Exam 1 Review

intervention

(implementing)

22 year-old male presents to urgent care with a chief complaint of right ankle pain after being struck by a baseball in the lower leg while playing after school with friends. He reports a pain level of 7/10 at the time of your assessment. He has no hx of illnesses or surgeries. He is not allergic to any medications. He says he does not take any medications. His mother drove him in to the urgent care clinic and states he took Tylenol 500mg for the pain about an hour ago. He is holding his ankle in his right hand and limping with ambulation. Questions for consideration: 1. What type of data is presented here? Do you have subjective data? Do you have objective data? If so, list. Do you have a primary or secondary source? if so, who is your primary and/or secondary source? What senses (if any) did you use in your assessment? 2. Is there any other data that you would collect? If so, what? 3. Choose a nursing diagnosis from the NANDA list. Remember, what is your PRIORITY! 4. Formulate a NANDA statement (Nursing diagnosis r/t etiology AEB signs/symptoms)

1.

4 point gait

1: 1 crutch 2: opposite foot 3: other crutch 4: other foot nothing moves together

Which factors does the nurse need to take before determining the types of nursing diagnoses that are applicable to the patient? A. Review the patient's past and present medical history. B. Analyze nursing assessment data to determine whether information is complete, C. Outline an individualized plan of care to address each concern D.consider potential complications to which the patient is susceptible E. Evaluate how the patient has responded to treatment

A, B, D

Which action by the nurse is most appropriate during the orientation phase for the patient interview? Always position patients in a comfortable reclined position to ensure the comfort during question. Ask which name a patient prefers to be called during care to show respect to the trash. Quickly conduct a review of systems to determine the need for a complete or focused assessment. Begin with questions about intimacy and sexuality to address sensitive issues first

Ask which name of patient her first because you care to show respect and build trust

When initiating a physical examination which action should the nurse take first? Review of the patient's prior medical records. Gather admission health history forms. Assess the patient vital signs. Perform light and deep palpitation for fluid.

Assess a patient's vital signs

The nurse obtains a lower than normal 88% on room air pulse oximetry reading on a patient which action by the nurse results from accurately employing the critical thinking skills of analysis in the nursing process? Assessing the patient patient first symptoms of hypoxia. Providing oxygen according to standing orders. Elevate the head of the bed if not can train dictated. Allowing the patient to be alone to rest more comfortably. Disgusting adaptations needed for daily activities with the patient

Assessing a patient for symptoms of hypoxia providing O2 according to standing orders elevate the head of the bed if not contraindicated

Which nursing diagnoses statement are approximately written according to the Nande format? A risk for infection related to elevated temperature and white blood cell count? Readiness for affective family process as evidenced by an expressive desire for improved communication and mutual respect verbalized by family members? Impaired health maintenance related to the inability to access healthcare as evidenced by failure to keep up with appointm, homebound status? Risk for hemorrhage as evidence by prolonged clotting time? Chronic pain related to osteoarthritis as manifested by verbalize postoperative discomfort

B. c. d

Which notation is most appropriate for the nurse include in a patient's chart regarding evaluation call patient will ambulate three times daily in the hallway before discharge without shortness of breath? Goal not met patient states he is tired. Go not met patient ambulated three times in room. Go Matt patient ambulated three times in the hallway. Gomez patient ambulated three times in the hallway without SOB

Call Matt patient ambulated three times in hallway without SOB

Which statement illustrates a characteristic of goals with in the care planning process? Goals are vague objectives communicating expectations for moving forward. Short term goals need not be measurable on lake long-term goals. Goal attainment can be measured by identifying nursing interventions. Long-term goals are helpful in judging a patient's progress.

Call Sherm goals are helpful in getting a patient progress

Stephen best describes the relationship of medical diagnosis and nursing diagnosis? Medical diagnoses are embedded in nursing diagnosis. Nursing diagnoses are derived from medical diagnosis. Medical diagnoses are not relevant to nursing diagnosis. Medical diagnosis maybe interrelated to nursing diagnosis

Call diagnoses may be interrealted to nursing diagnosis

On what premises nursing diagnoses identified for a patient? First impressions. Nursing intuition. Cluster data. Medical diagnosis

Cluster Data and recognize cues

diagnosis

Cluster related data ID nurse Diagnosis list supporting data such as etiology, signs, symptoms

Providing care to a patient admitted to rule out human immunodeficiency virus HIV infection wearing gloves during which activity may be an indication of bias? Collecting the patient's medical history. Initiating intravenous access. Performing oral care. Completing a bed Bath

Collecting the patient's medical history

Which entry in a patient electronic health record best indicates a need for a nurse together secondary rather than primary suggested data? Complaining of chest pain. Apical pulse of 110. Comatose. Difficulty swallowing

Comatose

What is the primary purpose of the nursing diagnosis? Resolving patient confusion? Communicating patient needs. Meeting accreditation requirements. Articulating the nursing scope of practice.

Communicating patient needs

The nurse receives change of shift report on the five patience and reviews prescriptions treatments and medication scheduled for the shift based on analysis of this information to nurse chooses which patients which is a critical thinking that describes the nurses actions? Problem-solving. Decision making. Inference. Reasoning.

Decision making

Situation is with necessity modification of a patient plan of care? Decreasing patience level of orientation. Discharge a patient for rehabilitation facility. Patient at Harris who stabbed Pana care. Set an onset of shortness of breath and patient receiving oxygen

Decreasing patience level orientation. Discharge a patient to rehabilitation facility. Sudden onset of shortness of breath and patient receiving oxygen.

Which cue by patient can be validated by laboratory and diagnostics test results? Deeply sign with fatigue. Bilateral crackles in the lungs. Oxygen saturation of 98 on room air? 2+ pitting Adema of the ankles and feet

Deeply saying with fatigue Reasoning accused book behavioral hint of a potential disease process or concern in this case the only cue is a deep sigh indicating petite the level of the tea can be verified by evaluating the patient's hemoglobin and hematocrit levels for anemia crackles oxygen saturation and pitting edema are all physical assessment findings not cues

What is the most significant problem that may result from an properly written in NAND a nursing diagnostic statement? Lack of direction for formulating patient complains of care. Emission of physician or primary care provider orders. Combining of two unrelated patient concerns. Increased team collaborative needs

Direction for formulating patient plans of care

Which factor should be taken into consideration by the nurse before and during a patient interview? Distance between the chairs in which the nurse and patient are sitting. Traditional treatments typically used by the patient to treat disease. Gender preference for primary care providers. Physical condition of the patient. Music preference of the patient.

Distance between the chairs in which the nurse and patient receiving. Traditional treatment typically used by the patient to treat disease. Gender preference for primary care providers. Physical condition of the patient

Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? What do you do for a living? Can you describe your work environment? When was your last physical? What immunizations do you have at this time? Is there a family history of heart disease cancer high blood pressure or stroke? Do you have any chest tightness shortness of breath or difficulty breathing while exercising?

Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?

Which action by the dayshift nurse provides objective data that enables the night shift her to feed in evaluation of Paris patient short term goal? Encouraging the patient to share observations from the day. Leaving a message with the charge nurse before shift change. Documenting patient assessment findings of a patient's chart. Checking with the pharmacist regarding possible drug interactions

Documenting patient assessment finding with the patient's chart

Which nursing intervention is the most important to complete before giving medication to a patient? Provide water to add the patient's ability to swallow the medication. Double check the patient's allergies before giving the drug. Ask a patient to verify having taking the medication before. Place the patient in a side lying position to prevent aspiration.

Double check the patient's allergies before giving those meds

What signs and symptoms would a nurse approximately cluster a supporting data for a patient with extreme anxiety? Denies any difficulty falling asleep. Elevated pulse rate escalated at 140 bpm. Continuous with tapping throughout intake interview. Demonstrates how to give insulin self injection without hesitation. Patient states I feel nervous all the time especially when I'm home alone

Elevated pulse rate. Continuous for tapping. Patient states I feel nervous all the time

The nurse notices that the patient is becoming short of breath and anxious which interventions are independent nursing actions I do not require the order of a primary care provider? Elevating the head of a patient. Administering oxygen by nasal cannula. Assessing a patient's oxygen saturation. Evaluating the patient's peripheral circulation.

Elevating the H Head of the patients bed. Assessing the patient's oxygen saturation. Evaluating the patient's peripheral circulation

Which intervention would be the most important for the nurse to include in a patient care plan if the patient is unable to complete activities of daily living without coming to ty? Instruct the patient to shower and shave simultaneously. This can continue the patient from bathing of hospitalized. Encourage the patient to rest between bathing activities. Ask the patient spouse to assist with all

Encourage the patient to rest between bathing activities

Which interventions can a nurse initiate independently while providing patient care? Wondering a blood transfusion. Escalating lung sounds. Monitoring skin integrity. Applying heel protectors. I just antibiotic dosages.

Escalating lung sounds. Monitoring skin integrity. Applying heel protectors

If the nurse choosing the nursing outcome classification an OC appetite for a chemotherapy patient which outcome indicators would be acceptable for evaluation of the goal attainment? Express desire to eat. Report that food smells good. Use of relaxation techniques before meals. Preparation of home-cooked meals for self and family. Use of nutritional information on labels to guide selections

Express desire to eat. Report that food smells good. Preparation of home-cooked meals for self and family

What is Gordon's Functional Health Patterns?

Framework that guides assessment of functional ability -Emphasizes holism and totality of a person's interactions with the environment

A patient discusses his job stress and family relationship with the nurse during his health history interview in which organizational framework is this type of data likely to be recorded extensively? Body systems model. Physical assessment model. Head to toe assessment model. Functional health patterns model

Functional health patterns model

Patient reports feeling tired and complains of not sleeping at night what action should the nurse perform first? Identify reason to patient is unable to sleep. request medication to help the patient sleep. tell the patient that sleep will come with relaxation. notify the position that the patient is restless and anxious.

ID reasons the patients is unable to sleep

Which activity by the nearest best demonstrates part of the working phase of a patient already? Summarizing previously discussed key topics. Including selected family members and care playing. Transferring hair and responsibilities to the home health nurse. Verifying your name by way to patient prefer she addres

Including select your family members in care planning. Disgusting health promotion activities that could be beneficial

If the nurse discovers that patient by L-Boy swollen and painful elbow physical examination which action should the nurse take next? Apply ice to decrease swelling and reduce pain. Tessa area to tell me the presence of Covid. Perform passive range of motion to promote in flexibility. Inspected patients left elbow in comparison.

Inspect the patient's left elbow to compare his appearance

The nurse is completing an assessment on a patient with sudden onset of abdominal pain during the assessment the nurse consider similar presentations to the underlying pathophysiology related to the patient's clinical manifestations which critical thinking skills should the nurse first used to determine the cause of the patient abdominal pain? Evaluation. Interpretation. Reflection. Inference.

Interpretation

Which action by the nurse would be most important in developing a patient centered plan of care for an alert and orientated adult

Listening to the patient's concern and beliefs about proposed treatment

Which resource is most helpful when paid or Tising identify the nursing diagnosis is? Nursing interventions classification. Gordon's functional health patterns. Must Lowell's hierarchy of needs. Nursing outcomes classifications.

Maslows hierarchy of needs

hygiene

Measures contributing to cleanliness and good health

Which nursing action is critical before delegating interventions to another member of the healthcare team? Locate all members of the healthcare team. Notify the position of potential complications. Know the scope of practice and competency of the other team member. Call a meeting of healthcare team to determine the needs of the patient.

No the scope of practice and competency of the other team members

Indirect care

Nursing intervention done to benefit the patient but WITHOUT direct patient care

what is the purpose of the nursing proces? Providing patient centered care? Identifying members of healthcare team organizing the way nurses think about patient care ? facilitating communication among members of the healthcare team?

Organizing the way nurses think about patient care

Which nursing goals written correctly for a patient with the nursing diagnosis of risk for infection after domino surgery? Nurse will encourage use of sterile technique during each dressing change. Patient white blood count will remain within normal range for at the hospitalization. Patient's visitors will be instructed with proper handwashing before direct contact with patient. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.

Patience by blood cell count will remain within normal range throughout hospitalization

What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? Patient treatment preferences. Cultural and ethnic influences. Nurse professional expertise. Kern evidence based research. Convinced of the nursing staff

Patience treatment preferences. Cultural ethnic influences. Nurses professional expertise. Current evidence based research

Which stores carry her but she would most affective and helping a patient coat emotionally with the new diagnosis of cancer? Reassessing for changes in the patient's physical condition. Teaching a patient various methods of stress reduction. Referring to patient from Music 1 and massage therapy. Including the patient to explore options for care

Patient is for options for care

What should be the primary focus for nursing interventions? Patient needs. Nurse concerns. Positions priorities. Patient family request

Patient needs

What is the most important reason for Lacy to use standardize taxonomy such as the INTP CCC or NANDA?

Patient safety

Patient has just experienced a cardiac arrest on the unit the nurse has implemented the acute care plan for management of Covid situation what is the next step and there should take resume all interventions for previously identify nursing diagnosis is. Performance steps of the nursing process related to the patient's current condition. Seek physician input related to updating the nurses diagnosis treatment. Evaluate the success of the acute care plan for management of the cardiac arrest

Performance steps of the nursing process related to the patient's current condition

What should the nurse consider before implementation of all nursing interventions? Potential communication barriers diverse cultural practices. Scope of practice. Functional status of the patient. Time are the most recent shift change

Potential communication barriers. Diapers cultural practices. Scope of nursing practice. Functional status of the patient

What is problem focused nursing diagnosis

Problem focused nursing diagnosis is a clinical judgment concerning an entire fireable human response to health condition/life process that exist in individual family group or community. For example anxiety related to situational crisis and stress

What is the most important action for her to take to have a new nursing diagnosis considered for an inclusion in the I CNP or NANDA taxonomies? Share concerns with the nurse manager of the nursing unit. Offer alternative care for a patient and family members. Discuss how to address patient needs with positions. Provide evidence based research to support your nursing care

Provide evidence-based research and supported nursing care

Which action by patience marks in the beginning of the physical assessment process? Redressing after physical examination. Breathing normally during escalation. Greeting the nurse an examination room. Sharing work environment information

Reading the nurse an examination room

which action should the nurse take first during the initial phase of implementation?

Reassess the Patient

Action are part of the valuation step in the nursing process? Recognizing the need for modification to the care plan. Documenting perform nursing interventions. Determining whether nursing interventions were completed. Reviewing with her patient meta-share term goal. Identifying realistic out comes with a patient input.

Recognizing the need for modification to the care plan. Reviewing weather patient method short term goal

Need for collaborative interventions provided by several healthcare team members? Hospice referral. Physical assessment. Activities of daily living. Health history interview

Referral hospice

What is the primary difference between Ananda one risk nursing diagnosis and a problem focused nursing diagnosis? Related factors are not a part of her wrist diagnosis. There are no cause-and-effect relationships establish. Defining characteristics are subjective and risk diagnosis. There are no nursing interventions prescribed with a risk diagnosis

Related factors are not a part of a risk diagnosis

The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse guided by critical thinking which action should the nurse take first? Ask a patient to describe the chief complaint. Request another nurse besides patient. Review information about the medical diagnosis and routine management. Complete a physical assessment of the patient.

Review information about the medical diagnosis and routine management

A patient come to the emergency department complaining of nausea and vomiting what should the nurse ask the patient about first? Family history of diabetes medication the patient is taking operations the patient has had in the past severity and duration of the nausea and vomiting

Severity and duration of nausea and vomiting

SMART

Specific, Measurable, Attainable, Realistic, Timely

Facilitate critical thinking through the use of which interpersonal skills? Teamwork. Intuition. Judgment. Conflict management. Advocacy. Reasoning.

Teamwork conflict management advocacy

Which task may be registered nurse safely delegate to unlicensed assistive personnel without prior intervention. Ambulating a patient with ataxia and then you right sided Harris Senia. Feeding a patient with cerebral palsy who recently aspirated. Transporting a patient to the hospital entrance for discharge. Administering prescribed program medication

Transporting a patient to the hospital entrance for discharge

What is Maslows needs

Use of Maslows hierarchy of needs help organize the most urgent to let urgent need

Which of the following reasons actions reflects inductive reasoning? Using subjective and objective data to confirm a diagnosis. Assessing for specific clinical presentation face on a disease process. Correlating elevated blood pressure to pathophysiology. Validating an automatic blood pressure cuff reading with a manual measurement.

Using subjective and objective data to confirm a diagnosis

3 point gait

Weight is distributed on both crutches and then on the *unaffected* leg -- then repeat sequence

Approaching a new clinical situation the nurse uses which question to facilitate precision in critical thinking? What do I know about the situation. What additional details do I need together. What does clinical presentation correlate with a diagnosis. Are the treatments appropriate for the diagnosis

What additional details I need to gather

Which question would most likely be appropriate for the nurse to ask while evaluating the relevance of patient data? Did the findings makes sense. How can this information be verified. What are the most significant factors in the problem. What is the relationship of this information to other data.

What is the most significant factors of this problem

Fowler's position

a semi-sitting position; the head of the bed is raised between 45 and 60 degrees with pillowing supporting under legs

If a patient is exhibiting signs and symptoms of each of these nursing diagnosis which should the nurse address first while playing care? Fatigue. Acute pain. Lack of knowledge. Disturb your body image

acute pain

two- point gait with crutches is what

both legs bear partial weight

cane walking

cane goes on the strong arm, when walking- bear weight on cane when moving weak leg

Evaluation

care plan evaluation did the patient reach their goal? continue? revise?

During the assessment of a patient needed for a total hip replacement the nurse asked the patient explain prior hospital experiences and more specifically any operative experiences these questions for flight on the nurses use of which intellectual standard of critical thinking? Clarity. Logic. Precision. Significance.

clarity

assessment

data collection primary- from the patient secondary- from the family, friends etc subjective- symptoms and health history objective- signs physical examination, labs, diagnostic testing

how does a patient walk downstair/upstairs with crutches

going up- good leg then crutch, then bad leg going down- crutch then bad leg, good leg

Which phrase best represents a related factor in a problem focused nursing diagnosis? Unsteady gait requiring the assistance of two people? Reading redness and swelling around the incision site? Ineffective adaptation to recent loss? Patient complaint of restlessness

ineffective adaptation to recent loss

direct care

interventions carried out WITH the patient

Implementation

interventions(independent, dependent, collaborative care, direct , indirect documentation careplans

supine

lying on the back

Call action should the nurse take regarding a patient plan of care if the patient appears to have some meth short-term goals of urinating within one hour of surgery? Consult the surgeon to see if the clinical pathways being followed. Discontinue the plan of care because patient has met establish cool. Monitor patient urine output to evaluate the need for a current plan of care. Notify the patient ago has been and no further intervention is needed.

monitor the patient urine output to evaluate the need for a current plan of care.

collaborative and interdependent nursing care

multiple areas

can you transfer a patient to another unit without doctors order?

no not without orders from a doctor

objective date

observe, measurable, vitals, (BP)

sims

patient in semipro position lying on left side

prone

patient lying face down

knee-chest

patient lying in prone position with buttocks and knees drawn to the chest

side-laying

patient lying on side

dorsal recumbent

patient lying supine legs bent

trendelenburg

patient lying supine with legs elevated higher than head

lithotomy

patient lying with legs in stirrups

Which action would the nurse undertake first one beginning to formulate a patient's plan of care? A list of possible treatments. Identify realistic outcome indicators. Consult with healthcare team members. Rank patient concerns for assessment data

patient risk for concerns for assessment data

Which statement is an appropriately written short term goal? Patient will walk to the bathroom independently without following within two days after surgery. Nurse will watch patient demonstrates proper insulin injection technique each morning. Patient spouse for Xpress satisfaction with patient's progress before discharge. Patient decision will be well approximated each time it is assessed by the nurse.

patient will walk to the bathroom independently without falling 2 days after surgery

subjective

primary patient states secondary- family, friends, spouse says if patient is unconscious

planning

prioritize nursing diagnosis personalize care plans short and long term outcome identification (NOC)

lower fowler

sitting in 15 -30 degree

semi-flower

sitting in 30-45 degrees

etiology

the cause of something

An alert oriented patient is admitted to the hospital with chest pain from whom should the nurse call collect primary data from the patient? Family member? Physician? Another nurse? The patient?

the patient

hand hygiene

washing hands with soap and water or alcohol-based hand rubs. ensure to use soap when a patient has C-diff

independent nursing care

you do NOT need a doctors order

dependent nursing care

you need a doctors order