Fundamentals Exam 1

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

Functional assessment

H.E.L.P

H = Help: Observe the first signs patient may need help. Look for signs of distress (pallor, pain, labored breathing). E = Environmental equipment: Look for safety hazards; ensure that all equipment is working (IVs, oxygen, catheter). L = Look: Examine patient thoroughly. P = People: Who are the people in the room? What are they doing?

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High risk for injury related to unsafe home enviroment

4 methods of the physical assessment

Inspection: the process of performing deliberate, purposeful observations in a systematic manner Palpation: use of the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body Percussion: the act of striking one object against another to produce sound Auscultation: the act of listening with a stethoscope to sounds produced within the body

Three helpful guides to facilitate clinical reasoning when prioritizing patient problems

Maslow's hierarchy of human needs, patient preference, and anticipation of future problems.

Medical diagnosis vs nursing diagnosis

Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness ex: Myocardial infarction (heart attack) is a medical diagnosis. Examples of nursing diagnoses for a person with myocardial infarction may include Fear, Altered Health Maintenance, Deficient Knowledge, Pain, and Altered Tissue Perfusion.

Nursing in early civilizations to 16th century

Most early civilizations believed that illness had supernatural causes. The theory of animism attempted to explain the cause of mysterious changes in bodily functions. This theory was based on the belief that everything in nature was alive with invisible forces and endowed with power. Good spirits brought health; evil spirits brought sickness and death. In providing treatment, the roles of the health care provider and the nurse were separate and distinct. The health care provider was the medicine man who treated disease by chanting, inspiring fear, or opening the skull to release evil spirits. The nurse usually was the mother who cared for her family during sickness by providing physical care and herbal remedies. This nurturing and caring role of the nurse has continued to the present

PE

Problem and etiology

Nursing diagnosis should be:

Specific, Measurable, Attainable, Realistic, Timely

ANA Scope and Standards of Practice

Standards of Practice address the key steps involved in caring for patients; Standards of Professional Performance address the key concepts that the nurse integrates into his or her role as a professional nurse.

Patient-centered measurable outcomes

Subject: the patient or some part of the patient. Verb: the action the patient will perform. Conditions: the particular circumstances in or by which the outcome is to be achieved. Not every outcome specifies conditions. Performance criteria: the expected patient behavior or other manifestation described in observable, measurable terms. Target time: when the patient is expected to be able to achieve the outcome. The target time or time criterion may be a realistic, actual date or other statement indicating time, such as "before discharge," "after viewing film," or "whenever observed." (SMART)

The standards you must apply when identifying outcomes and related nursing interventions are determined by

The law, national practice standards, joint commission, specialty prof organizations, AHRQ, employer

Evaluative statement

The two-part evaluative statement includes a decision about how well the outcome was met, along with patient data or behaviors that support this decision. Outcomes may have been met, partially met, or not met.

4 broad aims of Nursing

To promote health To prevent illness To restore health To facilitate coping with disability or death

Problem-focused nursing diagnosis

a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor.

Minimum Data Set (MDS)

a standard established by health care institutions that specifies the information that must be collected from every patient

Health

a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity

Nursing diagnosis

actual or potential health problem that an independent nursing intervention can prevent or resolve (actual problem is present; possible problem may be present, but more data are needed to confirm or disconfirm the problem; and potential problem may occur); defining characteristics are present as risk factors

Collaborative problem

actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team toward its resolution

Time-lapsed assessment

an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier

Nursing intervention

any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated, and collaborative interventions

Focused assessment

assessment conducted to assess a specific problem; focuses on pertinent history and body regions

Nursing history

assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care

Health promotion nursing diagnosis

behavior of an individual motivated by a personal desire to increase well-being and health potential

Implementation

carrying out the plan of care

Clinical pathways

case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay

Risk nursing diagnosis

clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

Initial comprehensive assessment

comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient

Nursing diagnosis are written to...

describe patient problems or issues that nurses can treat independently, such as activity, pain and comfort, and tissue integrity and perfusion problems.

The nurse has established client outcomes and outcome criteria. What should the nurse do next

develop a plan of care

Nursing Outcomes Classification (NOC)

developed by the Iowa Outcomes Project and presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention

In 1973, The American Nurses Association's Standards of Practice included...

diagnosing as a function of professional nursing.

Retrospective evaluation

evaluation of nursing care and patient outcomes after the patient has been discharged using postdischarge questionnaires, patient interviews, or chart review to collect data

Secondary traumatic effect

feeling of despair caused by the transfer of emotional distress from a victim to a caregiver, which often develops suddenly

Nursing Interventions Classification (NIC)

first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions

International nursing organization

first international organization of prof women

Data cluster

grouping of patient data or cues that points to the existence of a patient health problem

Etiology

identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor

Nurse-initiated intervention

independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional and that result from their assessment of patient needs

Wellness

is an active state of being healthy by living a lifestyle that promotes good physical, mental, emotional, and spiritual health.

One major requirement of a nursing diagnosis is that it focus on a problem that is:

legally treated by registered nurses

Compassionate fatigue

loss of satisfaction from providing good patient care

Evaluation

measurement of the extent to which the patient has achieved the goals specified in the plan of care; factors that positively or negatively influence goal achievement are identified, and the plan of care is terminated or revised

Nursing in early christian period

nursing began to have a formal and more clearly defined role in society. Led by the idea that love and caring for others were important, women called "deaconesses" made the first organized visits to sick people, and members of male religious orders gave nursing care and buried the dead. Both male and female nursing orders were founded during the Crusades (11th to 13th centuries). Hospitals were built for the enormous number of pilgrims needing health care, and nursing became a respected vocation

Outcome Identification

observation of the patient to demonstrate the resolution of the problems identified by the nursing diagnoses and general problem list, along with the time frame for accomplishing these outcomes

Quality Assurance Program

ongoing evaluation program designed and implemented to secure the excellence of health care; may involve an assessment of structure, process, and outcome standards

Clinical inquiry

ongoing process of questioning and evaluating practice and advancing informed practice

NANDA terminology for nursing diagnosis

pg 369

Standarized Care Plan

prepared plan of care that identifies the nursing diagnoses, patient goals, and related nursing orders common to a specific population (e.g., normal neonates) or problem

During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to establish

priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care.

PED

problem, etiology, and defining characteristics

Reciprocity

process allowing a nurse to apply for and be endorsed as a registered nurse by another state

Nursing assessments should be...

purposeful, prioritized, complete, systematic, factual, relevant, and recorded in standard manner

Emergency assessment

rapid focused assessment conducted to determine potentially fatal situations

Cue

significant information that is helpful in making decisions

Concurrent evaluation

the evaluation of nursing care and patient outcomes while the patient is receiving care, conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met

Assessment

the systematic and continuous collection, analysis, validation, and communication of patient data, or information

Delegation

the transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome

Nurse in latin means

to nourish

Patient centered assessment method

tool for assessing patient complexity using the social determinants of health that often explain why patients with the same or similar health conditions differ in their ability to manage their health and in their outcomes

In 1953, the term nursing diagnosis...

was introduced by Fry (1953) to describe a step necessary in developing a care plan.

Nursing care plan

written guide to direct the efforts of the nursing team as they work with the patient to meet health goals; specifies prioritized nursing diagnoses, patient goals, and nursing orders

Purposes of diagnosing

(1) identify how a person, group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); (3) identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems.

Maslow's Hierarchy of Needs

(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization

ANA model quality-assurance program

- A structure evaluation or audit focuses on the environment in which care is provided. Standards describe physical facilities and equipment; organizational characteristics, policies, and procedures; fiscal resources; and personnel resources. - The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. Criteria make explicit acceptable levels of performance for nursing actions related to patient assessment, diagnosis, planning, implementation, and evaluation. - Outcome evaluation focuses on measurable changes in the health status of the patient, or the end results of nursing care. While the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in patient health status.

Significant cues

- Change in a patient's usual health patterns that is unexplained by expected norms for growth and development - Deviation from an appropriate population norm - Behavior that is nonproductive in the whole-person context - Behavior indicating developmental lags or evolving dysfunctional patterns

Criteria vs. Standards

- Criteria are measurable qualities, attributes, or characteristics that identify skills, knowledge, or health states. They describe acceptable levels of performance by stating what is expected of the nurse or the patient. - Standards are the levels of performance accepted by and expected of nursing staff or other health team members. They are established by authority, custom, or consent

Nursing is recognized as a profession bc

- Well-defined body of specific and unique knowledge - Strong service orientation - Recognized authority by a professional group - Code of ethics - Professional organization that sets standards - Ongoing research - Autonomy and self-regulation

Nursing in 19th-21st centuries

- during the Civil War focused attention on the need for educated nurses in the United States. Schools of nursing, founded in connection with hospitals, were established on the beliefs of Nightingale, but the training they provided was based more on apprenticeship than on educational principles. Hospitals saw an economic advantage in having their own schools, and most hospital schools were organized to provide more easily controlled and less expensive staff for the hospital. This resulted in a lack of clear guidelines separating nursing service and nursing education. - As students and as graduates, female nurses were under the control of male hospital administrators and health care providers. The lack of educational standards, the male dominance in health care, and the pervading Victorian belief that women were subordinate to men combined to contribute to several decades of slow progress toward professionalism in nursing - World War II had an enormous effect on nursing. For the first time, as large numbers of women worked outside the home, they became more independent and assertive. These changes in women and in society led to an increased emphasis on education - Schools of nursing were based on educational objectives and were increasingly developed in university and college settings, leading to degrees in nursing for men, women, and minorities.

Planning

- planning that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care - establish patient goals to prevent, reduce, or resolve the problems identified in the nursing diagnoses and determination of related nursing interventions

Nursing

- profession that focuses on the holistic person receiving health care services and provides a unique contribution to the prevention of illness and maintenance of health - focused on assisting people, families, and communities to attain, recover, and maintain optimum health and function from birth to old age

Guidelines for writing nursing diagnosis

1. Phrase the nursing diagnosis (DX) as a patient problem or alteration in health state rather than as a patient need. 2. Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase "related to" (R/T). 3. Consider when at-risk populations or associated conditions should be identified. 4. Defining characteristics, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase "as manifested by" or "as evidenced by" (AEB). 5. Write in legally advisable terms. 6. Use nonjudgmental language. 7. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance). 8. Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement. 9. Reread the diagnosis to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.

5 rights of delegation

1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation

5 elements of evaluation

1.) IDENTIFYING evaluative criteria + standards (what are you looking for when you evaluate, e.g., expected patient outcomes) 2.) COLLECTING data to determine whether these criteria + standards are met 3.) INTERPRETING + summarizing findings 4.) DOCUMENT your judgement 5.) TERMINATING, CONTINUING or MODIFYING the plan

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? A. Perform the focused assessment as this is an independent nurse-initiated intervention. B. Request an order from Jill's physician since this is a physician-initiated intervention. C. Request an order from Jill's physician since this is a collaborative intervention. D. Request an order from the nutritionist since this is a collaborative intervention

A

Guideline

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is:

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of:

A cue

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. A. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. B. The nurse uses a binary decision tree for stepwise assessment and intervention. C. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. D. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. E. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. F. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

A,C A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." B. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" C. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." D. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." E. "We need to check your health status and see what kind of nursing care you may need." F. "We need to see if you require a referral to a physician or other health care professional."

A,E,F Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

National Database of Nursing Quality Indicators (NDNQI)

ANA-funded database of nursing-sensitive quality indicators aimed at promoting and facilitating the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes

Alfaro's Rule

ASSESS patients before preforming nursing actions RE-ASSESS them to determine their responses after you perform nursing actions REVISE your approach as indicated RECORD patient responses + any changes you made in the plan of care

Nursing Process

Assessment Diagnosis Planning Implementation Evaluation

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? A. Risk for Impaired Skin Integrity B. Related to prescribed bed rest C. As evidenced by D. As evidenced by reddened areas of skin on the heels and back

B

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? A. Administer pain medication. B. Reassess the patient. C. Prepare the equipment. D. Explain the procedure to the patient.

B

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" B. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D. "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

B Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure?A. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions B. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings C. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention D. A complete list of reimbursable charges for each nursing intervention

B The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. A. The nurse formulates nursing diagnoses. B. The nurse identifies expected patient outcomes. C. The nurse selects evidence-based nursing interventions. D. The nurse explains the nursing care plan to the patient. E. The nurse assesses the patient's mental status. F. The nurse evaluates the patient's outcome achievement.

B,C,D During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. A. Bronchial pneumonia B. Impaired gas exchange C. Ineffective airway clearance D. Potential complication: sepsis E. Infection related to pneumonia F. Risk for septic shock

B,C,F Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A. A nurse sits down with a patient and prioritizes existing diagnoses. B. A nurse assesses a woman for postpartum depression during routine care. C. A nurse plans interventions for a patient who is diagnosed with epilepsy. D. A busy nurse takes time to speak to a patient who received bad news. E. A nurse reassesses a patient whose PRN pain medication is not working. F. A nurse coordinates the home care of a patient being discharged.

B,D,E Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. A. The nurse uses the nursing interview to collect patient data. B. The nurse analyzes data collected in the nursing assessment. C. The nurse develops a care plan for the patient. D. The nurse points out the patient's strengths. E. The nurse assesses the patient's mental status. F. The nurse identifies community resources to help his family cope.

B,D,F The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A. Maslow's human needs B. Gordon's functional health patterns C. Human response patterns D. Body system model

B. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? A. Protocols for treating the patient problem B. Standardized treatment guidelines C. The nurse's ideas about the patient problem and treatment D. Clinical pathways for the treatment of sickle cell anemia

C A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

Clinical, Functional, and Quality-of-Life Outcomes

Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved. Functional outcomes describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes focus on key factors that affect someone's ability to enjoy life and achieve personal goals.

After performing an assessment on a client, the nurse determines that the client is having difficulty with airway clearance. The nurse supports this suspicion by listing as evidence: a nonproductive cough, crackles in the lower lobes, and a pulse oximeter reading of 94%. The nurse used which process?

Clustering

Cognitive, psychomotor, and affective outcomes

Cognitive outcomes describe increases in patient knowledge or intellectual behaviors—for example: "Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge." Psychomotor outcomes describe the patient's achievement of new skills—for example, "By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer." Affective outcomes describe changes in patient values, beliefs, and attitudes

A student health nurse is counseling a college student who wants to lose 20 lb. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the student has lost only 1 lb. Which is the BEST nursing response?A. Congratulate the student and continue the care plan. B. Terminate the care plan since it is not working. C. Try giving the student more time to reach the targeted outcome. D. Modify the care plan after discussing possible reasons for the student's partial success.

D

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? A. Correct the initial assessment form. B. Redo the initial assessment and document current findings. C. Conduct and document an emergency assessment. D. Perform and document a focused assessment of skin integrity.

D Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority

D.

Florence Nightingale

Defined nursing as both an art and a science, differentiated nursing from medicine, created freestanding nursing education; published books about nursing and health care; is regarded as the founder of modern nursing

During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to:

Establish priorities Identify and write expected patient outcomes Select evidence-based nursing interventions Communicate the nursing care plan