chapter 4 and 5

medical diagnosis

Statement of the patient's alterations in structure and function, and this results in the diagnosis of a disease or disorder that impairs normal physiologic functions.

Ethnocentrism

The assumption that one's culture provides the right way, the best way, and the only way to live.

Tertiary sources

information from Literature to provide background information, diagnostic tests, diet

Secondary sources

information from Relatives, significant others, medical records, lab reports

Primary source

information that is Produced by patient

core measures

measures of care that are tracked to show how often hospitals and healthcare providers use the care recommendations identified by evidence-based practice standards for patients who are being treated for conditions such as heart attack, heart failure, and pneumonia or for patients who are undergoing surgery.

Actual nursing diagnosis

nursing diagnosis based on human responses and supported by defining characteristics

Health promotion and wellness nursing diagnosis

nursing diagnosis that Only has a one-part label

Risk/high-risk nursing diagnosis

nursing diagnosis where patient may be more susceptible to a particular problem

c

A clinical judgment that a person is more susceptible to a particular problem than others in the same situation is defined as which type of nursing diagnosis? a- Actual b- Health promotion/wellness c- Risk/high risk d- Syndrome

Answer: c Rationale: Discharge teaching is an ongoing process and should not wait until the patient is ready to go home. The patient and family need to learn about home care before discharge, and the content should be presented in small sections and repeated as necessary because repetition enhances learning. The patient's readiness to learn and educational level also must be taken into consideration.

An older adult patient is being prepared for discharge after experiencing a stroke with some residual damage. The patient and family are scheduled to receive a large amount of information from the nurse regarding proper care and safety at home. What is the nurse's best course of action? a- Present the patient and family with all of the information a few days before discharge. b- Present the patient and family with all of the information the day before discharge. c- Break the teaching content down into manageable sections and present them individually in the days before discharge. d- Have a home health nurse teach the patient and family at home a week after discharge.

Syndrome nursing diagnosis

Clusters signs and symptoms to predict certain circumstances or events

Affective

Domain of learning that Involves feelings, needs, values, and opinion

Cognitive

Domain of learning that Involves learning and storing knowledge

Psychomotor

Domain of learning that Involves learning new skills

b

How does a nursing diagnosis differ from a medical diagnosis? a- A nursing diagnosis concerns a disease that impairs physiologic function. b- A nursing diagnosis evaluates a patient's response to actual or potential health problems. c- A nursing diagnosis determines the rate of Medicare reimbursement. d- A nursing diagnosis does not consider potential future problems.

Physiologic needs Safety needs Belonging needs Self-esteem needs Self-actualization needs

Maslow's hierarchy of needs

C

The nurse is preparing a patient for discharge after a surgical procedure. Which method is best for teaching the patient about his or her prescribed drugs? a- Prescription blank handwritten by the physician b- Magazine ads featuring the prescribed medications c- Verbal explanations along with drug summary sheets d- Unit-dose packages from this morning's medications

Answer: c Rationale: The patient's willingness to see, hear, and do indicates a learning style in the psychomotor, or "doing," domain. Demonstration of the skill with a step-by-step, hands-on approach is usually the best way for this type of learner to be trained in a new skill.

The nurse is preparing to teach a postsurgical patient who has a new colostomy about proper colostomy care. The patient says, "Just show me how to do it; let me try, and I'll learn what to do." Which domain of learning is indicated by this statement? a- Cognitive b- Affective c- Psychomotor d- Determined

Answer: d Rationale: After the patient's basic needs are assessed and met, he or she will be better able to focus on the educational material and be prepared for discharge. It is important for the patient to verbally demonstrate learning as well as perform any skill autonomously.

The nurse is supposed to perform postoperative teaching for a patient who is scheduled to be discharged the next day. The patient appears fatigued, in pain, and irritable. The nurse knows that there will be little time for teaching on the day of discharge. What is the nurse's best course of action? a- Deliver the teaching now because there won't be enough time tomorrow. b- Allow the patient to nap, and return to perform the teaching in 1 hour. c- Teach the family member who is present, so he or she can share the information with the patient after discharge. d- Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better.

C

The nurse who is new to a large urban hospital has found that many of the hospitalized patients are of different cultural groups in the area. Which approach is best for the nurse to take in caring for these patients? a- Care for all patients the same way because it is more efficient. b- Ask not to be assigned to these patients due to the nurse's lack of experience. c- Develop a plan of care that is individualized to each patient's needs. d- Follow a more experienced nurse around for several months to gain more experience.

Ethnography

Used to observe how patients follow healthcare regimen at home

D Rationale: Verification of the correct route of administration is an independent nursing action that is required as part of the "seven rights" of administration. Ordering drugs or labs and changing a route of administration are not within the scope of practice for a nurse.

Which is an independent nursing action? a- Orders medications based on the patient's medical diagnosis b- Orders laboratory tests depending on the medications ordered c- Chooses an alternate route for medications if indicated d- Verifies the correct route of medication administration