groups it with the routes) · end-tidal CO₂ monitoring · epidural analgesia · local anesthesia · nerve ablation (intractable cancer pain) · nerve blocks (acute surgical pain).

Barriers — patient misconceptions

• "If I ask for something for my pain, I may become addicted"
• "Sometimes it's better to put up with the pain than deal with the side effects"
• "I should somehow be able to control my pain. It is immature to talk about pain"
• "Better to wait until the pain gets really bad — if I take medication for moderate pain it won't relieve severe pain later"
• "I don't want to bother anyone — I know how busy they are"
• "It's natural to have pain after surgery"

ATI Concept Definitions

The program runs a concept-based curriculum, and the concepts are ATI’s. Every unit on this exam is a concept before it is a topic: the skin unit is tissue integrity, the pain unit is pain and comfort, Week 3 is communication. These are the definitions the program itself works from, condensed. Where an exam item asks you to define rather than apply, this is the register it is written in. It sits at the back because it is a glossary, not a lesson — read the parts first, then come here and notice how much of each one ATI compresses into a single sentence.

Source: the ATI Concept Definitions handout in the ATI course shell — the same list reproduced in the Nursing Program Student Manual. Definitions are condensed here. The ATI Communication material has now been read into Part 1 — SOLER, the six techniques the deck does not name, the interpreter rules, the four-phase relationship, the health-literacy definition and ATI’s SBAR variants are all marked where they appear. What cannot be brought across are ATI’s module tests, whose rationales are the best exam predictor available; take them in ATI itself.

The starred items, one more time

Other numbers worth knowing

Sequences and decision rules

The traps