Nursing Process Overview

Focused Physical Assessment

A focused nursing assessment is an individualized physical examination conducted at the beginning of an acute care-setting shift or when signs indicate a change in a patient's condition. The purpose of a focused assessment is to establish the current patient status and identify deviations from the patient's baseline. A typical focused nursing shift assessment or focused assessment of a patient with changing status may include assessment of: Vital signs Heart and lung sounds Abdominal sounds Edema Peripheral pulse strength Capillary refill Skin turgor and integrity Muscle strength Wounds IV sites Supplemental oxygen delivery Urinary catheters Intake and output levels Unique patient concerns or conditions

Comprehensive Physical Assessment

An initial comprehensive or complete physical examination is performed by a nurse when a patient is newly admitted to a health care facility, during an annual physical, or on initial interaction with a specialist. A comprehensive assessment includes: Thorough interview Health history Review of systems Extensive head-to-toe physical exam

A nurse is caring for a patient with scleroderma. The nurse spent time with the patient and used great communication skills. Why is effective communication so important in nursing practice? Advocacy of the health care team Avoidance of patient harm Collaboration with family members Occupational safety of nurses

Answer: Avoidance of patient harm Explanation: Advocacy of the health care team An important aspect of effective communication is patient advocacy, rather than advocacy of the health care team. Avoidance of patient harm In more than 62% of sentinel health care events (i.e., unexpected death, injury, or serious risk of injury) that occurred between 2011 and June 2013, communication breakdown was identified as one of the top three causes (The Joint Commission, 2013). Collaboration with family members An important aspect of effective communication is collaboration among health care team members, but avoiding patient harm is most important. Occupational safety of nurses Occupational safety of nurses is not identified as an important aspect of effective communication.

According to Suchman's Stages of Illness Model, when are clinical manifestations experienced by a patient? Stage 1 Stage 2 Stage 3 Stage 4 NOT SURE

Answer: Stage 1 Explanation: Stage 1 During stage 1 (symptom experience), a clinical manifestation of disease is experienced, and the person acknowledges that something is wrong and seeks a cure. Stage 2 In stage 2 (assumption of the sick role), the person decides that the illness is genuine and that care is necessary. Stage 3 In stage 3 (medical care contact), the individual seeks professional advice from health care providers. Stage 4 In stage 4 (dependent patient role), the patient usually undergoes treatment.

Which option is a type of verbal communication used by a successful nurse? Crossing arms when angry Charting a patient's vital signs in the electronic record Changing voice inflection Furrowing eyebrows

Answer: Charting a patient's vital signs in the electronic record Explanation: Crossing arms when angry Crossing arms is nonverbal communication. Charting a patient's vital signs in the electronic record Charting a patient's vital signs in the electronic record is using written words to communicate, which is part of verbal communication. Changing voice inflection Changing the voice inflection is nonverbal communication. Furrowing eyebrows Furrowing the eyebrows is nonverbal communication.

Which type of nursing informatics specialty competency is a nurse using when working with a committee to evaluate the ethics of implementing a new patient-tracking software program? Utility Leadership Technical Beginner

Answer: Leadership Explanation: UtilityUtility competencies address critical thinking and evidence-based practice applications. Nurses who have a utility competency recognize the relevance of nursing data for improving practice and can access multiple information sources for gathering evidence for clinical decision making. Correct LeadershipLeadership competencies address the ethical and management issues related to using information technology in nursing practice, education, research, and administration. TechnicalTechnical competencies pertain to the use of computers and other technological equipment and the use of a variety of software programs for word processing, spreadsheet and database development, presentation, referencing, and e-mail. BeginnerBeginner is not a type of nursing informatics specialty competencies. Beginner is a nursing informatics skill level. The nurse in this example is working at a nursing informatics skill level above beginner.

The nurse is caring for a post-operative patient. Which intervention is considered to be prevention-oriented? Oxygen administration Dressing change Post-operative ambulation Monitoring intake and output

Answer: Post-operative ambulation Explanation: Oxygen administration = Oxygen administration is a problem-oriented intervention. Dressing change = Dressing change is a problem-oriented intervention. Post-operative ambulation = Ambulating a patient after surgery is a prevention-oriented intervention because it aims to prevent complications. Monitoring intake and output = Monitoring intake and output is a problem-oriented intervention.

A nurse is teaching a high school student about the five senses as channels of communication. Which choice presented to the student is an example of an auditory channel assessment? Assessing urine for noxious odors Cleaning a patient and calling out for more linen Observing the patient's breathing pattern Documenting the findings in the patient's chart

Answer: Observing the patient's breathing pattern Explanation: Assessing urine for noxious odors Cleaning a patient and calling out for more linen Observing the patient's breathing pattern Documenting the findings in the patient's chart Assessing urine for noxious odors Assessing urine for noxious odors would be using the sense of smell. Cleaning a patient and calling out for more linen Cleaning the patient and asking for more linen is not using the auditory channel for assessment. Observing the patient's breathing pattern The nurse's observation of the patient's breathing pattern is using the auditory channel for assessment. Documenting the findings in the patient's chart The nurse documenting her findings in the patient's chart is not an auditory channel assessment.

A health care group collaborates because its members are very committed to an outcome. Which option includes this phase of group development? Forming Storming Norming Performing Forming

Answer: Performing Explanation: Forming During the forming phase, group members rely heavily on the leader to identify the group's mission and goals. Storming The storming phase may involve some personality conflicts among the group participants. Norming During the norming phase, increased trust and openness emerge, resulting in productivity and meaningful sharing of information. Performing Problem-solving takes place during performing, as group members are highly committed to outcomes.

The nurse is caring for a postoperative patient in the medical-surgical unit. Which interventions are considered to be independent nursing interventions? Select all that apply. Administration of IV fluids Use of incentive spirometer Administration of medications Hand hygiene Ambulating the patient

Answers: Use of incentive spirometer Hand hygiene Ambulating the patient Explanation: Administration of IV fluidsIV fluid administration is a dependent nursing intervention. Use of incentive spirometerUse of incentive spirometer is an independent nursing intervention. Administration of medicationsAdministration of medications is a dependent nursing intervention because it requires an order. Hand hygieneHand hygiene is an independent nursing intervention. Ambulating the patientAmbulating the patient is an independent nursing intervention.

The nurse is reviewing the patient's care plan and determines a goal has been met. What is this step of the nursing process called? Assessment Planning Implementation Evaluation

Answers: Evaluation Explanation: Assessment Assessment is the gathering of the patient data to formulate nursing diagnoses. Planning Planning is creating the plan of care and goals for the patient. Implementation Implementation is carrying out the interventions. Evaluation Evaluation involves the nurse reviewing the patient's achievement of goals established in the patient's plan of care.

Evaluation Overview

Care plan evaluation includes patient goal/outcome attainment, continue plan, revise/adapt plan, or discontinue plan?

Communication: Channel

Channel The channel is the way messages are conveyed and received through any of the five senses. A patient who shouts for help is using the auditory channel of communication. A nurse who observes a patient's gait for stability is using the visual channel for communication. A nurse who smells a patient's wound is using the olfactory channel. The number of channels used to convey information may affect the accuracy of communication. Typically, the more channels that are used to communicate, the more effectively the message is conveyed. In our example, the patient may have grimaced and pointed to the area of pain while asking for pain medication. The physical display of pain is a visual channel of communication.

Body Language

Body Language Body language communicates a person's thoughts more accurately than simple verbal interactions. When observing and interacting with patients, the nurse must be mindful of the following nonverbal cues: Posture, Stance, & Gait Facial Expressions Touch Gestures Symbolic Expression Posture, Stance, & Gait Posture, stance, and gait refer to the way a person stands, sits, or ambulates. An individual's posture and gait can convey volumes to those observing. Learn to recognize the following as you communicate: A relaxed body while sitting or standing indicates openness to what is being shared verbally in the conversation. The manner in which patients and nurses ambulate communicates clearly without any words being spoken. A person's gait gives multiple cues to the nurse.A distinctive, intentional gait may communicate self-confidence, the need for immediate action, or a variety of potentially negative cues.A patient who is walking slowly with a bowed head may be feeling hopeless or exhausted or be in deep thought. Facial Expressions Facial expressions, such as grimacing or rolling the eyes, communicate significant information. The nurse must be especially perceptive when communicating with the patient and family members to observe the visual cues to their feelings. Consider the following information: Some facial expressions may indicate fear or apprehension regarding impending procedures. If there is incongruence between verbal communication and nonverbal facial expressions of patients or family members, the nurse must assess the situation more carefully to identify and validate the most significant needs. Showing a facial expression of disgust when observing a patient's new wound may make the patient feel ashamed and embarrassed. Making inappropriate facial expressions may be offensive and hurtful to patients or their family members. Maintaining a neutral facial expression establishes an environment of caring and openness in which the patient and family members can feel safe to share their innermost concerns. Touch Making physical contact in patient care situations can communicate caring or can be perceived as restrictive, depending on the type of touch used. It is important for the nurse to be aware of or verify a patient's openness to touch before implementing it as a nursing intervention. The following tips will help you use touch appropriately: Gently touching a blind patient's arm before providing care helps to alert the patient to the nurse's presence. Therapeutic touch, such as holding the patient's hand or touching the patient's shoulder, can provide comfort and may alleviate pain. Therapeutic touch is especially important when a patient is undergoing a painful or stressful procedure. Ask permission to touch patients with a history of physical or sexual abuse or assault, or patients with various cultural or religious beliefs. Gestures The use of gestures may be challenging to nurses practicing in a multicultural environment. Although they may enhance verbal communication, the use of gestures may be viewed as inappropriate by patients of various cultures. Gestures may be most effective when used with people who have limited hearing. Gestures can also facilitate communication when a patient is unable to speak. Symbolic Expression Symbolic expression is exhibited through a person's physical appearance. The way a person chooses to adorn his or her self can communicate self-esteem, economic resources, or mental health. A patient's negative symbolic expression may indicate the need for more attention. A patient's positive symbolic expression may show signs of wellness. Be mindful of your own symbolic expression as a nurse so as to look professional. A professional appearance will communicate the message of competence and caring.

What Is Computer Literacy?

Computer literacy is knowledge of computers and the ability to use them efficiently. Computers are everywhere, and their applications continue to grow at an astounding rate. As health care becomes increasingly dependent on technology, the value of a nurse may be partly measured in terms of technological competency. A computer-literate nurse is able to easily learn and use new computer programs with minimal assistance.

Laboratory and other diagnostic tests are obtained during a patient office visit. These tests are associated with which type of patient assessment? Comprehensive Emergency Focused Shift

Correct Comprehensive Explanation: Comprehensive = Laboratory tests and other diagnostic tests are generally included in a comprehensive assessment. Emergency = Emergency assessments rapidly evaluate breathing, circulation, airway, and patient responsiveness. Focused = Focused assessment involves gathering vital signs and evaluating other physical aspects of the patient's medical condition. Shift = Nursing shift assessments are used to evaluate any changes in the patient's medical condition.

The nurse is explaining the patient's plan of care to the patient and notes that the patient's eyes are moving from side to side before he responds. How is this particular patient most likely processing the communication? Auditory channel Visual channel Olfactory channel Intrapersonal thoughts

Correct ANswer: Auditory channel Explanation: Auditory channelThe patient is listening and interpreting the communication before he provides feedback. Visual channelVisual channels of communication might include reading educational materials. Olfactory channelOlfactory communication involves the sense of smell. Intrapersonal thoughtsIntrapersonal communication is made up of the internal thoughts and feelings that a person has.

Which action will the nurse take when caring for a patient with chronic back pain? Focus on curative behaviors Allow expression of negative feelings Encourage the attitude of suffering with pain Reinforce hope for total relief in less than six months

Correct Answer(s): Allow expression of negative feelings Explanation: Focus on curative behaviorsChronic illnesses can last a lifetime; there is usually no cure. Allow expression of negative feelingsNurses can assist patients with strategies to cope with feelings of anger, frustration, and depression often associated with a chronic illness. Encourage the attitude of suffering with painThe attitude of being a victim, suffering with, or being afflicted by a chronic illness is viewed by nurses as a counterproductive behavior that needs positive intervention. Reinforce hope for total relief in less than six monthsOne of the classic characteristics of chronic illness/pain is that it will last longer than six months.

What does the use of information technology in health care enable? Select all that apply. Data retrieval Data suppression Data capture Data marketing Data storage

Correct Answer: Data retrieval Data capture Data storage Explanation: Data retrieval The use of information technology in clinical health care enables retrieval of patient health data. Data suppression Data suppression implies the concealment or hiding of data. The use of information technology in clinical health care does not enable data suppression. Data capture The use of information technology in clinical health care enables capture of patient health data. Data marketing Data marketing is the use of data in marketing or sales. HIPAA and facility policies prevent the use of health care data for data marketing purposes. Data storage The use of information technology in clinical health care enables storage of patient health data.

The nurse documents progress toward goals in the patient record as, "Goal unmet, patient unable to quit smoking." What is this notation called? Nursing diagnosis Nursing intervention Goal revision Evaluation statement

Correct Answer: Evaluation statement Evaluation statements are information documented in the patient's plan of care indicating the level of goal attainment.

Which is an example of a collaborative nursing intervention? Monitoring a patient's temperature and skin color for fever Administering antibiotics for infection as ordered by the provider Nursing assistant providing range-of-motion on the patient Turning a patient every two hours to prevent skin breakdown

Correct Answer: Nursing assistant providing range-of-motion on the patient Explanation: Monitoring a patient's temperature and skin color for feverMonitoring a patient for fever is an example of an independent nursing intervention. Incorrect Administering antibiotics for infection as ordered by the providerAdministering antibiotics for infection as ordered by the provider is an example of a dependent nursing intervention. Correct Nursing assistant providing range-of-motion on the patientCollaborative nursing interventions are initiated by the nurse or through consult with other health care team members, and conducted by other health care team members. Turning a patient every two hours to prevent skin breakdownTurning a patient every two hours to prevent skin breakdown is an example of an independent nursing intervention.

How can standardized nursing terminology directly enhance patient care? > Allows health care providers in different departments to better understand each other's reports > Allows the nurse to articulate pay raise requests to supervisors > Makes courses available to improve bedside manner > Improves the medical vocabulary of nurses

Correct Answer: Allows health care providers in different departments to better understand each other's reports Explanation: Allows health care providers in different departments to better understand each other's reports Standardized nursing terminology enhances patient care by facilitating better communication between health providers in different departments. Allows the nurse to articulate pay raise requests to supervisors Standardized nursing terminology does not enhance the ability of the nurse to articulate pay raise requests to supervisors. Makes courses available to improve bedside manner Standardized nursing terminology is not related to courses to improve bedside manner. Improves the medical vocabulary of nurses Improving the medical vocabulary of nurses does not directly enhance patient care.

The nurse is caring for a post-operative patient following hip repair. Which intervention is considered to be collaborative? Ambulation with physical therapy Vital sign monitoring Repositioning in bed Administration of pain medication

Correct Answer: Ambulation with physical therapy Explanation: The nurse is caring for a post-operative patient following hip repair. Which intervention is considered to be collaborative? Correct Ambulation with physical therapyAmbulation with physical therapy is a collaborative intervention that requires input among all members of the health care team. Vital sign monitoringMonitoring vital signs is an independent nursing intervention. Repositioning in bedRepositioning in bed is an independent nursing intervention with an aim of preventing skin breakdown. Administration of pain medicationAdministration of pain medication is a dependent intervention because it is ordered by the provider.

According to Suchman's Stages of Illness Model, what does the patient do during Stage 2? Assumes the sick role Undergoes treatment Experiences symptoms Makes medical care contact

Correct Answer: Assumes the sick role Explanation: Assumes the sick role During stage 2 (assumption of the sick role), the person decides that the illness is genuine and that care is necessary. Undergoes treatment During stage 4 (dependent patient role), the patient usually undergoes treatment. Experiences symptoms During stage 1 (symptom experience), a clinical manifestation of disease is experienced. Makes medical care contact In stage 3 (medical care contact), the individual seeks professional advice from health care providers.

Which is an example of an indirect-care intervention? Activities of daily living Informal counseling Patient assessment Communication with providers

Correct Answer: Communication with providers Explanation: Activities of daily livingDirect-care interventions include activities of daily living (ADLs). Informal counseling = Direct-care interventions include informal counseling. Patient assessment = Direct-care interventions include reassessment. Communication with providers = Indirect-care interventions are those that are performed to benefit the patient, but do not involve direct patient contact.

Which assessment should be performed during the patient's initial visit to a new health care provider? Brief Comprehensive Emergency Focused

Correct Answer: Comprehensive Explanation: Brief = A brief assessment is not an established form of nursing assessment. Comprehensive = A comprehensive assessment should be completed upon admission to a healthcare facility or during the first visit with a new health care provider. Emergency = Emergency assessments are extremely focused surveys of the injury/illness and occur when rapid decisions are needed. Focused = A focused assessment is normally done to evaluate the problem or concern at hand. It focuses on vital signs, edema, wounds, etc.

Determining a website's date of last update evaluates which criterion for credibility? Currency Authority Purpose Objectivity

Correct Answer: Currency Explanation: CurrencyThe currency of the information can be determined by checking for the date of last update. AuthorityDetermining the sponsor, publisher, or author evaluates the authority of the website. PurposeDetermining the intended audience evaluates the purpose of the website. ObjectivityDetermining evidence of bias evaluates the objectivity of the website.

Advocacy

Nurses advocate by supporting and working on behalf of patients or people for whom they have concern. Advocacy can be easy or challenging, depending on the situation. Nurses advocate for patients by coordinating care and supporting the changes necessary to improve conditions and outcomes.

The nurse is caring for a bedbound patient who develops a new area of skin breakdown, despite nursing interventions focused on prevention. The nurse informs the physician and updates the care plan with new interventions. How often is the care plan evaluated after the new interventions have been put into practice? Every 4 hours Every shift Daily Weekly

Correct Answer: Every Shift Explanation: Every 4 hoursNurses are not typically required to evaluate patient outcomes every 4 hours. Every shiftIn many agencies, nurses are required to evaluate outcomes at least once every shift. DailyPatient care plans are to be evaluated on a continual basis; daily would not be frequent enough. WeeklyPatient care plans are to be evaluated on a continual basis; weekly would not be frequent enough.

A nursing unit develops a quality improvement project aimed at decreasing patient falls. What type of guideline drives this quality improvement effort? Reimbursement Policies and procedures Evidence-based practice Patient satisfaction scores

Correct Answer: Evidence-based practice Explanation: ReimbursementQuality improvement efforts are not based on reimbursement. Policies and proceduresQuality improvement efforts are not driven by policies and procedures. Correct Evidence-based practiceQuality improvement efforts are driven by evidence-based practice guidelines. Patient satisfaction scoresQuality improvement efforts may be driven by patient satisfaction scores in some cases.

Which is the type of intervention that benefits the patient but does not involve face-to-face contact with the patient? Indirect-care Independent nursing Direct-care Prevention-based

Correct Answer: Indirect-care Explanation: Indirect-care Indirect-care interventions benefit the patient, but do not involve face-to-face contact with the patient. Independent nursing Independent nursing interventions are initiated and conducted by the nurse. Direct-care Direct-care interventions involve direct personal contact with the patient. Prevention-based Prevention-based interventions are implemented to prevent problems.

In addition to patient statements, what should the nurse be very attentive to during the interview? Family input Non-verbal cues Test results Vital signs

Correct Answer: Non-verbal cues Explanation: Family input = Input from family members can be important but family members may not be present during the interview. Non-verbal cues = Non-verbal cues can add valuable insight during the patient interview. If the verbal and non-verbal cues contradict each other, then the nurse needs to probe further to clarify the inconsistencies. Test results = Test results are important but would most likely not be available during the interview. Vital signs = Vital signs are important but are not formally assessed during the interview.

The nurse enters the patient's room and says, "Hi, my name is Barbara. I am your nurse. Let's discuss why you have been admitted to the hospital." What phase of the patient interview is taking place in this situation? Orientation Transition Working Termination

Correct Answer: Orientation Explanation: Orientation = The nursing introduction and purpose are covered during the orientation phase of the interview. Transition = The transition phase is not considered a phase of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Working = The working phase is used to gather information from the patient. Termination = The termination phase is used to let the patient know what to expect and give the patient a chance to ask any questions.

During which type of assessment would the nurse be most likely to assess skin turgor and capillary refill to determine the patient's clinical status? Comprehensive Emergency Focused Shift

Correct Answer: Shift Explanation: Comprehensive = A comprehensive assessment is based on the health care provider's examination and collected medical data. Emergency = Emergency assessment is based on the health care provider's interpretation of the patient's clinical condition in an emergency. Focused = A focused assessment is based on the nurse's assessment of the patient's specific medical problem. Shift = The nursing shift assessment requires a nurse to use clinical assessment skills (e.g., assessing skin turgor and capillary refill) to determine the patient's clinical status.

At the end of the interview, the nurse lets the patient know the interview is complete and the doctor will be in shortly. Before leaving the room, the nurse asks the patient if there are any questions. Which phase of the patient interview is represented by this statement? Orientation Transition Working Termination

Correct Answer: Termination Explanation: Orientation = The orientation phase is used as an introduction and determines the purpose of the interview. Transition = The transition phase is not considered a phase of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Working = Working phase is used to gather information from the patient. Termination = Summation and patient questions are included in the termination phase.

When nurses make determinations about patients needing emergent, urgent or non-urgent care, which type of assessment are they using? Comprehensive Focused Shift Triage

Correct Answer: Triage Explanation: Comprehensive = A comprehensive assessment does not incorporate the use of a three-tier system that identifies the patient's condition as emergent, urgent, or non-urgent. It is a full assessment taken during the patient's first visit to a health care facility. Focused = Determination of a patient's condition as emergent, urgent, or non-urgent is not a part of a focused assessment. Shift = Determination of a patient's condition as emergent, urgent, or non-urgent is not part of the nursing shift assessment. The shift assessment occurs at the beginning of every nursing shift to determine if there has been a change in the patient's condition. Triage = Triage incorporates the use of a three-tier or five-tier system to determine which patients are in most need of care. During a triage assessment, a nurse determines patient care as emergent, urgent, or non-urgent

A nursing student is giving a report on the different types of effective nonverbal communication. Which statement made by the student suggests that she understands effective nonverbal communication? Select all that apply. "When speaking to a patient, it is important to maintain eye contact." "Holding patients' hands when they are scared or worried is a good technique for nonverbal communication." "The nurse should never maintain eye contact; patients from different cultures might not appreciate it." "Sometimes silence is the best way to communicate with a patient." "A patient's spouse interrupting and not allowing me to discuss medical issues with the patient is a strong nonverbal signal."

Correct Answers: "When speaking to a patient, it is important to maintain eye contact." "Holding patients' hands when they are scared or worried is a good technique for nonverbal communication." "Sometimes silence is the best way to communicate with a patient." Explanation: "When speaking to a patient, it is important to maintain eye contact."Maintaining eye contact is an effective form of nonverbal communication. "Holding patients' hands when they are scared or worried is a good technique for nonverbal communication."Holding a patient's hand can help to provide emotional support. "The nurse should never maintain eye contact; patients from different cultures might not appreciate it."Maintaining eye contact should be done unless the patient states that he or she is uncomfortable. "Sometimes silence is the best way to communicate with a patient."Silence is effective to show that the nurse is mindfully "present" to support the patient. "A patient's spouse interrupting and not allowing me to discuss medical issues with the patient is a strong nonverbal signal."Although it is true that a strong signal is being sent by the spouse, interrupting the nurse as she's talking to the patient, this is verbal communication from the spouse and not a nonverbal signal.

What information should be included in a health history? Select all that apply. Patient's social history Reason for seeking medical care Patient demographic information Medications the patient is currently taking System-by-system review of the entire body

Correct Answers: Patient's social history Reason for seeking medical care Patient demographic information Medications the patient is currently taking Explanation: Patient's social history = The patient's social history is important to obtain during the health history since it includes information useful for determining risks and identifying problems. Reason for seeking medical care = Reason for seeking medical care is obtained during a health history. This is often asked very early in the health history interview. Patient demographic information = Patient demographics should always be included in a health history, and are usually the first questions asked. Medications the patient is currently taking = It is important to obtain the patient's current medications during a health history. System-by-system review of the entire body = System-by-system review of the entire body is performed during a review of systems. It is not part of the health history of the patient.

The nurse is caring for a patient who has a goal of losing 10 pounds within the next 2 weeks. After 2 weeks, the nurse and patient determine that the goals were unmet. What factors are looked at to determine what prevented goal achievement? Select all that apply. Realistic Barriers Modifications Motivation Rewards

Correct Answers: Realistic Barriers Modifications Motivation Explanation: RealisticThe nurse and patient reflect on whether or not the original goal was realistic. BarriersThe nurse and patient reflect on what barriers prevented goal achievement. ModificationsThe nurse and patient discuss what modifications need to be made to achieve the goal. MotivationThe nurse and patient do not consider the motivation involved in goal achievement. RewardsThe nurse and patient do not discuss rewards.

Delegation

Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task still remains accountable (ANA, 2010). Delegation is an indirect intervention based on assessment findings and established care priorities. The nursing process, however, cannot be delegated. In most jurisdictions, licensed practical nurses (LPNs) function in a dependent role and may not delegate (Kelly and Marthaler, 2011) to others. The registered nurse (RN) is most responsible for incorporating delegation into practice.

Communication

Effective communication and collaboration regarding patient care are essential for patient safety and positive patient outcomes. Change-of shift reports, ongoing communication with with providers and specialists, and accurate documentation of assessment findings provide continuity of care.

Six Elements of Communication

Elements of Communication The dynamic process of communication occurs when six key elements interact. These six key elements are: Referent Sender Receiver Message Channel Feedback For communication to be effective, the process must be interactive and ongoing. Realizing that a variety of factors may initiate the communication process helps the nurse to critically analyze the purpose and meaning of interactions.

Emergency Physical Assessment

Emergency assessments, including triage, are conducted in emergency situations to quickly assess the extent of patient injuries and determine care priorities. Attention is paid to the patient's: Airway Breathing Circulation During an emergency, the nurse may never have the time to do a complete assessment and may work to stabilize one body system at a time.

Communication: Feedback

Feedback To avoid misinterpretation of a message, it is essential that the receiver provide feedback to the sender regarding the conveyed meaning. By repeating or asking the receiver to restate the message, the sender is able to verify that the message was understood. In our example, feedback could be provided by the nurse saying to the patient, "I'm glad you informed me about your pain and your desire for pain medication. I'll review your chart and see what options are available right now."

Referrals

Healthcare referrals involve sending a patient to another member of the interdisciplinary healthcare team or agency for a consultation or other services. Referrals for specialized services can support and protect patients. Nurses are often instrumental in initiating these types of referrals.

The Nursing Minimum Data Set

Implementation of electronic records increases the necessity for standardized terminologies for documentation, because computers cannot make the association between different expressions meaning the same thing. The use of standardized terminologies promotes consistent documentation and allows the description and comparison of nursing care across a variety of settings, facilitating measurement of the impact of nursing interventions on patient outcomes (Lunney, Delaney, Duffy, et al., 2005). The Nursing Minimum Data Set (NMDS), proposed in 1991 and used today, represents one of the first attempts by nursing informatics specialists to standardize the collection of essential nursing data. These core data, used on a regular basis by most nurses in the delivery of care across settings, provide labels and accurate descriptions of nursing diagnoses, nursing care, outcomes of care, and nursing resources used. Collected on an ongoing basis, the NMDS enables nurses to compare data across populations, settings, geographic areas, and time (Werley and Lang, 1988).

Match the term with its definition. Knowledge of computers and the ability to use them efficiently Able to recognize need for information; locate, evaluate, use effectivelyUse of health information systems to support nursing practiceInformation literacy Nursing informatics Computer literacy

Knowledge of computers and the ability to use them efficiently = Computer literacy Able to recognize need for information; locate, evaluate, use effectively = Information literacy Use of health information systems to support nursing practice = Nursing informatics

Physical Care

Many interventions focus on physical care that is performed when treating patients. These interventions may include invasive procedures, such as starting an intravenous line or inserting a catheter, or they may be noninvasive, such as administering oral medications and repositioning. The nurse must perform the procedures competently and safely, taking into consideration any of the patient's special needs.

Medical informatics

Medical informatics refers to informatics related to health care and describes a distinct specialty in the discipline of medicine. It deals with the resources, devices, and methods required for the acquisition, storage, retrieval, and use of information in health and biomedicine. In addition to computers, informatics tools in health care include clinical guidelines, formal medical terminologies, and information and communication systems.

Types of Informatics

Medical informatics refers to informatics related to health care and describes a distinct specialty in the discipline of medicine. It deals with the resources, devices, and methods required for the acquisition, storage, retrieval, and use of information in health and biomedicine. In addition to computers, informatics tools in health care include clinical guidelines, formal medical terminologies, and information and communication systems. Nursing informatics is a specialty area of informatics that addresses the use of health information systems to support nursing practice. The American Nurses Association (ANA, 2008) states that the specialty of nursing informatics integrates nursing computer and information science for the management and communication of data, information, knowledge, and wisdom.

Communication: Message

Message The message is the content from the sender that is transmitted through communication. Messages are transmitted through all forms of communication, including spoken, written, and nonverbal modalities. Many mistakes of interpretation can take place in the communication process because of the variety of factors that influence the understanding of the message. The factors may include the people involved, mode of communication, and physical and emotional issues. For example, the patient presses the call light to get the attention of the nurse. The message that the patient requests attention is conveyed by turning on the light. When the nurse speaks with the patient, the patient sends another message to the nurse, this time verbal, asking for pain medication.

Types of Assessment

Methods through which assessment is conducted include observation, the patient interview, and a physical examination. Observation involves using sight, hearing, and smell throughout the assessment process to observe the patient's general affect, hygiene, and obvious physical conditions. Patient interview is a formal, structured discussion through which demographic and medical data are collected. Physical examination is the systematic and intentional assessment of a patient's body.

Nonverbal Communication

Nonverbal communication is communication without words. Body language constitutes the majority of all nonverbal communication (55%) as opposed to voice inflection (38%) Mehrabian (1971). Realizing the frequency and value of nonverbal communication helps the nurse to observe and assess patients more accurately. Nurses who perceive the potential effect of their own nonverbal behavior will communicate more professionally and consistently when interacting with others.

Public Communication

Nurses practice public communication often through patient and community education on healthcare issues. Public communication requires education, preparation, openness to diverse opinions, and communication skills that encourage acceptance and dialogue. Nurses may be asked to serve as professional experts on health care issues, a role which can include speaking about wellness at various workplaces, giving health education at health fairs, and speaking on behalf of a healthcare board of directors. Training in public speaking may be beneficial for nurses who anticipate extensive public communication in their professional roles.

Potential Evaluation Outcomes

Potential Evaluation Outcomes The evaluation process begins by asking the question, "Has the patient's goal been met?" Evaluation Goal Met When a goal is met, the nurse decides if the goal should be continued or discontinued, based on patient preference and the nurse's clinical judgment. Goal Partially Met When a goal is partially met, the nurse tries to figure out why and revises the care plan. The goal may be continued with a new timeframe or modified. Goal Unmet When a goal is unmet, the nurse should consider what went wrong in order to decide whether to continue, revise, or discontinue the goal.

Planning Overview

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

Communication: Receiver

Receiver There must be a receiver of information for the process of communication to take place. Receivers need to actively listen, observe, and engage in a conversation to decode the meaning of what is being communicated. Numerous factors may affect the ability of the receiver to accurately decode a message, including shared experiences with the sender, timing, educational background, cultural influences, and physical and emotional states. The message may be misinterpreted if clarity is not sought and achieved by the receiver. In our example, the receiver is the nurse to whom the patient is going to send the message.

TIGER Initiatives

The Technology Informatics Guiding Education Reform (TIGER) initiative (2014) identified a set of nursing informatics skills needed by all nurses practicing in the 21st century. The TIGER Vision Pillars include management and leadership, education, communication and collaboration, informatics design, and IT policy and culture. This skill set includes informatics competencies that range from basic computer skills to advanced level IT, and literacy competencies and expertise. TIGER's vision for the future of nursing addresses informatics and the use of emerging technologies to provide safer, patient-centered care by using evidence and technology in practice, education, and research.

Communication: Sender

Sender The sender is the person or group who has a message to deliver to a receiver. The sender encodes, or translates thoughts for interaction with the receiver, then chooses which mode of communication best delivers the message. An example of a sender is a patient wanting to deliver a message of needing pain medication.

Teaching

Teaching is an essential professional nursing intervention. It should be an ongoing process, and one that is used each time the nurse interacts with the patient. Nurses empower patients and their support systems through effective teaching. When nurses provide patients and their families with opportunities to ask questions and comprehend healthcare information, they become an integral part of the healthcare process.

What are the goals of nursing informatics?

The goal of nursing informatics is to improve the health of populations, communities, families, and individuals by optimizing information management and communication.

The nurse performs patient care interventions according to the individualized care plan. What is the next step in the process? Resolve the interventions. Determine the goals. Document the interventions. Plan the patient's care.

The nurse has assessed the patient and established a nursing diagnosis of Risk for Impaired Skin Integrity related to immobility. She has determined the interventions are to reposition the patient every two hours and maintain meticulous skin hygiene so that skin integrity is maintained. What is the next step of the nursing process? Correct Implement the interventionsImplementation occurs once the nurse has assessed the patient, established the nursing diagnosis, and planned the patient's care. Incorrect Determine the goalsGoals are determined as part of the planning process. The goal is to maintain skin integrity. Evaluate the patient's response to the interventionsThe interventions are implemented and then the nurse can evaluate their effectiveness. Plan the patient's careDetermining the interventions and goals in planning the patient's care. Once completed, the nurse implements the interventions.

Patient Interview

The patient interview is a formal, structured discussion in which the nurse questions the patient to obtain data about: Demographics Current health concerns Medical and surgical histories The patient interview consists of three phases: orientation, working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient.

Skill Levels in Nursing Informatics Beginners Experienced Specialists Innovator

There are four skill levels commonly recognized in nursing informatics: beginner, experienced, specialist, and innovator. All levels identify specific knowledge and skills involved in using information technology (IT) to enter, retrieve, and manipulate data to produce information for nursing practice and contribute to nursing knowledge. Beginner nursing informatics skills include computer, information, and web literacy; fundamental skills in information management and computer technology; and the ability to identify and collect relevant data. The nurse at the beginning level may have keyboarding skills, can document in the electronic health record (EHR), and look up medications and other health information on reputable Internet reference sites. The nurse at the experienced level of informatics competency is able to see data relationships and make judgments based on trends and patterns in data, is skilled in information management and the use of computer technology, and is able to suggest areas for IT system improvement. Examples of experienced competencies include relating data posted by others to the nursing assessment, basing the nursing process and clinical decisions on the data, and devising better ways of using data from the EHR. The nurse at the specialist level of competency focuses on information needs for the practice of nursing; integrates and applies information science, computer science, and nursing science; and applies skills in critical thinking, data management, processing, and system development. At the specialist level of competency, the nurse may conduct research based on information trends or patient data, devise applications for computer technology in nursing, or develop new software to enhance nursing care. Nursing informatics innovators conduct research and generate theory. They develop solutions and understand the interdependence of systems, disciplines, and outcomes.

Match the assessment method with its description. Using sight, hearing, and smell to observe general affect, hygiene Collection of demographic and medical data Systematic assessment of the patient's body Patient interview Observation Physical examination

Using sight, hearing, and smell to observe general affect, hygiene = Observation Collection of demographic and medical data = Patient interview Systematic assessment of the patient's body = Physical examination

Benefits of Using Standardized Nursing Terminology

A standardized nursing terminology is a structured vocabulary that provides a common means of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem. Standardized language applies to all types of communication within a profession, including spoken and written communication.

ADLs

Activities of daily living (ADLs) include tasks that are undertaken on a regular basis, such as eating, dressing, bathing, toileting, and ambulation. Because patients perform ADLs at different levels, it is important for the nurse to assess where deficits exist and to determine whether patients require short- or long-term interventions to address their needs.

Acute vs. Chronic Illness Illness can be categorized as acute or chronic, depending on the clinical course and prognosis of the disease, injury, or other condition. Acute Illness is any condition characterized by signs and symptoms of rapid onset and short duration which affect normal functioning. Chronic Illness is any condition in which signs and symptoms persist over a long period and affect normal functioning.

Acute illness is typically characterized by an abrupt onset and short duration of less than six months. Clinical Manifestations (Signs and Symptoms)Will appear quickly.May be self-limiting or resolve quickly with treatment, or they may be severe and fatal.ConsequencesPhysical and psychologic consequences can affect a patient's immediate functional ability.Residual effects may last beyond the course of the disease or injury itself.ExamplesCold or fluEar infectionBladder infectionChickenpoxMigraine headacheHeart attack hronic illness is characterized by physical or mental impairment that lasts longer than six months and requires ongoing long-term care. Clinical Manifestations (Signs and Symptoms)Last more than six months; some may last a lifetime.May be characterized by periods of remission (disappearance of clinical manifestations) and exacerbation (worsening of clinical manifestations).ConsequencesPhysical and psychologic consequences can significantly affect a patient's physical and mental functioning.Activities related to the management, such as the drug regimen, laboratory tests, health care provider visits, and nutritional monitoring often interfere with lifestyle and normal daily activities.The ability to carry out activities of daily living varies from person to person and depends on the progression of the illness.Overall decline in health status may sometimes be controlled with lifestyle management and/or drug therapy, but is typically irreversible.ExamplesDiabetesArthritisAlzheimer's diseaseObesityCancerHeart disease

Computer Ethics

Advances in the use of information technology prompted the creation of The Computer Ethics Institute (CEI) in l985. CEI was founded to serve as a forum and resource for identifying, assessing, and responding to ethical issues related to information technology. CEI also promotes the recognition of ethics in the development and use of computer technologies. CEI created the Ten Commandments of Computer Ethics to address common ethical, legal, and professional issues as they relate to information technology: Thou shalt not use a computer to harm other people. Thou shalt not interfere with other people's computer work. Thou shalt not snoop around other people's computer files. Thou shalt not use a computer to steal. Thou shalt not use a computer to bear false witness. Thou shalt not copy or use proprietary software for which you have not paid. Thou shalt not use other people's computer resources without authorization or proper compensation. Thou shalt not appropriate other people's intellectual output. Thou shalt think about the social consequences of the program you are writing or the system you are designing. Thou shalt always use a computer in ways that ensure consideration and respect for your fellow humans.

Documentation

All interventions that are performed by nurses or other healthcare personnel need to be documented. A common adage states, "If it's not documented, it's not done." Nurses must document interventions to accurately convey patient activities, nursing interventions, and patient outcomes to other care providers. If a nurse does not document that a medication was administered, for example, the patient may receive an additional dose of the same medicine. If completion of patient orders is not documented—such as if laboratory results are not reported and the patient needs to have another blood draw—the patient may be adversely affected medically and financially (e.g., a repeated blood draw is painful and costly). Documentation of interventions is most commonly charted in the patient's EHR, care plan, or standardized flow sheets according to agency policy. All documentation about interventions should be completed in a timely, accurate, and professional manner.

The nurse, in collaboration with the patient, decides a goal has been met. What is the next step? The goal is discontinued. The entire care plan is revised. A decision is made to continue or discontinue the goal. A decision is made to continue or discontinue the care plan.

Answer: A decision is made to continue or discontinue the goal. Explanation: The goal is discontinued. The nurse and patient may decide to continue a goal for sustained improvement even after it has been met. The entire care plan is revised. When a goal is met, the care plan may be partially revised but the entire care plan does not need to be revised. A decision is made to continue or discontinue the goal. When a goal is met, the nurse decides if the goal should be continued or discontinued, based on patient preference and the nurse's clinical judgment. A decision is made to continue or discontinue the care plan. When a goal is met, the care plan remains active.

Why is the storming phase important in small group communication? Permits ground rules to be set. Encourages all members of the small group to become involved. Problem solving occurs during this phase. Brings out personality conflicts that require resolution to progress.

Answer: Brings out personality conflicts that require resolution to progress. Explanation: Permits ground rules to be set. The phase that permits ground rules to be set is forming, not storming. Encourages all members of the small group to become involved. The phase that encourages all members of the small group to become involved is norming, not storming. Problem solving occurs during this phase. The phase where problem solving occurs is performing, not storming. Brings out personality conflicts that require resolution to progress. Storming brings out personality conflicts that require resolution to progress.

What are the five phases of small group communication? Opinion, disagreement, arbitration, agreement, and conclusion Individual, bipartite, coalition, small group, and consensus Forming, storming, norming, performing, and adjourning Assessment, divergence, convergence, expansion, and rule

Answer: Forming, storming, norming, performing, and adjourning Explanation: Opinion, disagreement, arbitration, agreement, and conclusion Opinion disagreement, arbitration, agreement, and conclusion are not phases of small group communication. Individual, bipartite, coalition, small group, and consensus Individual, bipartite, coalition, small group, and consensus are not phases of small group communication. Forming, storming, norming, performing, and adjourning Forming, storming, norming, performing, and adjourning are the correct phases of small group communication. Assessment, divergence, convergence, expansion, and rule Assessment, divergence, convergence, expansion, and rule are not phases of small group communication.

Which patient scenario fits within the topical area of Background in SBAR communication? Recent past medical history of a distal radius fracture Currently complaint of pain Needs for pain medications Provider is notified

Answer: Recent past medical history of a distal radius fracture Explanation: Recent past medical history of a distal radius fracture The patient having a recent past medical history of a distal radius fracture is consistent with Background in SBAR: What led up to this current situation? Currently complaint of pain The patient is currently complaining of pain is consistent with Assessment in SBAR: What is the identified problem, concern, or need? Needs for pain medications The patient needing pain medications is consistent with Assessment in SBAR: What is the identified problem, concern, or need? Provider is notified The provider being notified is consistent with Recommendation in SBAR: What actions or interventions should be initiated for this problem?

Which situation shows an example of nonverbal communication when the nurse is assessing the patient? The nurse notes the patient grimacing and guarding the abdomen. The nurse asks if the patient has ever smoked cigarettes. The patient states she has pain in her left side. The nurse charts the findings in the electronic record.

Answer: The nurse notes the patient grimacing and guarding the abdomen. Explanation: The nurse notes the patient grimacing and guarding the abdomen. Grimacing is a form of body language and nonverbal communication. The nurse asks if the patient has ever smoked cigarettes. When a nurse asks a history question, this is verbal communication. The patient states she has pain in her left side. The patient's response to history questions is also a form of verbal communication. The nurse charts the findings in the electronic record. Electronic or written documentation are both forms of verbal communication.

Which question falls within a topical area of SBAR communication? What is happening in the future? Who will contact a patient's family? Has the nurse contacted the provider? What actions should be initiated for this problem?

Answer: What actions should be initiated for this problem? Explanation: What is happening in the future? To ask what is happening in the future mischaracterizes the situation; instead, asking "What is happening now?" is the topical area Situation. Who will contact a patient's family? To ask who will contact the patient's family is not a topical area of SBAR. Has the nurse contacted the provider? The nurse contacting the provider is not a topical area of SBAR. What actions should be initiated for this problem? "What actions should be initiated for this problem?" is a question that represents Recommendation in SBAR.

Why is it important for one nurse to verify documentation with another nurse? The provider wants it to be done that way. Charting can sometimes be misinterpreted. The nurse is incompetent. It is required by law to have verification.

Answer: Charting can sometimes be misinterpreted. Explanation: The provider wants it to be done that way. The method requested by the doctor is not necessarily going to be nonverbal. Charting can sometimes be misinterpreted. Verbal communication in the form of written or electronic documentation can be misinterpreted by the reader, so verification of information is important. The nurse is incompetent. Even a competent nurse can benefit from verification of information. It is required by law to have verification. Documentation should be verified even if not required by law.

Which statement about nursing documentation is true? Only direct-care interventions need to be documented. Interventions should only be documented in the care-plan. Missing documentation does not harm patients. Documentation conveys interventions and outcomes to other care providers.

Answer: Documentation conveys interventions and outcomes to other care providers. Explanation: Only direct-care interventions need to be documented. All interventions that are performed by nurses or other health care personnel need to be documented. Interventions should only be documented in the care-plan. Documentation of interventions is most commonly charted in the patient's EHR, care plan, or standardized flow sheets according to agency policy. Missing documentation does not harm patients. Missing documentation can harm patients. For example, if a nurse forgets to document that a medication was given, the patient may receive an additional dose of the same medicine. Documentation conveys interventions and outcomes to other care providers. Nurses must document interventions to accurately convey patient activities, nursing interventions, and patient outcomes to other care providers.

Which action is appropriate when attempting to build trust and rapport with a patient during the assessment process? Standing when the patient is sitting Ensuring patient comfort and privacy Avoiding eye contact with the patient Slightly leaning away from the patient

Answer: Ensuring patient comfort and privacy Explanation: Standing when the patient is sitting = Being at eye level and with nothing between the nurse and the patient is an effective method for developing a rapport with the patient. Standing when the patient is sitting should be avoided if possible. Ensuring patient comfort and privacy = Ensuring the patient is comfortable and has adequate privacy is an effective method for building trust. Avoiding eye contact with the patient = The nurse should maintain appropriate eye contact with the patient. Lack of eye contact can communicate disinterest. Slightly leaning away from the patient = Slightly leaning towards the patient is a positive approach for developing a rapport with the patient.

A nurse enters a patient room to assess the patient's blood pressure, temperature, pulse, and pain. What type of assessment is being performed? Comprehensive Emergency Focused Shift

Answer: Focused Explanation: Comprehensive = A comprehensive assessment is completed upon admission to a healthcare facility or during the first visit with a new health care provider. Emergency = An emergency assessment is an extremely focused survey of an injury or illness and occurs when rapid decisions are needed. Focused = A focused assessment is normally done to evaluate a specific problem or concern. It focuses on vital signs, edema, wounds, etc. Shift = A nursing shift assessment is done to evaluate any changes in a patient at the beginning of a work shift.

The nurse has assessed the patient and established a nursing diagnosis of Risk for Impaired Skin Integrity related to immobility. She has determined the interventions are to reposition the patient every two hours and maintain meticulous skin hygiene so that skin integrity is maintained. What is the next step of the nursing process? Implement the interventions Determine the goals Evaluate the patient's response to the interventions Plan the patient's care

Answer: Implement the interventions Explanations: Implement the interventions = Implementation occurs once the nurse has assessed the patient, established the nursing diagnosis, and planned the patient's care. Incorrect Determine the goals = Goals are determined as part of the planning process. The goal is to maintain skin integrity. Evaluate the patient's response to the interventions = The interventions are implemented and then the nurse can evaluate their effectiveness. Plan the patient's care = Determining the interventions and goals in planning the patient's care. Once completed, the nurse implements the interventions.

Nursing care can be categorized as direct or indirect, depending on the nursing ___________. Implementation Interventions Staff Health care team

Answer: Interventions Exactly: Implementation Implementation is a step in the nursing process. Interventions The nursing interventions are either direct or indirect. Staff Staff does not relate to the type of nursing care delivered to patients. Health care team The health care team does not relate to the type of health care delivered to patients.

During which phase of the patient interview does the nurse state the purpose of the interview? Orientation Transition Working Termination

Answer: Orientation Explanation: Orientation The purpose of the interview is stated during the orientation phase. In addition, the nurse's introduction begins to build trust and rapport with the patient. Transition This is not one of the phases of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Working During the working phase of the interview, the nurse conducts the actual health interview. Termination During the termination phase, the nurse gives the patient an opportunity to ask any final questions or add additional information that might have been missed earlier. The nurse also discusses what the patient should expect next.

What are the highest-priority interventions? Problem-oriented Independent nursing Direct-care Prevention-based

Answer: Problem-oriented Explanation: Problem-orientedProblem-oriented interventions often take high priority because they deal with immediate issues. Independent nursingIndependent nursing interventions may or may not deal with immediate issues. Direct-careDirect-care interventions may or may not deal with immediate issues. Prevention-basedPrevention-based interventions may or may not deal with immediate issues.

According to Suchman's Stages of Illness Model, when will the patient seek medical care contact? Stage 1 Stage 2 Stage 3 Stage 4

Answer: Stage 3 Explanation: Stage 1 In stage 1 (symptom experience), a clinical manifestation of disease is experienced. Stage 2 In stage 2 (assumption of the sick role), the person decides that the illness is genuine and that care is necessary. Stage 3 In stage 3 (medical care contact), the individual seeks professional advice from health care providers. Stage 4 In stage 4 (dependent patient role), the patient usually undergoes treatment.

A graduate nurse has a question about the communication process. Which of these is the first element of the process? The referent initiates the communication. The receiver encodes the message to ensure accurate interpretation. The sender decodes his or her thoughts to initiate communication. The receiver forms a referent to initiate interpretation of the message.

Answer: The referent initiates the communication. Explanation: The referent initiates the communication. The referent is an event or thought that initiates the communication. The receiver encodes the message to ensure accurate interpretation. The receiver decodes the message (rather than encodes) to interpret what the sender is communicating. The sender decodes his or her thoughts to initiate communication. The sender encodes (rather than decodes) his or her thoughts to initiate communication. The receiver forms a referent to initiate interpretation of the message. The referent is not the receiver; rather, the referent is the event that leads to the conversation.

Why does the nurse focus on airway status when developing a nursing diagnosis for a patient with asthma? To label the medical illness To define the patient's illness as explicitly as possible To identify the patient's illnesses To identify the patient's response to illness

Answer: To identify the patient's response to illness Explanation: To label the medical illness - Medical diagnosis labels medical illnesses. To define the patient's illness as explicitly as possible - The scope of medical diagnosis is intentionally narrow to define the patient's illness as explicitly as possible. To identify the patient's illnesses - The purpose of medical diagnosis is to clearly identify a patient's illness so that appropriate medical treatment can be provided. To identify the patient's response to illness - The purpose of nursing diagnosis to clearly identify response to illness, health problems or life processes so that appropriate nursing care can be provided.

Which type of assessment is a five-tier system that classifies patients by levels numbered 1 through 5? Comprehensive Focused Shift Triage

Answer: Triage Explanation: Comprehensive A comprehensive assessment includes a thorough interview, health history, and physical exam, and usually occurs with a first visit to a hospital or health care provider's office. Focused A focused assessment is a brief assessment that the nurse performs to evaluate a specific concern about the patient's condition. Shift A nursing shift assessment occurs with each change of shift. The specifics about what is required during a shift assessment vary by institution. Triage Triage frequently uses a five-tier system that classifies patients by levels numbered 1 through 5, with level 1 being a critical life-threatening condition and level 5 being a less urgent situation.

Which type of assessment is performed on a patient entering an emergency department to identify if the patient needs to be treated immediately or can wait to see the health care provider? Comprehensive Focused Shift Triage

Answer: Triage Explanation: Comprehensive A comprehensive assessment is performed during an initial visit with a new health care provider. Focused A focused assessment is normally done to evaluate the problem or concern at hand. It focuses on vital signs, edema, wounds, etc. Shift A nursing shift assessment is done to evaluate any changes in the patient at the beginning of a work shift. Triage Triage is a type of assessment that is performed on a patient entering an emergency department to identify if the patient needs to be treated immediately or can wait to see the health care provider.

A nurse is performing an interview and asks the patient about allergies and medications. These questions occur during which phase of the patient interview? Orientation Transition Working Termination

Answer: Working Explanation: Orientation The orientation phase is used as an introduction and determines the purpose of the interview. Transition The transition phase is not considered a phase of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Working Obtaining information about allergies and medications is covered during the working phase. Termination The termination phase is used to let the patient know what to expect and give the patient a chance to ask any questions.

What was Nursing Interventions Classification (NIC) developed to do? > Provide a standardized language to document nursing interventions. > Encourage nurses to use taxonomy. > Evaluate nursing care driven by nursing diagnoses. > Identify health problems or life processes so that appropriate nursing care can be provided.

Answer; Provide a standardized language to document nursing interventions. Explanation: Provide a standardized language to document nursing interventions. Nursing Interventions Classification (NIC) was developed by a research team at the University of Iowa to provide a standardized language to describe, define, and document nursing interventions. Encourage nurses to use taxonomy. The NANDA-I list of nursing diagnoses was developed to encourage nurses to use taxonomy. Evaluate nursing care driven by nursing diagnoses. There are many ways to evaluate nursing care driven by nursing diagnosis; however, NIC was not developed for that. Identify health problems or life processes so that appropriate nursing care can be provided. Nursing care plans are developed to identify health problems or life processes so that appropriate nursing care can be provided.

A nursing student is teaching her peers about the communication process. What should she include in her teaching? Select all that apply. Feedback is important to ensure the correct interpretation of the message. Senders initiate communication by encoding their own thoughts and feelings. Senders initiate communication by decoding their own thoughts and feelings. A referent is what the receiver formulates upon getting the message. Channels of communication can be delivered through all five senses.

Answers: Feedback is important to ensure the correct interpretation of the message. Senders initiate communication by encoding their own thoughts and feelings. Channels of communication can be delivered through all five senses. Explanation: Feedback is important to ensure the correct interpretation of the message. Feedback is important to ensure the message was interpreted correctly. Senders initiate communication by encoding their own thoughts and feelings. Encoding is the process of translating thoughts and feelings into a message that is then communicated by the sender. Senders initiate communication by decoding their own thoughts and feelings. The receiver decodes the message to interpret the communication. A referent is what the receiver formulates upon getting the message. A referent is a thought or feeling that the sender has that initiates the communication process. Channels of communication can be delivered through all five senses. Communication can be delivered through sight, sound, touch, taste, and smell.

Why does the use of computerized data collection and research in health care increase the need for standardized nursing terminologies in documentation? Research cannot be done without nurses always using standardized terminologies when documenting. Computerized data collection cannot be done without the use of standardized terminologies. Standardized terminologies help protect patient confidentiality in computerized charting. Computers cannot make associations between different written descriptions meaning the same thing without standardized terminologies.

Computers cannot make associations between different written descriptions meaning the same thing without standardized terminologies. Computers cannot make the association between different expressions meaning the same thing, so meaningfully extracting and organizing relevant data electronically is limited without standardized terminologies and labels.

Which of the Ten Commandments of Computer Ethics is broken when a nurse reads a co-worker's personal email messages without permission? Thou shalt not interfere with other people's computer work. Thou shalt not appropriate other people's intellectual output. Thou shalt not use a computer to bear false witness. Thou shalt not snoop around other people's computer files.

Correct Answer(s): > Thou shalt not interfere with other people's computer work. Thou shalt not appropriate other people's intellectual output. > Thou shalt not use a computer to bear false witness. > Thou shalt not snoop around other people's computer files. Explanation: Thou shalt not interfere with other people's computer work. Reading a co-worker's personal email messages without permission does not interfere with their computer work. Thou shalt not appropriate other people's intellectual output. Appropriation of intellectual output describes theft. Reading a co-worker's email messages is not theft. Thou shalt not use a computer to bear false witness. Bearing false witness describes the dissemination of false information. Reading a co-worker's email messages is not bearing false witness. Thou shalt not snoop around other people's computer files. Reading a co-worker's email messages without permission is considered snooping and an invasion of privacy.

The nurse monitors trends in patient outcomes as they relate to specific nursing interventions and notes positive changes. Procedures are changed based on the nurse's research. What is this process called? Quality improvement Nursing process Care planning Evaluation

Correct Answer(s): During evaluation, the nurse determines whether the patient's goals were achieved. Explanation: Evaluation is the fourth step in the nursing process.Evaluation is the fifth and final step in the nursing process. During evaluation, the nurse determines whether the patient's goals were achieved.During evaluation, the nurse determines whether the patient's goals were achieved. Evaluation of goal attainment is the only part of the nursing process that is not collaborative.Evaluation of goal attainment is a collaborative process involving the patient. Goals are discontinued once met.Whether a goal is met, partially met, or unmet, the nurse and patient must consider the value of continuing, revising, or discontinuing the goal.

How does computerized provider order entry (CPOE) contribute to patient safety? Select all that apply. Ensures legible orders Enables immediate billing Reduces the potential for delays in care Ensures medication prescribed is appropriate for the patient's condition Reduces the risk of transcription errors Exactly! Ensures legible orders CPOE ensures legible orders because they do not involve handwritten documents. Enables immediate billing CPOE does not necessarily trigger immediate billing, and immediate billing capabilities do not contribute to patient safety efforts. Reduces the potential for delays in care CPOE reduces the potential for delays in care by reducing the need for order clarification, and, in some systems, by notifying the appropriate department automatically of new orders. Ensures medication prescribed is appropriate for the patient's condition CPOE does not ensure that the medication prescribed is appropriate for the patient's condition; that is the responsibility of the health care provider. Reduces the risk of transcription errors CPOE reduces the risk for transcription error by removing the human transcription step in the ordering process.

Correct Answer(s): Ensures legible orders Reduces the potential for delays in care Reduces the risk of transcription errors Explanation: Ensures legible orders CPOE ensures legible orders because they do not involve handwritten documents. Enables immediate billing CPOE does not necessarily trigger immediate billing, and immediate billing capabilities do not contribute to patient safety efforts. Reduces the potential for delays in care CPOE reduces the potential for delays in care by reducing the need for order clarification, and, in some systems, by notifying the appropriate department automatically of new orders. Ensures medication prescribed is appropriate for the patient's condition CPOE does not ensure that the medication prescribed is appropriate for the patient's condition; that is the responsibility of the health care provider. Reduces the risk of transcription errors CPOE reduces the risk for transcription error by removing the human transcription step in the ordering process.

Which statement indicates successful patient teaching about illness? "Illness is a state of health." "Illness is unidimensional." "Illness is primarily physical." "Illness is the same as disease."

Correct Answer(s): Explanation:

The nurse is performing patient care interventions and documenting interventions in the chart. Which step of the nursing process is this? Diagnosis Planning Implementation Evaluation

Correct Answer(s): Implementation Explanation: Diagnosis The diagnosis step occurs when the nurse identifies a diagnostic label to describe the patient's condition. Planning When the nurse identifies the interventions to be performed in order to meet the patient goals, the nurse is in the planning phase of the nursing process. Implementation Implementation consists of performing patient care interventions and documenting interventions in the patient's chart. Evaluation Evaluation occurs when the nurse determines level of goal attainment for the patient.

Which goal would be appropriate to include in a care plan for a patient with chronic obstructive pulmonary disease (COPD)? Improve quality of life Reduce preventive behaviors Foster hope for a complete cure Promote dependence on nursing staff

Correct Answer(s): Improve quality of life Explanation: Improve quality of lifeEmphasis is on improving quality of life through preventive behaviors in people with chronic diseases. Reduce preventive behaviorsPreventive behaviors are emphasized for people with chronic diseases, and should be increased, rather than reduced. Foster hope for a complete cureChronic diseases may sometimes be controlled with lifestyle management or drug therapy, but they are considered irreversible and incurable. Promote dependence on nursing staffPeople with chronic diseases have to manage the disease on a daily basis as independently as possible. The nursing staff is there to provide support, care, and education.

Which questions should be asked about an online health resource to determine the objectivity of the resource? Are there links to information sources? Is there evidence bias in the website? What are the goals of the website? Who is the author of this website? Is bias explicit or hidden?

Correct Answer(s): Is there evidence bias in the website? What are the goals of the website? Is bias explicit or hidden? Explanation: Are there links to information sources?Determining if there are links to information sources evaluates the accuracy of the website, not the objectivity. Is there evidence bias in the website?Determining if there is evidence bias evaluates the objectivity of the website. What are the goals of the website?Determining the goals of the website evaluates the objectivity of the website. Who is the author of this website?Determining the author of the website evaluates the authority, not the objectivity, of the website. Is bias explicit or hidden?Determining if bias is explicit or hidden evaluates the objectivity of the website.

Which question should be asked about an online health information website to verify its content? What are the author's credentials? Does the website include citations or references to other sources? Is this information found in other sources? Is this site trying to sell me something?

Correct Answer(s): Is this information found in other sources? Explanation: What are the author's credentials?A question about the author's credentials evaluates the authority of the website, but does not verify the content. Incorrect Does the website include citations or references to other sources?A question about the presence of the citations evaluates the accuracy of the website, but does not verify the content. Correct Is this information found in other sources?Determining that the information can be found in other credible sources verifies the content. Is this site trying to sell me something?A question asking whether the website is trying to sell something evaluates the purpose of the website, but does not verify the content.

A nurse learns that a famous celebrity has been admitted. The nurse logs into the EHR system, opens the celebrity's EMR to read the chart, and then logs off. What consequences could there be for this action? Select all that apply. Reassignment to care for the celebrity Legal penalties Formal reprimand Promotion to charge nurse Immediate dismissal

Correct Answer(s): Legal penalties Formal reprimand Immediate dismissal Explanation: Reassignment to care for the celebrity EHR systems have the ability to trace any user who illegally accesses patient health care data, and this action may be easily detected. The nurse would not be reassigned to care for the celebrity as a consequence of this violation. Legal penalties EHR systems have the ability to trace any user who illegally accesses patient health care data, and this action may be easily detected. The nurse may face legal penalties for violation of HIPAA laws. Formal reprimand EHR systems have the ability to trace any user who illegally accesses patient health care data, and this action may be easily detected. The nurse may face a formal reprimand for violation of facility policy and HIPAA laws. Promotion to charge nurse EHR systems have the ability to trace any user who illegally accesses patient health care data, and this action may be easily detected. The nurse would not be promoted as a consequence of this violation. Immediate dismissal EHR systems have the ability to trace any user who illegally accesses patient health care data, and this action may be easily detected. Depending on facility policy, the nurse may face immediate dismissal for violation of facility policy and HIPAA laws.

What information is contained in the evaluation statement? Select all that apply. Level of goal attainment Factors contributing to the goal being met or not Revisions needed in the plan of care Date when the goal will be reevaluated The name of the person evaluating the goal

Correct Answer(s): Level of goal attainment Factors contributing to the goal being met or not Revisions needed in the plan of care Explanation: Level of goal attainment Evaluation statements include level of goal attainment such as, goal met, partially met, or unmet. Factors contributing to the goal being met or not Evaluation statements include evidence of factors contributing to the goal being met, partially met, or unmet. Revisions needed in the plan of care Evaluation statements indicate revisions needed in the plan of care. Date when the goal will be reevaluated The date when the goal will be reevaluated is not included in the evaluation statement. The name of the person evaluating the goal The name of the person evaluating the goal is not included in the evaluation statement.

Which assessment finding indicates the nurse is caring for a patient with an acute illness? Verbalizes a decrease in health relapses Reports low back pain for eight months Describes functional limitations related to arthritis Presents with an abrupt onset of flu-like symptoms

Correct Answer(s): Presents with an abrupt onset of flu-like Explanation: Verbalizes a decrease in health relapsesPatients often fluctuate between maximal functioning and serious health relapses with chronic illnesses, not acute illnesses. Reports low back pain for eight monthsAcute illnesses have a short duration of less than six months. Chronic illnesses last more than 6 months. Describes functional limitations related to arthritisBoth acute and chronic illnesses can affect normal functioning, but arthritis is a chronic illness. Presents with an abrupt onset of flu-like symptomsClinical manifestations (flu-like symptoms) of acute illnesses appear quickly.

Which statements are examples of ethical or legal concerns related to health care information technology? Select all that apply. Prevention of computer fraud and misuse Assignment of an EHR password to an authorized user Ownership and integrity of health care data Preservation of patient privacy and confidentiality IT training sessions held for all nursing staff

Correct Answer(s): Prevention of computer fraud and misuse Ownership and integrity of health care data Preservation of patient privacy and confidentiality Explanation: Prevention of computer fraud and misuse Prevention of computer fraud and misuse is an ethical and legal concern related to health care information technology. Assignment of an EHR password to an authorized user The assignment of an EHR password to an authorized user is not a legal or ethical concern, but the unauthorized access of EHRs raises ethical and legal concerns. Ownership and integrity of health care data Ownership and integrity of health care data is an ethical and legal concern related to health care information technology. Preservation of patient privacy and confidentiality Preservation of patient privacy and confidentiality is an ethical and legal concern related to health care information technology. IT training sessions held for all nursing staff IT training sessions for all nursing staff may address legal or ethical concerns, but this type of training is not a legal or ethical concern related to health care information technology.

According to research findings, how is the use of mobile technology, such as hand-held devices and tablets, advantageous in the health care setting? Select all that apply. Prevention of medical errors Decreased health care staff efficiency Improvements in research valuing Decreased job satisfaction Improvements in patient care outcomes

Correct Answer(s): Prevention of medical errors Improvements in research valuing Improvements in patient care outcomes Explanation: Prevention of medical errors Mobile technology provides instant access to safe dose, compatibility, and pharmacokinetic information that is essential for safe medication administration and prevention of medical errors. Decreased health care staff efficiency There is no evidence to suggest that the use of mobile technology, such as hand-held devices and tablets, is associated with decreased health care staff efficiency. Improvements in research valuing Among hand-held technology users, there is a significant improvement in research awareness and valuing, quality of care, job satisfaction, and reduction in barriers to research use. Decreased job satisfaction Evidence suggests that there is increased, not decreased, job satisfaction among hand-held technology users in health care. Improvements in patient care outcomes Use of mobile information technology has been associated with improvements in research utilization and patient care outcomes.

Which characteristic is typical of a chronic illness? Abrupt episode of vomiting Condition that lasts for one month Remissions with exacerbations Pain that is resolved in 24 hours

Correct Answer(s): Remissions with exacerbations Explanation: Abrupt episode of vomitingAn acute illness has an abrupt onset, whereas chronic illness typically has a slower onset and has a long-term duration of over six months. Condition that lasts for one month - Chronic illness has a long-term duration of over six months. Remissions with exacerbations - Chronic illness may be characterized by periods of remission (disappearance of clinical manifestations) and exacerbation (worsening of clinical manifestations). Pain that is resolved in 24 hours - Chronic illness has a long-term duration.

Using Suchman's Stages of Illness Model, order the five stages of reaction to illness. Symptom experience Medical care contact Assumption of the sick role Perceived recovery Dependent patient role

Correct Answer(s): Symptom experience Assumption of the sick role Medical care contact Dependent patient role Perceived recovery

Match the informatics technology with its primary function. Uses the Internet to link medical experts to clinicians Assists to make surgical procedures less invasive Supports efficient distribution of visual information Facilitates data entry and information access Robotics technology Digital imaging technology Telehealth technology Mobile device technology

Correct Answer(s): Uses the Internet to link medical experts to clinicians = Telehealth technology Assists to make surgical procedures less invasive = Robotics technology Supports efficient distribution of visual information = Digital imaging technology Facilitates data entry and information access = Mobile device technology

In what ways has the use of informatics in health care benefitted research? Select all that apply. Computer programs can analyze data to identify trends, allowing meaningful organization of information for research. Research methods have advanced to require fewer subjects to achieve meaningful research results. Complete patient electronic health records are released regularly for public research use. Comparisons of nursing care data can be easily used to support evidence-based nursing. Digital health care data is an accessible source of information easily utilized in research.

Correct Answer(s): Computer programs can analyze data to identify trends, allowing meaningful organization of information for research. Comparisons of nursing care data can be easily used to support evidence-based nursing. Digital health care data is an accessible source of information easily utilized in research. Explanations: Computer programs can analyze data to identify trends, allowing meaningful organization of information for research. Data management programs can analyze data to identify trends and patterns, allowing meaningful organization of information. Research methods have advanced to require fewer subjects to achieve meaningful research results. Informatics has not benefitted research by advancing methods which require fewer subjects. Research methods have not reduced the number of subjects required to achieve meaningful research results. Complete patient electronic health records are released regularly for public research use. Complete patient electronic health records are not released for public research use. Access to protected patient data is regulated by facility policies and HIPAA guidelines. Comparisons of nursing care data can be easily used to support evidence-based nursing. Comparisons of nursing care data at the nurse-patient level can initiate comparisons across patient populations, and findings can support evidence-based nursing, evidence-based staffing, and specific billing for nursing services (Welton and Sermeus, 2010). Digital health care data is an accessible source of information easily utilized in research. The computerization of health care data provides an accessible source of information easily utilized in research.

What information is obtained during a patient interview? Select all that apply. Financial status Current health concerns Political and social views Medical and surgical history Culture, ethnicity, and spiritual views

Correct Answer(s): Current health concerns Medical and surgical history Culture, ethnicity, and spiritual views Explanation: Financial status = Inquiring about the patient's financial status is inappropriate during the patient interview. Current health concerns = The nurse inquires about current health concerns during the patient interview. Political and social views = Inquiring about political and social views is inappropriate and unprofessional. Medical and surgical history = Medical and surgical history of the patient is obtained during a patient interview. Culture, ethnicity, and spiritual views = Culture, ethnicity, and spiritual views of the patient are all gathered during the patient interview so that the nurse can provide culturally appropriate and sensitive care.

The nurse is about to conduct a focused assessment at the beginning of the work shift. Which assessments will be performed? Airway Peripheral pulses Skin turgor Urinary output Wounds

Correct Answer(s): Peripheral pulses Skin turgor Urinary output Wounds Explanation: Airway = During a focused assessment, there is an assumption that the patient has a patent airway and is not in an emergency clinical situation. Assessment of the airway is most often associated with emergency assessments. Peripheral pulses = Peripheral pulses are briefly assessed during a focused assessment, especially if the patient has a history of cardiac or vascular disease. Skin turgor = Assessment of skin turgor is a common assessment conducted in an acute care setting to help determine hydration status. Urinary output = Urinary output is commonly assessed to determine a change in a patient's condition and identify deviations from the patient's baseline. Wounds = Wounds and wound healing are commonly assessed in an acute care setting during a focused assessment.

Which are benefits of the use of informatics in medical record management? Select all that apply. Remote access by multiple providers Elimination of data security concerns Compilation of data in one location Searchability of aggregate data Reduction of staff IT training needs

Correct Answer(s): Remote access by multiple providers Compilation of data in one location Searchability of aggregate data Explanation: Remote access by multiple providers Remote access by multiple providers is a benefit of the use of informatics in medical record management. Elimination of data security concerns Data security concerns have not been eliminated through the use of informatics in medical record management. Significant data security concerns exist with the use of information technology. Compilation of data in one location Compilation of data in one location is a benefit of the use of informatics in medical record management. Searchability of aggregate data Searchability of aggregate data is a benefit of the use of informatics in medical record management. Reduction of staff IT training needs With the increased use of informatics in medical record management, the need for IT training among staff has increased, not decreased.

Which goal would be appropriate to include in a care plan for a patient with chronic obstructive pulmonary disease (COPD)? Improve quality of life Reduce preventive behaviors Foster hope for a complete cure Promote dependence on nursing staff

Correct Answer(s): "Illness is a state of health." Explanation: "Illness is a state of health."Illness is a state of health characterized by decreased or impaired abilities to engage in physical or mental functioning that was previously experienced (Segen, 2006). "Illness is unidimensional."Illness is multidimensional, affecting physical, mental, social, or intellectual. "Illness is primarily physical."Illness may be physical or mental and the experience of illness goes beyond the physical dimension. "Illness is the same as disease."Illness is not necessarily synonymous with disease status.

According to Suchman's stages of illness, stage 4 is characterized by what patient decision? Accept treatment Assume the sick role Abandon the sick role Make medical contact

Correct Answer(s): Accept treatment Explanation: Accept treatmentDuring stage 4 (dependent patient role), the patient usually undergoes treatment. Incorrect Assume the sick roleDuring stage 2 (assumption of the sick role), the person decides that the illness is genuine and that care is necessary. Abandon the sick roleDuring stage 5 (perceived recovery), the patient abandons the sick role and resumes usual tasks and roles to the greatest degree possible. Make medical contactIn stage 3 (medical care contact), the individual seeks professional advice from health care providers.

Why is the use of standardized nursing terminology important when treating a patient as part of a multidisciplinary nursing team? Encourages specialty nursing teams to provide their own nursing terminology for other nursing teams to learn Facilitates easier understanding of the health care provider's orders for patient care Enhances the nurse's ability to communicate with the patient, family members, and team members Allows all nurses to use the same vocabulary to facilitate communication

Correct Answer: Allows all nurses to use the same vocabulary to facilitate communication Explanation: Encourages specialty nursing teams to provide their own nursing terminology for other nursing teams to learnStandardized nursing terminology does not encourage nursing teams to spend time learning multiple nursing terminologies. Facilitates easier understanding of the health care provider's orders for patient careNursing terminology is not related to a health care provider's orders. Enhances the nurse's ability to communicate with the patient, family members, and team membersWhen communicating with the patient and family, the nurse should use language the patient and family members would understand, and it is usually not nursing terminology. Allows all nurses to use the same vocabulary to facilitate communicationStandardized nursing terminology effectively avoids the use of synonyms in medical terms in order to avoid confusion and promote understanding between nurses.

How does the use of standardized nursing terminologies contribute to advances in the field of nursing? > Enables secure and private electronic digital image transfer between facilities > Facilitates measurement of the impact of nursing interventions on patient outcomes > Reduces costs associated with printing nursing documentation > Documents and summarizes nursing overtime hours to advocate for better work conditions

Correct Answer: Facilitates measurement of the impact of nursing interventions on patient outcomes Explanation: Enables secure and private electronic digital image transfer between facilities The use of standardized nursing terminologies has no impact on the secure transfer of digital images between facilities. Facilitates measurement of the impact of nursing interventions on patient outcomes The use of standardized nursing terminologies facilitates measurement of the impact of nursing interventions on patient outcomes to demonstrate the contribution of nursing care to health care outcomes. Reduces costs associated with printing nursing documentation The use of standardized nursing terminologies has minimal impact on costs associated with printing nursing documentation. Documents and summarizes nursing overtime hours to advocate for better work conditions The use of standardized nursing terminologies does not assist with documenting and summarizing nursing overtime hours to advocate for better work conditions.

The nurse is caring for a patient receiving anticoagulant therapy. Which intervention is considered to be a dependent intervention? Holding dose due to abnormal lab value Reporting lab values Educating on signs of bleeding Educating on dietary modifications

Correct Answer: Holding dose due to abnormal lab value Explanation: Holding dose due to abnormal lab valueHolding a medication dose due to an abnormal lab value is a dependent nursing intervention. A potential change to the medication requires an order from the provider. Reporting lab valuesReporting lab values is an independent nursing intervention. Educating on signs of bleedingEducating the patient on signs of bleeding is an independent nursing intervention. Educating on dietary modificationsEducating the patient on dietary modifications is an independent nursing intervention.

Nurses conduct change-of-shift reports to communicate assessment findings and outstanding nursing interventions. What type of intervention is this? Direct-care Indirect-care Problem-oriented Prevention-oriented

Correct Answer: Indirect-care Explanation: Direct-careShift report is not considered to be a direct-care intervention because it is conducted without patient involvement. Correct Indirect-careChange-of-shift report is an indirect-care intervention because it benefits the patient without direct contact. Problem-orientedA problem-oriented intervention is implemented to manage and treat existing problems. Prevention-orientedA prevention-oriented intervention is implemented to prevent problems.

Which is a comprehensive, research-based, standardized collection of interventions and activities that nurses often reference when documenting interventions? Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) NANDA-I approved list of nursing diagnostic labels Joint Commission Standards

Correct Answer: Nursing Interventions Classification (NIC) When documenting interventions, nurses often reference Nursing Interventions Classification (NIC), which is a comprehensive, research-based, standardized collection of interventions and activities that align with NANDA-I diagnoses and associated Nursing Outcomes Classification (NOC). Explanation: Nursing Interventions Classification (NIC) When documenting interventions, nurses often reference Nursing Interventions Classification (NIC), which is a comprehensive, research-based, standardized collection of interventions and activities that align with NANDA-I diagnoses and associated Nursing Outcomes Classification (NOC). Nursing Outcomes Classification (NOC) NOC is an outcomes classification system used to determine goal attainment. NANDA-I approved list of nursing diagnostic labels When the nurse is assigning the nursing diagnosis, the nurse consults the NANDA-I approved list of nursing diagnostic labels. Joint Commission Standards Joint Commission standards guide when care-plans are completed and re-evaluated; however, they are not a reference for nursing interventions.

What is a formal way to analyze patient and treatment outcomes? Quality improvement Nursing process Care planning Evaluation

Correct Answer: Quality improvement Explanation: Quality improvement Quality improvement (QI) is a formal way to look at patient and treatment outcomes and to determine what can be done differently to yield positive results in given situations. Nursing process The nursing process is a systemic way for nurses to collect and analyze data about a patient. Care planning Care planning is the standardized way nursing care is planned and implemented. Evaluation Evaluation is the part of the nursing process that determines if the patient's goals have been met.

Which statement describes the main purpose of the Nursing Minimum Data Set (NMDS)? To compile all the data a nurse obtains from patients into one file To minimize the amount of data collected in nursing practice To allow for remote health consultations To standardize the collection of essential nursing data

Correct Answer: To standardize the collection of essential nursing data Explanation: To compile all the data a nurse obtains from patients into one file The main purpose of the NMDS is not to compile all the data a nurse obtains from patients into one file. To minimize the amount of data collected in nursing practice The main purpose of the NMDS is not to minimize the amount of data collected in nursing practice. To allow for remote health consultations Telemedicine, not the NMDS, allows for remote health consultations. To standardize the collection of essential nursing data The purpose of the NMDS is to standardize the collection of essential nursing data through the use of standardized labels and accurate descriptions of nursing diagnoses, nursing care, outcomes of care, and nursing resources.

Which nurse response suggests understand of SBAR? Select all that apply. "I am going to ask you questions about your health history." "I will be providing discharge instructions for you before you leave the hospital. You will then be taken home and introduced to your home health care nurse." "Hello, Mrs. K. I am Joe, and I will be taking care of you today." "I have developed a plan of care based on the information you gave me in your history." "Who came here with you today?"

Correct Answer: "I am going to ask you questions about your health history." "I have developed a plan of care based on the information you gave me in your history. Explanation: Which nurse response suggests understand of SBAR? "I am going to ask you questions about your health history."The nurse's response, "I am going to ask you some questions about your health history" is included in the Background of SBAR. "I will be providing discharge instructions for you before you leave the hospital. You will then be taken home and introduced to your home health care nurse."The nurse's response, "I will be providing discharge instructions for you before you leave the hospital. You will be taken home and introduced to your home health care nurse" is not part of SBAR. "Hello, Mrs. K. I am Joe, and I will be taking care of you today."The nurse's response, "Hello, Mrs. K. I am Joe and I will be taking care of you today" is not part of SBAR. "I have developed a plan of care based on the information you gave me in your history."The nurse's response, "I have developed a plan of care based on the information you gave me in your history" is included in the Assessment phase of SBAR. "Who came here with you today?"The nurse's response, "Who came here with you today" is not part of SBAR.

Which skill demonstrates information literacy? Ability to use computer stations at the hospital Effectively using laptops and tablets in patient care Ability to properly use the electronic health records to pull up information from a patient's last visit Achieving competence using a workstation on wheels to document patient vital signs

Correct Answer: Ability to properly use the electronic health records to pull up information from a patient's last visit Explanations: Ability to use computer stations at the hospitalThe ability to using computer stations at hospitals is computer literacy, not information literacy. Effectively using laptops and tablets in patient careNeeding minimal assistance using laptops and tablets is a part of computer literacy, not information literacy. Correct Ability to properly use the electronic health records to pull up information from a patient's last visitThe ability to properly use the electronic health record to pull up information from a patient's last visit demonstrates information literacy. Achieving competence using a workstation on wheels to document patient vital signsAchieving competence in using a workstation on wheels to take patient vital signs is part of computer literacy, not information literacy.

Which level of nursing competency is demonstrated by a nurse who does not do research or make judgments based on patient data, but has web literacy and a good understanding of nursing computer systems? Innovator Specialist Experienced Beginner

Correct Answer: Beginner Explanation: Innovator An innovator is able to generate theories and understand the interdependence of various systems, disciplines, and outcomes. Specialist Specialists go beyond understanding of nursing computer systems to conduct research based on information trends or patient data. Experienced Experienced nurses go beyond understanding of nursing computer systems to make judgments based on trends and patterns in data. Beginner Beginner skills in nursing include: computer, information, and web literacy; fundamental skills in information management; and computer technology.

Which two major fields of study are integrated in nursing informatics? Information science and pharmaceutics Computer programming and computer science Biomedical engineering and information science Computer science and information science

Correct Answer: Computer science and information science Explanation: Information science and pharmaceutics Nursing informatics integrates information science as a field of study. Pharmaceutics, while a consideration in nursing informatics work, is not integral to nursing informatics work. Computer programming and computer science Computer programming, while a necessary tool in developing IT systems, is not integral to nursing informatics work. Biomedical engineering and information science Nursing informatics integrates information science as a field of study. Biomedical engineering, while sometimes part of nursing informatics tools, is not integral to nursing informatics work. Computer science and information science Nursing informatics integrates nursing, computer, and information science for the management and communication of data, information, knowledge, and wisdom.

A nurse makes preliminary observations about a patient. What is the term for this action? General survey Health history Physical assessment Review of systems

Correct Answer: General survey Explanation: General survey = Observing the patient and making preliminary observations is commonly referred to as the general survey. Health history = A health history includes patient demographics, family/medical/surgical histories, current medication usage, and allergies. Physical assessment = A physical assessment involves a hands-on exam, measurement of vital signs, and possibly laboratory and diagnostic testing. Review of systems = A review of systems includes a system-by-system review, with the nurse asking focused questions about particular symptoms.

A patient sets a goal of quitting smoking within the next 30 days. After 30 days, the patient has not quit but reports that he has reduced his smoking by 50%. The goals for the next 30 days are revised. What does the nurse document in regard to goal attainment? Goal met. Goal partially met. Goal unmet. Goal unattainable.

Correct Answer: Goal partially met. Explanation: Goal met.Documentation of "goal met" would occur if the smoking cessation was successful. Correct Goal partially met."Goal partially met" would be documented because the patient was able to make positive steps toward meeting the goal. Goal unmet.The goal is not "unmet" because the patient was able to make changes toward the original goal. Goal unattainable."Goal unattainable" is not an appropriate documentation for the evaluation statement.

Documentation of interventions is provided to insurance companies for billing and reimbursement. Which Federal guidelines do health care facilities follow when providing patient information to other agencies? Health Insurance Portability and Accountability Act (HIPAA) Nursing Interventions Classification (NIC) North American Nursing Diagnosis Association International (NANDA-I) Joint Commission and Centers for Medicare and Medicaid

Correct Answer: HIPAA Explanation: Health Insurance Portability and Accountability Act (HIPAA) Within HIPAA guidelines, patient documentation of interventions is provided to insurance companies and others for billing and reimbursement. Nursing Interventions Classification (NIC) NIC is a reference tool for nursing interventions. North American Nursing Diagnosis Association International (NANDA-I) NANDA-I is an organization for nursing taxonomy. Joint Commission and Centers for Medicare and Medicaid Joint Commission is a regulatory agency that provides standards for hospitals to follow; however, it is not HIPAA.

What does/did the TIGER initiative do for nursing informatics? Advocates for nurses to have more authority in ordering appropriate patient medications Mandates that all nurses become leaders in health care IT use in clinical settings Identified a set of nursing informatics skills needed by all nurses in current practice Established the Nursing Minimum Data Set

Correct Answer: Identified a set of nursing informatics skills needed by all nurses in current practice Explanation: Advocates for nurses to have more authority in ordering appropriate patient medicationsThe Technology Informatics Guiding Education Reform (TIGER) initiative does not advocate for nurses to have more authority in ordering appropriate patient medications. Mandates that all nurses become leaders in health care IT use in clinical settingsThe Technology Informatics Guiding Education Reform (TIGER) does not mandate that all nurses become leaders in health care IT use in clinical settings. Correct Identified a set of nursing informatics skills needed by all nurses in current practiceThe Technology Informatics Guiding Education Reform (TIGER) initiative (2014) identified a set of nursing informatics skills needed by all nurses practicing in the 21st century. Established the Nursing Minimum Data SetThe Technology Informatics Guiding Education Reform (TIGER) initiative did not establish the Nursing Minimum Data Set.

Why should the nurse reference Nursing Interventions Classification (NIC) when documenting interventions? It is useful for clinical documentation. It ensures compliance with HIPAA guidelines. It provides information for billing and reimbursement. It helps the nurse determine goal attainment.

Correct Answer: It is useful for clinical documentation. Explanation: It is useful for clinical documentation. The Nursing Interventions Classification (NIC) system is useful for clinical documentation, communication, reimbursement, research, and measurement of productivity. It ensures compliance with HIPAA guidelines. NIC does not ensure compliance with HIPAA guidelines. It provides information for billing and reimbursement. NIC does not provide the information for billing and reimbursement. It helps the nurse determine goal attainment. Nursing outcomes classification (NOC) helps the nurse determine goal attainment. It is useful for clinical documentation.The Nursing Interventions Classification (NIC) system is useful for clinical documentation, communication, reimbursement, research, and measurement of productivity.

The nurse evaluates the outcomes to determine if short-and long-term goals have been achieved. How is this decision made by the nurse? Through consultation with the provider Through critical thinking Consultation with policies and procedures Consultation with unit nurse manager

Correct Answer: Patient involvement Explanation: Patient involvementMonitoring whether the patient's goals were attained is collaborative, involving the patient in the decision. Asking the familyIt is not up to the family to decide if goals were met. Physician inputThe physician may be involved, but it is not up to the provider to determine if nursing goals were met. Resolving the care planThe care plan is not resolved during the evaluation process.

The nursing staff of a small emergency department implements a process to reduce wait times. What is this process called? Quality Improvement Evidence-based practice Patient satisfaction The Joint Commission

Correct Answer: Quality Improvement Explanation: Quality ImprovementQuality improvement is a formal way to look at patient and treatment outcomes to determine what can be done differently. Evidence-based practiceImplementing evidence-based guidelines is a component of quality improvement. Patient satisfactionPatient satisfaction will increase with this quality improvement plan. The Joint CommissionThe Joint Commission requires the use of quality improvement.

Which type of physical assessment is usually governed and directed by the policies of the health care facility? Comprehensive Emergency Focused Shift

Correct Answer: Shift: Explanation: Comprehensive = A comprehensive assessment is always performed during the initial visit to a new health care provider or health care facility. Emergency = An emergency assessment is an extremely focused survey of the injury/illness when rapid decisions are needed. This type of assessment is governed by the clinical situation. Focused = A focused assessment is done routinely by a nurse to check vital signs, edema, and wound status, and is governed by the clinical situation. Shift = Each health care facility has its own policies for what should be included in a shift assessment.

According to Suchman's stages of illness, a nurse who does not go to work because of illness has entered what stage of illness? Stage 2 Stage 3 Stage 4 Stage 5

Correct Answer: Stage 2 Explanation: Stage 2This stage (Stage 2) gives an individual permission to act sick and to be excused temporarily from typical social and personal obligations. Stage 3In stage 3 (medical care contact), the individual seeks professional advice from health care providers. Stage 4During stage 4 (dependent patient role), the patient usually undergoes treatment. Stage 5During stage 5 (perceived recovery), the patient abandons the sick role and resumes usual tasks and roles to the greatest degree possible.

A hospitalized patient is receiving treatment and expresses anxiety about the procedure. This person is in which stage of illness? Stage 3 Stage 4 Stage 5 Stage 6

Correct Answer: Stage 4 Explanation: Stage 3 - In stage 3 (medical care contact), the individual seeks professional advice from health care providers. Stage 4 - During stage 4 (dependent patient role), the patient usually undergoes treatment. During this stage, patients often feel dependent on others and may experience ambivalent or fearful thoughts that cause them to reject treatment, the advice of health care providers, and the illness. More often, care is accepted and administered to an ambivalent patient. Stage 5 - During stage 5 (perceived recovery), the patient abandons the sick role and resumes usual tasks and roles to the greatest degree possible. Stage 6 - There is no stage 6 in Suchman's Stages of Illness Model.

During which phase of the interview is the patient given an opportunity to ask questions and add any additional information that may have been forgotten? Orientation Transition Working Termination

Correct Answer: Termination Explanation: Orientation = The orientation phase is used to introduce the nurse and the patient. Transition = The transition phase is not considered a phase in the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Working = The working phase is used to gather a health history and systems review data. Termination = The patient should be given the opportunity to ask questions and add further information to the interview during the termination phase.

A nurse is performing an interview and asks the patient about allergies and medications. These questions occur during which phase of the patient interview? Orientation Transition Working Termination

Correct Answer: Working Explanation: Orientation = The orientation phase is used as an introduction and determines the purpose of the interview. Transition = The transition phase is not considered a phase of the patient interview. The three phases are the orientation phase, the working phase, and the termination phase. Working = Obtaining information about allergies and medications is covered during the working phase. Termination = The termination phase is used to let the patient know what to expect and give the patient a chance to ask any questions.

Which assessments are completed first during an emergency? Select all that apply. Ability to urinate Airway Allergies Breathing Circulation

Correct Answers: Ability to urinate Allergies Breathing Circulation Explanation: Ability to urinate = The ability to urinate is important to assess but is not the priority during an emergency. Airway = Airway is the first assessment made during an emergency situation. If the airway isn't patent, this is an emergent issue that needs to be addressed. Allergies = Information about allergies is very important to obtain but is not a priority over airway, breathing, and circulation. Breathing = Assessment of breathing should always be a part of an emergency assessment. Circulation = Circulation must be assessed during an emergency.

Match the type of nursing diagnoses to the correct example of that diagnosis. > Actual: Objective > Risk > Health-promotion > Actual: Subjective Patient voices readiness to learn "My head hurts" Skin red with open lesion Patient unsteady when walking

Correct Answers: Actual: Objective = Skin red with open lesion Risk = Patient unsteady when walking Health-promotion = Patient voices readiness to learn Actual: Subjective = "My head hurts"

Nurses coordinate many types of interventions when initiating a care plan. How are nursing interventions categorized? Select all that apply. By purpose By priority By timeframe By who initiates or conducts them By type of patient contact

Correct Answers: By purpose By who initiates or conducts them By type of patient contact Explanation: By purposeInterventions are categorized by their purpose. By priorityInterventions are not categorized by their priority. By timeframeInterventions are not categorized by their timeframe. Correct By who initiates or conducts themInterventions are categorized by who initiates and conducts them. Correct By type of patient contactInterventions are categorized by whether they involve personal patient contact.

Which are the indirect-care interventions? Select all that apply. Collaboration Referrals Delegation Reassessment Patient teaching

Correct Answers: Collaboration Referrals Delegation Explanation: CollaborationCollaboration is an indirect-care intervention because it does not involve face-to-face patient contact. ReferralsReferrals are Indirect-care interventions because they do not involve face-to-face patient contact. DelegationDelegation is an indirect-care intervention because it does not involve face-to-face patient contact. ReassessmentReassessment is a direct-care intervention, as it involves direct patient contact. Patient teachingPatient-teaching is a direct-care intervention; it involves direct patient contact.

According to The Joint Commission requirements, when are care plans to be evaluated? Continuously Every shift Daily Only if the patient's condition changes

Correct Answers: Continuously Explanation: Continuously The Joint Commission requires patient care plans to be evaluated on a continual basis. Making modifications to care plans as a patient's status changes is a necessary component of providing safe patient care. Every shift In many agencies, nurses are expected to evaluate outcomes at least once during every shift. Daily Daily is not often enough to evaluate patient care plans. Only if the patient's condition changes It is not enough to evaluate the patient's care plan only when the patient's condition changes.

Which statement about indirect-care interventions is true? Delegation is an indirect-care intervention. Indirect-care interventions are conducted through personal conduct with the patient. Indirect-care interventions include reassessment. Indirect-care interventions are not as important as direct care interventions.

Correct Answers: Delegation is an indirect-care intervention. Explanation: Delegation is an indirect-care intervention. Delegation is an indirect-care intervention based on assessment findings and established care priorities. Indirect-care interventions are conducted through personal conduct with the patient. Direct-care interventions are conducted through personal contact with the patient. Indirect-care interventions include reassessment. Reassessment is a direct-care intervention. Indirect-care interventions are not as important as direct care interventions. Indirect-care and direct-care interventions are equally important.

Which notations are appropriate for the nurse to include in a patien t's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)?" Select all that apply. Goal not met; patient states he is tired. Goal met; patient ambulated three times in room. Goal met; patient ambulated three times in the hallway. Goal met; patient ambulated three times in the hallway with SOB. Goal met; patient ambulated three times in the hallway without SOB.

Correct Answers: Goal not met; patient states he is tired. Goal met; patient ambulated three times in the hallway without SOB. Explanation: Goal not met; patient states he is tired.The notation indicates that the goal was not met. The nurse and patient should reflect on factors that prevented achievement of the goals such as barriers to goal achievement. Goal met; patient ambulated three times in room.The notation indicates that the goal was met; however, the statement does not reflect that information. Goal met; patient ambulated three times in the hallway.The notation indicates that the goal was met; however, the statement does not reflect that information. Goal met; patient ambulated three times in the hallway with SOB.The notation indicates that the goal was met; however, the statement does not reflect that information. Goal met; patient ambulated three times in the hallway without SOB.The notation indicates that the goal was met and all of the outcome criteria were attained. The nurse decides if the goal should be continued to support sustained improvement, or discontinued.

Which are the direct-care interventions? Select all that apply. Informal counseling ADLs Reassessment Advocacy Research

Correct Answers: Informal counseling ADLs Reassessment Explanation: Informal counselingDirect-care interventions are those that are conducted through personal contact with the patient including informal counseling. ADLsDirect-care interventions are those that are conducted through personal contact with the patient including activities of daily living (ADLs). ReassessmentDirect-care interventions are those that are conducted through personal contact with the patient including reassessment. AdvocacyAdvocacy is an indirect-care intervention. ResearchResearch is an indirect-care intervention.

Why is it important to make modifications to a patient's care plan when the status changes? It is a necessary component to providing safe patient care. Because the Joint commission requires care plan modification. So the hospital can get reimbursed for the interventions provided. To facilitate communication among providers.

Correct Answers: It is a necessary component to providing safe patient care. Explanation: It is a necessary component to providing safe patient care. Modifying the patient's care plan upon patient status changes is a necessary component to providing safe patient care. Because the Joint commission requires care plan modification. The Joint Commission requires care plan evaluation on a continual basis. So the hospital can get reimbursed for the interventions provided. Reimbursement to the hospital based on the interventions provided due to care plan modification is not why care plan modification is important. To facilitate communication among providers. The care plan is a tool with which to communicate to other providers; however, the primary reason to modify the care plan is not provider communication.

Match the intervention category with the intervention. Monitoring a patient's temperature and skin color for feverIndependent Administering antipyretic medication for fever as ordered by the providerDependent Nursing assistant providing bathing and dressing assistance to a patientCollaborative

Correct Answers: Monitoring a patient's temperature and skin color for fever = Independent Administering antipyretic medication for fever as ordered by the provider = Dependent Nursing assistant providing bathing and dressing assistance to a patient = Collaborative

The patient has a goal of, "Skin will remain intact while in the hospital." The nurse notices the patient has a new stage 2 pressure ulcer. What should the nurse do? Reflect on factors that prevented the goal from being achieved. Document the goal as met. Delete the goal and write a new one. Wait until the skin has healed, then document the goal as met.

Correct Answers: Patient is consistently ambulating 50 feet twice daily. Goal is met. Patient ambulating 20-50 feet twice daily. Goal is partially met. Patient is on bed rest due to development of pulmonary embolus. Goal is unmet.

Which statement about the evaluation step of the nursing process is true? Evaluation is the fourth step in the nursing process. During evaluation, the nurse determines whether the patient's goals were achieved. Evaluation of goal attainment is the only part of the nursing process that is not collaborative. Goals are discontinued once met.

Correct Answers: Reflect on factors that prevented the goal from being achieved. Explanation: Reflect on factors that prevented the goal from being achieved.The nurse and patient should reflect on factors that prevented the goal from being achieved. Document the goal as met.The nurse should document the patient's level of goal attainment. Delete the goal and write a new one.Goals should never be deleted. Wait until the skin has healed, then document the goal as met.A new goal should be written for the skin breakdown.

Security of patient health data is governed by facility policy and HIPAA guidelines when accessed through which IT devices or systems? Select all that apply. Tablets and hand-held devices Bedside computers Paper charts Telehealth systems Electronic health record

Correct Answers: Tablets and hand-held devices Bedside computers Telehealth systems Electronic health record Explanation: Tablets and hand-held devices Health care providers using any IT device or system as part of patient care need to work within facility policy and HIPAA guidelines to protect the security of patient health data. Bedside computers Health care providers using any IT device or system as part of patient care need to work within facility policy and HIPAA guidelines to protect the security of patient health data. Paper charts Security of patient health data within paper charts is governed by facility policy and HIPAA guidelines, but paper charts are not considered IT devices or systems. Telehealth systems Health care providers using any IT device or system as part of patient care need to work within facility policy and HIPAA guidelines to protect the security of patient health data. Electronic health record Health care providers using any IT device or system as part of patient care need to work within facility policy and HIPAA guidelines to protect the security of patient health data.

Which questions should the patient ask to evaluate a website's credibility? Select all that apply. Is the website viewed by a large audience? When was the website last updated? Can the information be found in other sources? Is the information presented in a captivating fashion? Who is the intended audience of the website?

Correct Answers: When was the website last updated? Can the information be found in other sources? Who is the intended audience of the website? Explanation: the website viewed by a large audience? The number of people who view a website does not directly reflect its accuracy, though accurate and credible sites are often frequently visited. When was the website last updated? Evaluating when the site was last updated enables the patient to assess the currency and credibility of the site. Can the information be found in other sources? Verification of information by asking if it is found in other sources helps evaluate the credibility of the site. Is the information presented in a captivating fashion? Proper and exciting presentation of the information may get positive attention, but it does not necessarily mean that it is accurate and credible. Who is the intended audience of the website? Determining the purpose of the website helps reveal whether the site is intended to inform or persuade the audience. For example, a website with the goal of educating patients is generally more forthright with information and, therefore, more credible than a website created to sell a certain product.

The nurse evaluates the patient's progress towards goals and determines if goals can be met. What does this include? Patient involvement Asking the family Physician input Resolving the care plan

Correct Answers: Quality improvement Explanation: Quality improvementQuality improvement (QI) is a formal way to look at patient and treatment outcomes and to determine what can be done differently to yield positive results in given situations. Nursing processThe nursing process is a systemic way for nurses to collect and analyze data about a patient. Care planningCare planning is the standardized way nursing care planned and implemented. EvaluationEvaluation is the part of the nursing process that determines if the patient's goals have been met.

The nurse is caring for a patient in the rehab unit and preparing her for discharge. The nurse determines that the patient has unmet goals. What is the next step in the process? All goals are discontinued and documented as unattainable. The care plan is discontinued and documented as noncompliant. The nurse stops the discharge process. The nurse decides to continue, revise, or discontinue the goal.

Correct Answers: The nurse decides to continue, revise, or discontinue the goal. Explanation: All goals are discontinued and documented as unattainable.Unmet goals are not documented as unattainable. The care plan is discontinued and documented as noncompliant.The care plan is not discontinued and the patient is not documented to be noncompliant just because goals were not met. The nurse stops the discharge process.The nurse does not stop the discharge process. The nurse decides to continue, revise, or discontinue the goal.With unmet goals, the nurse decides to continue, revise, or discontinue the goal.

What is the first thing a nurse should do when interacting with a patient? Examine the patient Interview the patient Provide a personal introduction Obtain a complete medical history

Correct: Provide a personal introduction Explanation: Examine the patient Examining the patient should occur after the chart has been reviewed. Interview the patient Interviewing the patient should occur after the chart has been reviewed. Provide a personal introduction When meeting with a patient for a health interview or physical exam, the nurse should provide an introduction and an explanation for the interview or exam. Obtain a complete medical history Obtaining a complete medical history, if necessary, would not occur until after a personal introduction has been completed.

Counseling

Counseling is the process through which individuals use professional guidance to address personal conflicts or emotional problems. Nurses counsel patients by providing a "listening ear" or stimulating a patient's thought or decision-making process. Informal counseling may occur when the patient is faced with a new diagnosis, a chronic condition, a loss, or acute illness. Informal counseling encourages patients to express their concerns and emotions, as well as to ask questions.

Criteria for evaluating websites providing health care information include:

Criterion - Evaluation Questions Authority - Who is the sponsor or publisher? Is this a personal page? Where does it come from? Is the author or organization listed? What are the author's credentials? Purpose - Does the site inform? Explain? Share? Disclose? Sell? What is the intended audience?Coverage - Are citations correct? Is there a balance of text and images? Currency - When was the site created? How often is it updated? Objectivity - What are the goals and objectives of the site? Is there evidence of bias? Is bias explicit or hidden? Accuracy - Are there footnotes or links to information sources? Verification - Can the information be found in other sources?

What are the methods through which assessment is conducted? Select all that apply. Diagnosis Observation Patient interview Physical examination

Current Answer: Observation Patient interview Physical examination Explaination: Diagnosis Diagnosis is the phase of the nursing process when patient data are analyzed, validated, and clustered to identify patient problems. Observation Observation is an assessment method used to gather significant information about a patient's emotional condition and health status. Patient interview The patient interview is a formal, structured discussion in which the nurse questions the patient to obtain demographic and medical data. Physical examination Physical examination is the systematic and intentional assessment of a patient's body.

Current Initiatives in Health Care IT

Current efforts to increase the positive impact of information technology in health care are focused on initiatives to promote efficiency and accuracy of patient care, such as: Admission systems that capture demographic patient data and bed availability Improved functionality and applications of the electronic health record Computerized provider order entry Bar-code medication administration E-prescribing and telehealth Personal health records Radiofrequency identification (RFID) of health care objects for tracking, inventory management, and validation of use with correct patient

rder concepts of knowledge in informatics from shallow to applied. Data Information Knowledge Wisdom

Data are considered the foundation of information, knowledge, and wisdom. In informatics, the structural and functional relationships between these four concepts are often represented in a hierarchical relationship, progressing from data (shallow, rule-based knowledge) to wisdom (the appropriate use of knowledge).

Data as the Foundation Data Information Knowledge Wisdom

Data are considered the foundation of information, knowledge, and wisdom. In informatics, the structural and functional relationships between these four concepts are often represented in a hierarchical relationship, progressing from data (shallow, rule-based knowledge) to wisdom (the appropriate use of knowledge). Data: Facts, observations, measurements; can be used as a basis for reasoning, discussion, or calculation. Until organized and processed, data are meaningless. Information: Organized and processed data; can be communicated, are meaningful and useful to the recipient. Knowledge: Organized and processed information; can be applied to problem-solving and decision-making. Transformation of patient data to clinical information becomes nursing knowledge. Wisdom: Addresses use of knowledge & experience to manage & solve problems; is appropriate application of knowledge. At this level, a nurse uses critical thinking to interpret & evaluate nursing knowledge.

Data Security and Confidentiality

Data security and confidentiality of patient information present major legal and ethical issues in health care technology and are governed by strict policies and laws. When using information technology, it is important that nurses know applicable laws and regulations, policies, procedures, the ethical codes of their employers, and the ethical codes of their professional organizations. Electronic Health Record Access ViolationAccess to electronic records requires a user to have system access and verification codes as a measure of security and protection of patients' privacy.The codes leave an electronic trail that can be used to trace any user who illegally accesses a patient's health care data.HIPAA and Legal PenaltiesThe Health Insurance Portability and Accountability Act (HIPAA) standards for how security and confidentiality of health care information must be maintained.The act also outlines legal penalties for any health care staff who breach security of health care data. Safe Practice Alert! Sign-on and password codes for access to an electronic health record system must never be shared with anyone.

Diversity Considerations of Communication

Diversity Considerations Consideration of diversity is important in providing nursing care to various populations. Understanding that communication varies widely with individuals of different ages, genders, and cultures helps nurses to care most effectively for all of their patients. Life Span Children demonstrate a need for greater personal space as they age (Aiello and Aiello, 1974). Older adults of some cultures require personal care from younger, same-gender members of their family (Knott, 2002). Gender Making direct eye contact immediately before touching a patient of the opposite sex may help to communicate caring and alleviate anxiety in the patient (Pullen, Barrett, Rowh, et al., 2009). In some cultures, nurses of the opposite sex may not be permitted to perform personal care or examine private areas of the patient's body (Pullen, 2007). Culture and Ethnicity People born in more densely populated areas typically require less personal space for comfort. English-speaking people typically prefer at least 18 inches of distance between themselves and others when conversing. In contrast, Middle Eastern people may be comfortable standing very close while communicating (Purnell, 2013).

The nurse performs patient care interventions according to the individualized care plan. What is the next step in the process? Resolve the interventions. Determine the goals. Document the interventions. Plan the patient's care.

Document the Interventions Explanation: Resolve the interventions.The interventions are not resolved until the evaluation process has occurred. Determine the goals.Goals are determined as part of the planning process. Document the interventions.After the patient care has been performed, the nurse documents them in the patient's chart. Plan the patient's care.Care planning was completed prior to performing the interventions.

Orientation Phase of Assessment

During the orientation phase, the nurse should provide a personal introduction and state the purpose of the interview. The nurse should also ask how the patient prefers to be addressed. Some individuals prefer formal titles of respect (e.g., Dr., Mr., Ms., Professor) and the use of surnames, whereas others are comfortable with less formality. How a patient is addressed is the patient's choice. The orientation phase is essential for establishing trust between the nurse and the patient, which affects all future interactions. There are many ways in which the nurse can build trust: Ensure the patient is comfortable and has adequate privacy. Sit at eye level with nothing between the nurse and patient. Maintain appropriate eye contact. Avoid distracting behaviors and other nonverbal cues that might signal that the nurse isn't paying attention. Lean slightly toward the patient. Smile. Speak using a professional voice, with a moderate rate and tone of speech.

Working Phase of the Assessment Interview

During the working phase of the interview, the nurse must stay focused on the purpose of the interaction. Active, engaged listening is imperative during this process. Sometimes, how the patient shares information is more important than what the patient says. The nurse should watch for emotional cues indicating fear or painful experiences and the appropriateness of verbal and nonverbal cues. The nurse may ask both open-ended and closed-ended questions during the interview. Open-ended questions encourage narrative responses from patients. Closed-ended, focused, and direct questions elicit specific information, such as the exact location of a patient's pain. Direct questions can be expanded upon with open-ended questions if more extensive information is needed. The patient interview usually includes: Health history - including demographic data, reason for seeking care, allergies, medications, medical, family, and social history, and health promotion practices. Review of systems - including the nurse patient-reported data of each system in the body.

Standards for Online Health Resources

Ethical standards and guidelines for Internet health sites are being developed and promoted by several organizations. The Health on the Net Foundation (HON) is an international initiative created in 1995 that focuses on the promotion and use of reliable online health information (HON, 2013). The Internet Healthcare Coalition, founded in 1997, was created to promote quality health resources online and to ensure that consumers and professionals are able to find reliable, high-quality information online. This organization consults with various government agencies, including the World Health Organization, the U.S. Food and Drug Administration, and the U.S. Federal Trade Commission, on efforts to promote credible online health care information and combat online health fraud (Mack, 2000).

Evaluation

Evaluation is the fifth and final step of the nursing process, and involves the nurse reviewing the patient's achievement of goals established in the patient's plan of care. During the evaluation process, the nurse uses critical thinking to determine whether a patient's short- and long-term goals were met, as well as whether desired outcomes were achieved. Monitoring whether the patient's goals were attained is collaborative and involves the patient in the decision.

Implementation

Implementation consists of performing patient care interventions and documenting interventions in the patient's chart. This step occurs after the nurse has already assessed the patient, established the nursing diagnosis, and planned the patient's care. It is a critical step in the scope of caring for a patient in that it ensures that the patient's care activities are carried out.

eHealth Code of Ethics

In 2000, the eHealth Code of Ethics was introduced for health care sites and services on the Internet. The goal of the eHealth Code of Ethics is "to ensure that people worldwide can confidently, and with full understanding of known risks, realize the potential of the Internet in managing their own health and the health of those in their care." The guiding principles that provide the framework for this ethical code are candor, honesty, quality, informed consent, privacy, and professionalism in online health care, responsible partnering, and accountability (Rippen and Risk, 2000).

Define Informatics

Informatics is a broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science.

Informatics

Informatics is a broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science.

What Is Information Literacy?

Information literacy is the ability to recognize when information is needed and to locate, evaluate, and effectively use the needed information (American Library Association, 2000). As the amount of available information increases exponentially, individuals must acquire the skills to select, evaluate, and use needed information.

Interpersonal communication

Interpersonal communication takes place between two or more people. It may be formal or informal and conversational, and it may or may not have a stated goal or purpose. In the context of an interview, it may vary from the strictly formal collection of medical history to a very casual exchange about the patient's pet dog. Effective interpersonal communication among healthcare team members is essential to ensure patient safety. Research indicates that 70-80% of medical errors involve issues of interpersonal communication (Agency for Healthcare Research and Quality, 2004). QSEN focus alert Open communication among interdisciplinary teams of healthcare professionals creates a culture of safety, which is necessary to protect patients from harm and meet patient safety standards.

Interprofessional Communication

Interprofessional Communication as a type of Interpersonal Communication Communication breakdown between the various members of the interdisciplinary healthcare team can result in devastating outcomes. This is especially true when patient care is being transferred to new care providers. Data from The Joint Commission (2013) indicates that almost 70% of sentinel events were caused by communication breakdown, and 50% of those cases occurred during patient handoff. One method of interpersonal communication that has been adopted to increase safety of interprofessional and handoff communication is the SBAR model: situation, background, assessment, and recommendation.

Intrapersonal Communication

Intrapersonal communication occurs internally and focuses on one's personal needs; it can influence a person's well-being. Intrapersonal communication includes: Positive Self-Talk Negative Self-Talk Meditation Positive self-talk is internal conversation that provides motivation and encouragement; it may be used to build self-esteem and self-confidence. (Example: Patients talking themselves through an IV insertion or other painful procedure.) Negative self-talk is harmful or destructive internal conversation. This type of self-talk may damage the ability of an individual to achieve his or her greatest potential or to overcome adversity. (Example: Patients telling themselves they cannot get through procedures.)

Match the ANA-recognized nursing terminology system with the content that it includes. Clinical data elements for use in all nursing settings Nursing diagnoses Diagnoses, interventions, and outcomes Nursing administrative data elements for use in all nursing settings CCC: Clinical Care Classification NANDA-I: NANDA International NMMDS: Nursing Management Minimum Data Set NMDS: Nursing Minimum Data Set

Match the ANA-recognized nursing terminology system with the content that it includes. Clinical data elements for use in all nursing settings NMDS: Nursing Minimum Data Set Nursing diagnoses NANDA-I: NANDA International Diagnoses, interventions, and outcomes CCC: Clinical Care Classification Nursing administrative data elements for use in all nursing settings NMMDS: Nursing Management Minimum Data Set

Match the dates to the correct historical development in nursing. The term "nursing process" was first used by Lydia Hall. The nursing process was first used to define steps used in patient care. ANA identified 5 steps of the nursing process in its Standards of Practice. Outcome identification was added to the nursing process by the ANA. 1960s 1991 1955 1973

Match the dates to the correct historical development in nursing. The term "nursing process" was first used by Lydia Hall. = 1955 The nursing process was first used to define steps used in patient care. = 1960s ANA identified 5 steps of the nursing process in its Standards of Practice. = 1973 Outcome identification was added to the nursing process by the ANA.= 1991

Networking Internet Email and Listserv Social Media Blog

Networking Networking is the process of developing and using an interaction format with professional colleagues and agencies. In the context of information technology, networking is using technology to interact with individuals and resources. Information technology enables connections with many kinds of resources that can be beneficial in the delivery of health care. Use of networking in health care requires careful attention to maintaining professional online conduct and patient confidentiality. Internet: The Internet is a shared global computer network that enables health care team members to connect with resources and libraries, which may contain information to assist in effective clinical decision-making and improved patient outcomes. Email and Listserv: E-mail has become a common means of communication. A listserv is a computer program that automatically sends messages to multiple e-mail addresses on a mailing list. Listservs can be used in health care to connect groups of patients with common problems, or to send updated information to large groups. Social Media: Social media allows participating individuals to communicate easily via the internet to share information and resources. Social media enables a potentially massive community of participants to collaborate, providing a mechanism for tapping into collective power in ways previously unachievable. When participating and interacting on social media, nurses must always follow confidentiality policies and HIPAA guidelines to protect patient privacy. Examples of social media include Facebook, Twitter, and LinkedIn. Blog: A blog is a regularly updated website or web page that is typically managed by an individual or small group. Blogs often contain regular entries of commentary, descriptions of events, or other material such as graphics or videos. Most blogs are interactive, allowing visitors to leave comments and message each other. Many blogs focus on health care issues.

Four Primary Types of Communication Used in Nursing

Nurses engage in four basic types of professional communication: Intrapersonal Interpersonal Small-group Public communication Each has a different focus and potential outcome.

Nursing Education

Nursing Education As technology has advanced and basic information technology skills have become a minimum competency for effective nursing practice, information technology has become integrated into the nursing education curriculum and become part of the educational delivery system. Examples of the use of information technology in nursing education include: Distance learning opportunities are widely available for formal degree programs and continuing education. Virtual realities and simulations allow the learner to participate in immersion scenarios that help in the development of critical-thinking and decision-making skills. Online discussion boards, classrooms, support groups, and social media sites are used for educational activities. An important part of the TIGER vision is the reform of nursing education to provide the 21st-century nurse with informatics skills that enable the use of IT to provide the most effective and safe care possible.

Research

Nursing care continues to evolve as nursing research provides new knowledge and recognizes best practices to improve patient care and outcomes. To implement research-based interventions, nurses must read recent literature and remain current in practice. Accurate communication of care plans among healthcare team members, and the use of informatics to locate relevant research and treatment options, support the implementation of best practices.

Nursing informatics

Nursing informatics is a specialty area of informatics that addresses the use of health information systems to support nursing practice. The American Nurses Association (ANA, 2008) states that the specialty of nursing informatics integrates nursing computer and information science for the management and communication of data, information, knowledge, and wisdom.

Reassessment

One form of direct care that is ongoing throughout all stages of the nursing process is reassessment. After the nurse completes a patient's initial assessment and develops a plan of care, continual reassessment of the patient allows the nurse to detect noticeable changes in the patient's condition, requiring adjustments to interventions outlined in the plan of care.

Consider the goal Patient will ambulate 50 feet twice a day with assistance. Determine if the evaluation statement describes a goal that is met, partially met, or unmet. Patient is consistently ambulating 50 feet twice daily. Patient ambulating 20-50 feet twice daily. Patient is on bed rest due to development of pulmonary embolus. Goal is partially met. Goal is met. Goal is unmet.

Patient is consistently ambulating 50 feet twice daily.Goal is met. Patient ambulating 20-50 feet twice daily.Goal is partially met. Patient is on bed rest due to development of pulmonary embolus.Goal is unmet.

Match each type of nursing informatics competency with its description. Pertains to use of computers, technological equipment, and software Addresses critical thinking and EBP IT applications for improving practice Addresses management of IT use in nursing practice and administration Technical competency Utility competency Leadership competency

Pertains to use of computers, technological equipment, and software = Technical competency Addresses critical thinking and EBP IT applications for improving practice = Utility competency Addresses management of IT use in nursing practice and administration = Leadership competency

Record Management

Record Management Workflow list from a patient's electronic health record. (Courtesy Epic Systems Corporation, Verona, Wisc., 2012.) Functionalities within electronic health records (EHRs) represent significant innovations in the ease of access and storage of medical records. Specific benefits include: Remote access by multiple providers Implementation of computerized or electronic medical records makes patient records readily available through remote access to multiple providers at the same time. This availability of patient information supports efficient delivery of effective care. Compilation of data in one location As EHRs become fully implemented, they include provider order entries, progress notes for all disciplines, computerized medication profiles, access to diagnostic test results on a timely basis, DSSs, and online clinical reminders and alerts. Search ability of aggregate data As care records are aggregated in a data storage system, the patient data can be searched for cases, trends, and outcomes that can be analyzed to determine the best evidence for practice. Improved individual patient health management The ability to quickly review a patient's longitudinal data at the point of care supports the improved management of each patient. For example, being able to see blood pressure documented over time enables the nurse to assess the effect of an ordered medication. Ability to create task lists Customized task lists for specific health care staff groups can be generated by the EHR based on the order information in the database. For example, a nursing task list can be generated for a single patient or group of patients and organized by the type of tasks required, or when the tasks are due (e.g., wound dressing changes every morning and evening). Task lists generated by the EHR help ensure that patient care and medication administration tasks are completed at the appropriate times.

Situation, Background, Assessment, and Recommendation (SBAR)

Situation, Background, Assessment, and Recommendation (SBAR) SBAR Acronym: Situation, Background, Assessment, and Recommendation SBAR is widely accepted as a method of handoff communication and as a structured method for all communications between providers. It involves interpersonal communication designed to enhance patient safety and outcomes. The SBAR model outlines the current situation, the related background, the assessment of the problem, and a recommendation for a solution. SBAR communication requires the sharing of clear information focused on the four topical areas: Situation: What is happening right now? Background: What led up to this current situation? Assessment: What is the identified problem, concern, or need? Recommendation: What actions or interventions should be initiated for this problem?

Small-Group Communication

Small-group communication focuses on meeting established goals or the needs of group participants. This type of communication includes focus groups, support groups, and task forces. The five phases of group development include: Forming Storming Norming Performing Adjourning Forming Leaders identify the mission and goals of the group, ground rules are set, and trust is established through development of i Storming Group members with control issues usually emerge during this phase, resulting in personality conflicts. The group leader works with all members to resolve conflicts and build cohesion. The group leader needs to ensure that all members feel safe voicing their opinions without fear of ridicule by other group members. Norming Group leader encourages all members to become involved, resulting in productivity and meaningful sharing. If one person dominates the discussion, the group leader must redirect interaction in this phase. Performing Problem-solving takes place during this phase, as group members are highly committed to outcomes. Collaboration is also effective. Adjourning Group disperses after the goals have been achieved.

Suchman's Stages of Illness Model Suchman's Stages of Illness Model (1965) describes illness behavior and how individuals arrive at the coping mechanisms related to illness. According to the model, the process of being ill is composed of five stages. Click on each green circle to read how each stage is characterized by certain decisions and behaviors. Stage 1: Symptom Experience Stage II: Assumption of the Sick Role Stage III: Medical Care Contact Stage IV: Dependent Patient Role Stage V: Perceived Recovery

Stage I Stage 1: Symptom Experience During stage 1, a clinical manifestation of disease is experienced, and the person acknowledges that something is wrong and seeks a cure. The outcome of stage 1 is that the person accepts the reality of symptoms and decides to take action in seeking care. Stage II Stage II: Assumption of the Sick Role During stage 2, the person decides that the illness is genuine and that care is necessary. This stage gives an individual permission to act sick and to be excused temporarily from typical social and personal obligations. The results of this stage are either acceptance of the sick role or rejection of its necessity. Stage III Stage III: Medical Care Contact In stage 3, the individual seeks professional advice from health care providers. A health care provider identifies and validates the illness and legitimizes the sick role. During this stage, the condition still may be denied, or the person may seek additional medical care or may accept the adverse condition, the medical diagnostic authority, and the plan for treatment. Stage IV Stage IV: Dependent Patient Role During stage 4, the patient usually undergoes treatment. During this stage, patients often feel dependent on others and may experience ambivalent or fearful thoughts that cause them to reject treatment, the advice of health care providers, and the illness. More often, care is accepted and administered to an ambivalent patient. In this stage, the patient has a significant need to be educated and provided with emotional support. Stage V Stage V: Perceived Recovery During stage 5, the patient abandons the sick role and resumes usual tasks and roles to the greatest degree possible. Some people do not willingly give up the sick role; they begin to view themselves as chronically ill, or they malinger in the health care setting, acting sick for secondary gain. Individuals with permanent disabilities after an illness may require therapy to assist them in making adjustments necessary for performing activities of daily living (Suchman, 1965).

Critical Thinking in the Nursing Process

Step 1. Close Observation. Collect information. Steps 2 and 3. Careful Analysis. Review patient data and use standard language. Set patient-centered, measurable goals. Steps 4 and 5: Effective implementation. Initiate interventions to meet realistic goals. Communicate with the patient, their family, and support team to evaluate outcomes.

Specialty Areas in Nursing Informatics There are various specialty areas within nursing informatics, including technical, utility, and leadership categories. Nurses can be specialists and build skill levels within any of these areas. Technical Utility Leadership

Technical competencies pertain to the use of computers and other technological equipment and the use of a variety of software programs for word processing, spreadsheet and database development, presentation, referencing, and e-mail. Utility competencies address critical thinking and evidence-based practice applications. Nurses who have a utility competency recognize the relevance of nursing data for improving practice and can access multiple information sources for gathering evidence for clinical decision-making. Leadership competencies address the ethical and management issues related to using information technology in nursing practice, education, research, and administration. Specific leadership competencies include the application of accountability, maintenance of privacy and confidentiality, and quality assurance (Herbert, 2008).

Terminologies Recognized by the ANA

The American Nurses Association recognizes specific standardized nursing terminologies and multidisciplinary terminologies that support nursing practice. The use of standardized nursing terminologies provides visibility to the nursing profession and documents the value of professional nursing. These standardized nursing terminologies can also be used amongst multidisciplinary teams, allowing for further sharing of vital information. Use of multidisciplinary terminologies aids health care team members in understanding each other when communicating about a patient. Nursing Terminologies Recognized by the American Nurses Association: NMDS: Nursing Minimum Data Set: Clinical data elements for use in all nursing settings NMMDS: Nursing Management Minimum Data Set: Nursing administrative data elements for use in all nursing settings CCC: Clinical Care Classification: Diagnoses, interventions, and outcomesI CNP: International Classification of Nursing Practice: Diagnoses, interventions, and outcomes NANDA-I: NANDA International: Nursing diagnoses NIC: Nursing Interventions Classification: Nursing interventions NOC: Nursing Outcomes Classification: Outcomes related to nursing care Omaha System - Diagnoses, interventions, and outcomes for home care, public health, and community PNDS: Perioperative Nursing Data Set - Diagnoses, interventions, and outcomes for use in the perioperative area Multidisciplinary Terminologies Recognized by the American Nurses Association ABC: Alternative Billing Codes = More than 4500 descriptions of integrative health care services, remedies, and supplies; ABC fills the gaps of traditional medical code sets LOINC: Logical Observation Identifiers Names and Codes = Universal code system for identifying laboratory and clinical observations SNOMED CT: Systematic Nomenclature of Medicine Clinical Terms = Coding system, controlled vocabulary, classification system, and thesaurus; designed to capture information about patient's history, illnesses, treatment, and outcomes

The International Classification for Nursing Practice

The International Classification for Nursing Practice (ICNP), developed under the auspices of the International Council of Nurses (ICN), provides a standard to facilitate the description and comparison of nursing practice locally, regionally, nationally, and internationally. The ICNP articulates the contributions of nursing to health and health care, enhances communications, and improves the quality and continuity of health care on a global basis. The World Health Organization Family of International Classifications (WHOFIC) accepted ICNP as a related terminology in 2008.

Research Access

The computerization of health care data provides an accessible source of information easily utilized in research. Computer applications are available for quantitative and qualitative research designs. Data management programs can analyze data to identify trends and patterns, allowing meaningful organization of information. Comparisons of nursing care data at the nurse-patient level can initiate comparisons across patient populations, and findings can support evidence-based nursing, evidence-based staffing, and specific billing for nursing services (Welton and Sermeus, 2010).

Direct-Care Interventions Reassessment ADLs Physical Care Counseling Teaching

The inclusion of both direct- and indirect-patient interventions in a patient care plan assists the nurse in providing comprehensive care to the patient, although the impact of indirect care may not be obvious to the patient. Direct-care interventions are those that are conducted through personal contact with the patient. Direct-care interventions include reassessment, activities of daily living (ADLs), physical care, informal counseling, and teaching. Some direct-care interventions must be conducted by the registered nurse (RN), but others may be delegated to another healthcare team member with proper training and supervision by the nurse.

Match the type of communication with the appropriate scenario. The nurse is obtaining a personal health history from her patient. The nurse feels confident by using positive self-talk. The nurse is addressing a quality task force. A nurse is asked to serve as a professional expert on health care issues. Small group Public Interpersonal Intrapersonal

The nurse is obtaining a personal health history from her patient. = Intrapersonal The nurse feels confident by using positive self-talk. - Interpersonal The nurse is addressing a quality task force. Small group A nurse is asked to serve as a professional expert on health care issues. Public

Termination Phase of the Assessment Interview

The termination phase is the last phase of the interview. As the end of the interview approaches, care is taken to review key findings and prepare the patient for the conclusion of the discussion. This can be done by summarizing and validating the information covered with the patient. As the interview concludes, the patient should be allowed an opportunity to interject additional pertinent information. The interview is concluded with the nurse acknowledging the patient's participation and describing the next assessments or procedures that the patient should expect.

Two Modes of Communication

There are two basic modes of communication: verbal and nonverbal. Understanding the difference between the two modes and the methods by which they convey information is essential. According to seminal research by Mehrabian (1971), nonverbal communication is 93% of communication, whereas only 7% is verbal. Verbal communication is conveyed through:Spoken wordsWritten wordsElectronic interaction Nonverbal communication takes place through:Body languageVoice inflection

Match the type of assessment with its description. Thorough interview, health history, and physical exam Brief assessment when there is a concern about the patient's condition Very focused survey with rapid decisions to address immediate concerns Frequent assessments to evaluate the patient and note changes in baseline Emergency Shift Comprehensive Focused

Thorough interview, health history, and physical exam = Comprehensive Brief assessment when there is a concern about the patient's condition = Focused Very focused survey with rapid decisions to address immediate concerns = Emergency Frequent assessments to evaluate the patient and note changes in baseline = Shift

Types of Physical Assessment

Three primary types of physical assessments are conducted by nurses in a variety of practice settings: Comprehensive Focused Emergency Determining which is indicated depends on the situation and timing of the nurse-patient interaction. It is the responsibility of the nurse to determine if a patient's condition warrants more frequent or extensive assessment in any given situation. The decision is often governed by facility policy (such as conducting a focused nursing assessment during each shift) or by clinical situation (critical situations warrant more frequent focused assessments). Some components of the assessment can be delegated, such as measurement of vital signs, but the evaluation and planning related to assessment findings must be done by the nurse. The nurse is accountable to know what components of assessment can legally and safely be delegated and what cannot.

Triage

Triage is a form of emergency assessment in which patients are classified according to treatment priority. Patients are categorized by the urgency of their condition. Most emergency rooms use a three-tier or five-tier triage system. The trend is moving toward a five-tier system. The three-tier system classifies patients as emergent, urgent, and nonurgent. The five-tier system classifies patients by levels numbered 1 through 5.Level one is a critical life-threatening condition.Level five is a less urgent clinical situation. Triage is usually performed when the patient enters the emergency room. However, the increasing patient load at emergency departments has engendered a trend toward telephone triage, which can help a patient determine whether a trip to the emergency department is necessary, or if the patient can wait and make a clinic appointment.

Use of Mobile Technology

Use of mobile information technology has been associated with improvements in research utilization and patient care outcomes. Hand-held technology assists in the transformation of assessment data, interventions, and outcome documentation into evidence-based decision making in nursing (Hardwick, Pulido, and Adelson, 2007). The most obvious advantage of mobile technology is prevention of medication errors. As the final providers in the administration process, nurses are in a position to prevent a medication error. Mobile technology provides nursing students and nurses with instant access to safe dose, compatibility, and pharmacokinetic information that is essential for safe medication administration (Yoost, 2011). Among hand-held technology users, there is a significant improvement in research awareness and valuing, quality of care, job satisfaction, and reduction in barriers to research use (Doran, Straus, Haynes, et al., 2009).

Categorizing Interventions Interventions categorized by their purpose > Problem-based interventions: > Prevention-based interventions: Interventions categorized by the person responsible for initiating and conducting them > Independent nursing interventions > Dependent nursing interventions > Collaborative nursing interventions Interventions categorized by whether they involve personal patient contact > Direct-care interventions > Indirect-care interventions

When discussing the many types of interventions that nurses coordinate, it is useful to categorize them. Interventions may be categorized according to their purpose, the person responsible for initiating and conducting them, or whether the intervention involves personal contact with the patient. Interventions categorized by their purpose Problem-based interventions: Implemented to manage and treat existing problems Prevention-based interventions: Implemented to prevent problems Interventions categorized by the person responsible for initiating and conducting them Independent nursing interventions: Initiated and conducted by the nurse Dependent nursing interventions: Initiated by a provider in the form of an order, and conducted by the nurse Collaborative nursing interventions: Initiated by the nurse or through consult with other healthcare team members, and conducted by other healthcare team members Interventions categorized by whether they involve personal patient contact Direct-care interventions: Involve direct personal contact with the patient Indirect-care interventions: Benefit the patient, but do not involve face-to-face contact with the patient

Voice Inflection

When speaking to a patient, the nurse should consider his or her voice inflection. Inflection refers to the tone, volume, and rate or rhythm of speech. Significance of the information being communicated is shown through voice inflection. The nurse's tone of voice can either enhance or inhibit communication. If the nurse's tone sounds condescending to the patient, the patient may feel offended and halt further communication. If a nurse uses a caring tone, it may encourage the patient to feel comfortable in discussing concerns and contribute to building a trusting relationship.

What word does the nurse use to describe the five steps? o Race o Process o Story o Content

Correct Answer: Process. Explanation: o Race. Race does not pertain to the nursing process. o Process. Nursing is a process. o Story. Story does not pertain to the nursing process. o Content. Content is not a word that describes the nursing process.

What is a part of the assessment process? Data collection Care plan Interventions Prioritize diagnoses

Correct Data collection Correct Data collection = Data collection is a part of nursing assessment. Care plan - Developing the care plan is a part of the planning step of the nursing process. Interventions - Interventions are a part of the implementation step of the nursing process. Prioritize diagnoses - Prioritizing diagnoses is a part of the planning step of the nursing process.

What analytical questions are asked at each step in the nursing process? Select all that apply. "Is the data collection thorough and accurate?" "Are outcomes general and hopeful?" "Have all underlying factors been addressed in the care plan?" "Are the interventions available?" "Could interventions impact the patient negatively?"

Correct Answer: Dynamic Explanation: Collaborative - The nursing process facilitates communication and collaboration, but the cyclical nature of the process does not make it collaborative in nature. Analytical - Analytical thinking skills are necessary when using the nursing process, but do not make the nursing process analytical in nature. Outcome based - The nursing process is outcome based, but its cyclical nature makes it a dynamic and adaptable process. Dynamic - The nursing process is dynamic and adaptable due to the multiple ways it changes to meet the patient needs.

Assessment Overview

Data Collection: Primary via patient interview; secondary data; subjective data (symptoms and health history); objective data (signs, physical examination, lab results, diagnostic test results)

History of the Nursing Process

Now that you have considered the value of the nursing process, take a moment to understand its inception and progression. Nurse Lydia Hall pioneered the usage of the term nursing process in 1955. She presented her theory of nursing by drawing three interlocking circles, each representing a distinct aspect of nursing: care, core, and cure. Dorothy E. Johnson (1959) believed that nursing should focus on the patient as an individual, instead of the disease. She identified two areas that nurses could concentrate on to bring the patient back to a state of mental and physical balance: reducing stressful stimuli and supporting natural and adaptive processes. Ida Jean Orlando (1961) suggested that nurses use interpersonal relationships to meet the needs of the patient as defined by the patient, not as defined by the nurse. This approach supported the patient as a member of the health team. Ernestine Wiedenbach (1963) identified four main elements of nursing: philosophy, purpose, practice, and the art of nursing. The American Nurses Association (ANA) (1973) identified the five steps of the nursing process: (1) assessment, (2) diagnosis, (3) planning (including outcome identification), (4) implementation, and (5) evaluation.

Team-Based Patient Care

A patient's healthcare team members may include several nurses, the primary care provider, medical or surgical specialists, respiratory therapists, a dietician, a spiritual adviser, social workers, and various therapists such as physical or occupational, or even music and art therapists. Collaboration and delegation among a patient's healthcare team members is essential for the overall well-being of the patient. When planning team-based patient care, remember the following aspects: Collaboration and delegation of care are integral to the implementation step of the nursing process. Effective collaboration with and delegation to various members of the healthcare team require the nurse to become familiar with the scope of practice and abilities of each member. After the nurse has established the scope of practice and abilities of the healthcare team members, their unique skills and abilities can be coordinated to benefit patient care and achieve positive patient outcomes. The unique skills and abilities of healthcare team members can be coordinated to benefit patient care and achieve positive patient outcomes after the nurse has established team members' scope of practice. Planning comprehensive care that addresses the multiple needs of patients often facilitates shorter recovery or rehabilitation periods, leading to reduced length of hospitalization and greater patient satisfaction.

Characteristics of the Nursing Process

Analytical At each step in the nursing process, analytical questions must be asked:Is the data collection thorough and accurate? Are outcomes specific and realistic? Have all underlying factors been addressed in the care plan? Could any nursing interventions impact the patient negatively? Are the interventions safe? Does new data indicate that the care plan should be modified? Dynamic The nursing process is dynamic; it changes over time in response to patients' individual needs. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any health care setting and at every level of care, from the intensive care unit to outpatient wellness clinics. Organized When nurses follow the steps of the nursing process, patient care is well organized and comprehensive. The nursing process provides a standardized and systematic method of addressing patient needs, and it is understood by nurses worldwide. Outcome-Oriented The nursing process is outcome-oriented, so health care team members are held accountable for their actions with regard to patient care. Patients benefit from outcome-oriented care because they are consistently and safely treated. The care plan is effective if the agreed-upon goals are met; otherwise, the plan is modified to better address patient needs. Collaborative Collaboration among several members of the health care team (such as the primary care provider, therapists, and social workers) is often required to adequately address patient needs. Nurses may incorporate actions by the patient or family to address patient goals, particularly if the patient is not acutely ill or requires home care. Adaptable The nursing process is adaptable for hospital inpatient care, outpatient care, long-term care, or care in a home setting. The nursing process can be used to assess the needs of individuals as well as large communities. Nurses must identify the expectations of patients and their families to develop patient-centered plans of care. Acknowledging patient preferences empowers patients and their families to actively participate in the health care process.

NANDA identified which goal initially during the development process? Implement nursing diagnostic categories. Promote research to validate diagnostic labels. Encourage nurses to use taxonomy in practice. Revise nursing taxonomy.

Answer: Implement nursing diagnostic categories Explanation: Implement nursing diagnostic categories.The initial goals of NANDA were to generate, name, and implement nursing diagnostic categories. Explanation: Implement nursing diagnostic categories.The initial goals of NANDA were to generate, name, and implement nursing diagnostic categories. Promote research to validate diagnostic labels.A goal of NANDA today is to promote research to validate diagnostic labels, but this was not an initial goal. Encourage nurses to use taxonomy in practice.A goal of NANDA today is to encourage nurses to use taxonomy in practice, but this was not an initial goal. Revise nursing taxonomy.A goal of NANDA today is to revise nursing taxonomy but this was not an initial goal.

During which process is a patient's illness identified in order to provide appropriate medical care? Medical diagnosis Nursing diagnosis. Identification of risk or related factors Identification of defining characteristics

Answer: Medical diagnosis Explanation: Medical diagnosis - The purpose of medical diagnosis is to clearly identify a patient's illness so that appropriate medical treatment can be provided. Nursing diagnosis - The purpose of nursing diagnosis to clearly identify health problems or life processes so that appropriate nursing care can be provided. Identification of risk or related factors = Related factors are the underlying cause or etiology of a patient's problem. Identification of defining characteristics - Defining characteristics are cues or clusters of related assessment data that are signs, symptoms, or indications of an actual or health-promotion nursing diagnosis.

Which group of people make up NANDA? Nurses from all nursing areas Nurses and physicians Nurses, physicians, and lay people Nurses and healthcare administrators

Answer: Nurses from all nursing areas Explanation: Nurses from all nursing areas - NANDA is composed of nurses from all nursing areas, including practice, research, education, administration, and specialty areas of practice. Nurses and physicians - Physicians are not included in NANDA. Nurses, physicians, and lay people - Physicians and lay people are not included in NANDA. Nurses and healthcare administrators - Healthcare administrators that are not nurses would not be part of NANDA.

NANDA is known for its pioneering work in which aspect of nursing? Nursing autonomy Nursing language and classification Analysis of assessment data Identification of illnesses to guide nursing care

Answer: Nursing language and classification Explanation: Nursing autonomyNursing autonomy is promoted by having a standardized nursing taxonomy. Nursing language and classificationNANDA pioneered work in nursing language and classification with its identification of nursing diagnoses. Analysis of assessment dataAnalysis of assessment data helps the nurse select appropriate nursing diagnoses. Identification of illnesses to guide nursing careThe purpose of nursing diagnosis is to identify health problems or processes to guide nursing care.

Which subcategory of planning is recognized by professionals and educators as part of the traditional five-step nursing process? Incorrect Nursing interventions classificationNursing interventions classification is not part of the planning step. Interventions are considered to be implementations. Medical outcome identificationMedical outcome identification is not part of the nursing process. Correct Outcome identificationOutcome identification is a part of the nursing process. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process. Medical interventions classificationMedical interventions classifications are not part of the nursing process.

Answer: Outcome identificationOutcome identification is a part of the nursing process. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process. Explanation: Nursing interventions classificationNursing interventions classification is not part of the planning step. Interventions are considered to be implementations. Medical outcome identificationMedical outcome identification is not part of the nursing process. Outcome identificationOutcome identification is a part of the nursing process. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process. Medical interventions classificationMedical interventions classifications are not part of the nursing process.

Which outcomes are the result of using nursing diagnoses? Accurately labels medical illnessesMedical diagnosis identifies and labels medical illnesses. Promotes accountability in nursing care Supports independence in nursing practiceThe use of nursing diagnosis supports independent nursing practice. Establishes standardization of patient careThe use of nursing diagnosis establishes a standardization of patient care among nursing professionals. Clearly identifies a patient's illnessThe purpose of medical diagnosis is to clearly identify a patient's illness so that appropriate medical treatment can be provided.

Answer: Promotes accountability in nursing care Supports independence in nursing practiceThe use of nursing diagnosis supports independent nursing practice. Establishes standardization of patient careThe use of nursing diagnosis establishes a standardization of patient care among nursing professionals. Explanation: Accurately labels medical illnessesMedical diagnosis identifies and labels medical illnesses. Promotes accountability in nursing careThe use of nursing diagnosis promotes accountability in nursing care. Supports independence in nursing practiceThe use of nursing diagnosis supports independent nursing practice. Establishes standardization of patient careThe use of nursing diagnosis establishes a standardization of patient care among nursing professionals. Clearly identifies a patient's illnessThe purpose of medical diagnosis is to clearly identify a patient's illness so that appropriate medical treatment can be provided.

The patient fell and fractured his hip. He also has diabetes, heart failure, and osteoporosis. Which aspect of the patient's history would a nursing diagnosis focus on? Sudden onset of pain Intertrochanteric hip fracture Degenerative joint disease Left-sided heart failure

Answer: Sudden onset of pain Explanation: Sudden onset of pain - Sudden onset of pain identifies a health problem the patient may have in response to a medical problem. This aspect of the history would be the focus of a nursing diagnosis. Intertrochanteric hip fracture - Intertrochanteric hip fracture is a medical diagnosis. Degenerative joint disease - Degenerative joint disease is a label for a medical illness. Left-sided heart failure - Left-sided heart failure is a label for a medical illness.

Which statement comparing medical diagnosis and nursing diagnosis is true? Nursing diagnosis identifies and labels medical illnesses in addition to life processes. Medical diagnosis identifies and labels medical illnesses. The scope of nursing diagnosis is narrow while the scope of medical diagnosis is broad. The purpose of nursing diagnosis is to clearly identify problems so appropriate nursing care can be provided. The purpose of medical diagnosis is to identify illness so medical treatment can be provided. Nursing diagnosis identifies psychological problems while medical diagnosis identifies physical problems.

Answer: The purpose of nursing diagnosis is to clearly identify problems so appropriate nursing care can be provided. Explanation: Nursing diagnosis identifies and labels medical illnesses in addition to life processes. Medical diagnosis identifies and labels medical illnesses.Nursing diagnosis identifies and labels health problems or life processes. Medical diagnosis identifies and labels medical illnesses. The scope of nursing diagnosis is narrow while the scope of medical diagnosis is broad.The scope of medical diagnosis is intentionally narrow while the scope of nursing diagnosis is slightly broader. The purpose of nursing diagnosis is to clearly identify problems so appropriate nursing care can be provided. The purpose of medical diagnosis is to identify illness so medical treatment can be provided.The purpose of nursing diagnosis to clearly identify health problems or life processes so that appropriate nursing care can be provided. The purpose of medical diagnosis is to clearly identify a patient's illness so that appropriate medical treatment can be provided. Nursing diagnosis identifies psychological problems while medical diagnosis identifies physical problems.Nursing diagnosis identifies physical or psychological problems or processes. Medical diagnosis identifies physical or psychological medical illnesses.

Which characteristic of the nursing process refers to changes over time in response to patients' individual needs? Dynamic Analytical Organized Adaptable

Answer: Adaptable Explanation: Dynamic The dynamic characteristic of the nursing process refers to how the nursing process changes over time in response to patients' individual needs. Analytical The analytical characteristic of the nursing process refers to nurses using critical thinking for each step of the nursing process. Organized The organized characteristic of the nursing process refers to patient care being well organized and comprehensive. Adaptable The adaptable characteristic of the nursing process refers to nursing care plans being developed for patients in any care setting, as well as for targeted populations and communities.

Which step of the nursing process does a nurse use when finding blood pressure of 180/75, a heart rate of 90, and a patient complaint of chest pain? Implementation Evaluation Diagnosis Assessment

Answer: Assessment Explanation: Implementation - Before implementing any actions, the nurse should assess the patient to determine which nursing actions are appropriate. Evaluation - Evaluation is the last step of the nursing process and involves looking at nursing interventions to determine effectiveness. Diagnosis - Prior to creating a diagnosis, the nurse should assess the patient to obtain data to give insight into the cause of the chest pain and abnormal vital signs. Assessment - Assessment is always the first step when managing patient care. The nurse must analyze that data in order to create nursing diagnoses and a patient-centered care plan.

What is the primary purpose for documenting nursing interventions? Facilitate communication Legal record-keeping Implement policy Proof of performance

Answer: Facilitate communication Explanation: Facilitate communication Communication is the most important reason why proper documentation is performed. It facilitates communication among all health care members and decreases the potential for errors. Legal record-keeping Legal record-keeping is an important reason to do proper documentation, but there is another more important reason for clearly documenting all nursing interventions. Implement policy Documentation is required by policy, but there is another more important reason for clearly documenting all nursing interventions. Proof of performance Documenting interventions does prove they were performed, but there is another more important reason for clearly documenting all nursing interventions.

Stella Jones, RN, reassesses a patient one hour after giving morphine for the patient's pain. The patient states that she is still in horrible pain, eliciting a response of 8 out of 10. What would be the most appropriate intervention? Check blood pressure. Give additional breakthrough pain medication. Reassess pain level in two hours. Monitor heart rate every 30 minutes.

Answer: Give additional breakthrough pain medication. Explanation: Check blood pressure.Checking the patient's blood pressure does not address the patient's pain level and would be part of the assessment step of the nursing process. Give additional breakthrough pain medication.Giving additional breakthrough pain medication is the most appropriate intervention for controlling pain. Reassess pain level in two hours.Reassessing the patient's pain level in two hours would add more data to the assessment step of the nursing process, but does not assist with controlling pain. Monitor heart rate every 30 minutes.Monitoring the patient's heart rate every 30 minutes is not relevant to controlling pain. This would add more data for assessment of the nursing process.

A nurse is creating a care plan and wants to put direct care items before indirect care items. Which of these is in the correct order? Order a low-salt diet for the patient, and then help the patient to ambulate. Set up home care for the patient, and then give the patient an injection. Arrange for the schedule of the physical therapist to come, and then apply a medicated transdermal patch. Help the patient ambulate, and then order occupational therapy to come.

Answer: Help the patient ambulate, and then order occupational therapy to come. Explanation: Order a low-salt diet for the patient, and then help the patient to ambulate. The correct order in this case is helping the patient to ambulate and then ordering a low-salt diet. Set up home care for the patient, and then give the patient an injection. The correct order in this case is to give the patient an injection and then set up home care. Arrange for the schedule of the physical therapist to come, and then apply a medicated transdermal patch. The correct order in this case is applying a medicated transdermal patch and then scheduling physical therapy. Help the patient ambulate, and then order occupational therapy to come. Correct, the direct care item, helping the patient ambulate, does come first in this sequence.

What does the term "dynamic nature" of the nursing process refer to? Change over time in response to the patient's needs Change over time in response to the nurse's needs Change over time in response to the provider's needs Change over time in response to the family's needs

Answer: Lydia Hall Explanation: Ernestine WiedenbachErnestine Wiedenbach was responsible for identifying four main elements of nursing: the art, philosophy, purpose, and practice Ida Jean OrlandoIda Jean Orlando recommended the use of interpersonal relationships to improve patient care. Lydia HallLydia Hall coined the term "nursing process" in 1955. Dorothy E. JohnsonDorothy E. Johnson believed in a holistic, patient focused philosophy of nursing, instead of the current disease model.

Which statement illustrates the collaborative characteristic of the nursing process? The nursing process can be used to assess the needs of individuals as well as large communities. The nursing process provides a systematic method of addressing patient needs, and is understood by nurses worldwide. The nursing process allows patient care to be comprehensive and well organized. Nurses may incorporate actions by the patient or family to address patient goals.

Answer: Nurses may incorporate actions by the patient or family to address patient goals. Explanation: The nursing process can be used to assess the needs of individuals as well as large communities.The fact that the nursing process can be used to assess the needs of individuals as well as large communities is characteristic of the adaptable nature of the nursing process. The nursing process provides a systematic method of addressing patient needs, and is understood by nurses worldwide.The nursing process provides a standardized and systematic method of addressing patient needs and is understood by nurses worldwide is an organized characteristic of the nursing process. The nursing process allows patient care to be comprehensive and well organized.The nursing process allows patient care to be comprehensive and well organized. Nurses may incorporate actions by the patient or family to address patient goals.The fact that a nurse may incorporate patient and family actions into the plan of nursing care, in order to achieve patient outcomes, makes this a characteristic of the collaborative nature of the nursing process.

Which option exemplifies a short-term goal the nurse may identify during the planning step of the nursing process? Correct Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication.A time period of 2 hours is an appropriate choice for a short-term goal. This time period is the shortest of all the answer choices. Incorrect Patient verbalizes a pain level of 2 or 3, out of 10, during A.M. care within 24 hours.Identifying goals at 24 hours is more suggestive of a long-term goal. Patient verbalizes a pain level of 1 out of 10 at the 2-week provider follow-up appointment.Creating goals at a 2-week timeframe is a long-term not a short-term goal. Patient verbalizes a pain level of 0 out of 10 at the 1-month provider follow-up appointment.Establishing a time period of pain relief within the 1-month provider follow-up appointment is a long-term not a short-term goal.

Answer: Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. Explanation: Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain A time period of 2 hours is an appropriate choice for a short-term goal. This time period is the shortest of all the answer choices. Patient verbalizes a pain level of 2 or 3, out of 10, during A.M. care within 24 hours.Identifying goals at 24 hours is more suggestive of a long-term goal. Patient verbalizes a pain level of 1 out of 10 at the 2-week provider follow-up appointment.Creating goals at a 2-week timeframe is a long-term not a short-term goal. Patient verbalizes a pain level of 0 out of 10 at the 1-month provider follow-up appointment.Establishing a time period of pain relief within the 1-month provider follow-up appointment is a long-term not a short-term goal.

Which term describes the nurse prioritizing the diagnoses and identifying goals that are realistic, measurable, and patient-focused with specific outcomes? Assessment Planning Diagnosis Evaluation

Answer: Planning Explanation: Assessment: Assessment is when the nurse gathers patient data through observation, interviews, and physical assessment. Planning: Planning is when the nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused, with specific outcomes. Diagnosis: During the diagnosis step, the nurse analyzes, validates, and clusters patient data to identify patient problems. Evaluation: During evaluation, the nurse determines if the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

What analytical questions are asked at each step in the nursing process? "Is the data collection thorough and accurate?" "Are outcomes general and hopeful?" "Have all underlying factors been addressed in the care plan?" "Could interventions impact the patient negatively?"

Answers: "Is the data collection thorough and accurate?" "Have all underlying factors been addressed in the care plan?" "Could interventions impact the patient negatively?" Explanations: "Is the data collection thorough and accurate?" - "Is the data collection thorough and accurate?" is an analytical question. "Are outcomes general and hopeful?" - "Are outcomes general and hopeful?" is not an analytical question. The appropriate question would be, "Are outcomes specific and realistic?" "Have all underlying factors been addressed in the care plan?" - "Have all underlying factors been addressed in the care plan?" is an analytical question. "Are the interventions available?" - "Are the interventions available?" is not an analytical question. The correct question would be, "Are the interventions safe?" "Could interventions impact the patient negatively?" - The nurse must think through the planned interventions and ensure that each one is safe for the patient. "Could interventions impact the patient negatively?" is an analytical question.

Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site? Select all that apply. The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse verifies that no pain medications were ordered and tells patient she has no medications ordered. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain. The nurse assesses the surgical site to determine the cause of the increased pain.

Answers: The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain. The nurse assesses the surgical site to determine the cause of the increased pain. Explanation: The nurse verifies that no pain medications were ordered and calls provider on call for pain medications.The nursing process requires nurses to think analytically, using many aspects of critical thinking. The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. Calling a provider indicates the nurse is critically thinking about interventions for the patient. The nurse verifies that no pain medications were ordered and tells patient she has no medications ordered.There is no intervention listed for the patient, so there are no steps that will help lower the patient's pain level. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient.The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. The nurse does not need a provider order to implement non-pharmaceutical interventions. The nurse assesses vital signs and checks to see when patient was last medicated for pain.The nursing process requires nurses to think analytically using many aspects of critical thinking. The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. The nurse is assessing to see if there is new data that necessitates modification of the existing plan of care. The nurse assesses the surgical site to determine the cause of the increased pain.In addition to assessing vital signs and pain level, the nurse should assess the surgical site to determine if there are new signs of poor wound healing or infection. The root cause of the pain should be considered when planning further interventions.

Match type of outcome or goal with its correct definition or example. Within 1 week, the patient will stand with support to brush teeth. Within 3 months, the patient will stand unsupported for 20 minutes. Classification of patient outcomes evaluating the effects of interventions. Classification of interventions that nurses perform on behalf of patients. Long-term goal Short-term goal Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC)

Answers: Within 1 week, the patient will stand with support to brush teeth. = Short-term goal Within 3 months, the patient will stand unsupported for 20 minutes. = Long-term goal Classification of patient outcomes evaluating the effects of interventions. = Nursing Outcomes Classification (NOC) Classification of interventions that nurses perform on behalf of patients. = Nursing Interventions Classification (NIC)

Which statements made by a nursing student would indicate an understanding of the benefits of using the ICNP® nursing taxonomy in practice? Select all that apply. ICNP® nursing diagnoses can be applied in the acute care setting as well as in other health care related settings. Supporting patient data takes the place of nursing diagnosis in the ICNP® taxonomy. Use of the ICNP® taxonomy gives nursing a voice within the comprehensive health information system. ICNP® taxonomy is beneficial within the United States but its use is limited globally. The standardized terminology makes the ICNP® taxonomy adaptable to the EMR format of documentation.

Correct Correct Answers: ICNP® nursing diagnoses can be applied in the acute care setting as well as in other health care related settings. Use of the ICNP® taxonomy gives nursing a voice within the comprehensive health information system. The standardized terminology makes the ICNP® taxonomy adaptable to the EMR format of documentation. Explanation: ICNP® nursing diagnoses can be applied in the acute care setting as well as in other health care related settings.The ICNP® taxonomy can be utilized at the bedside, at the point of care outside of the hospital, in research, and in the development of practice standards. Supporting patient data takes the place of nursing diagnosis in the ICNP® taxonomy.The ICNP® taxonomy begins with the nurse collecting and organizing patient assessment data into logical clusters or patterns. ICNP® calls this patient information "supporting data." The nurse then uses clinical reasoning to interpret the meaning of the data clusters, and selects the relevant ICNP® nursing diagnosis/diagnoses. Use of the ICNP® taxonomy gives nursing a voice within the comprehensive health information system.Use of the ICNP® taxonomy helps to ensure adequate representation of nursing within multidisciplinary health information systems. ICNP® taxonomy is beneficial within the United States but its use is limited globally.The ICNP taxonomy is intended for worldwide use, allowing for terminology recognition at a time when the borders of health care have widened and nursing practice is global. The standardized terminology makes the ICNP® taxonomy adaptable to the EMR format of documentation.Standard terminology and common language are key factors for systematizing nursing documentation within the electronic medical record (EMR).

A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient's pain level, is the nurse assessing subjective or objective data? · o Subjective data, because only the patient can experience the pain. o Subjective data, because the blood pressure is an accurate measure of the patient's pain. o Objective data, because the pain level can be turned into a number on a one to ten scale. o Objective data, because the patient can point to the "oucher" picture indicating the experienced pain level.

Correct o Subjective data, because only the patient can experience the pain. Explanation: o Subjective data, because only the patient can experience the pain. The pain level is subjective, because it is spoken or pointed out as an "oucher" card in the case of the patient with a tracheotomy. · o Subjective data, because the blood pressure is an accurate measure of the patient's pain. While it is true that pain level is subjective, it is not true that blood pressure, which is an objective measure, is an accurate measure of the patient's pain. · o Objective data, because the pain level can be turned into a number on a one to ten scale. The pain is not objective in that subjective data are spoken, either by the patient or someone else. o Objective data, because the patient can point to the "oucher" picture indicating the experienced pain level. The pain is not objective, in that only the patient can experience it and tell about it. Even though the pain level can be pointed out by the boy using the "oucher" picture, pain is still a subjective measure.

A nurse is preparing a presentation to the unit on ANA, the organization that identified the five steps of the nursing process. What does ANA stand for? American Nurses Association Active Nurses Academy American Nurses Academy Association Nurses Alive

Correct Answer: American Nurses Association Explanation: American Nurses Association - ANA stands for American Nurses Association. Active Nurses Academy - This is not an actual nursing association. American Nurses Academy - This is not a real nursing association. Association Nurses Alive - This organization does not exist.

Place the five steps of the nursing process in the correct order. Assessment Evaluation Diagnosis Planning Implementation

Correct Answer: Assessment Diagnosis Planning Implementation Evaluation

Which statement illustrates the collaborative characteristic of the nursing process? The nursing process can be used to assess the needs of individuals as well as large communities. The nursing process provides a systematic method of addressing patient needs, and is understood by nurses worldwide. The nursing process allows patient care to be comprehensive and well organized. Nurses may incorporate actions by the patient or family to address patient goals.

Correct Answer: Change over time in response to the patient's needs - The dynamic nature refers to the way the process changes to meet the patient's needs. Explanation: Change over time in response to the patient's needs - The dynamic nature refers to the way the process changes to meet the patient's needs. Change over time in response to the nurse's needs - The dynamic nature does not refer to the nurse's needs, but focuses on the needs of the patient. Change over time in response to the provider's needs - The dynamic nature does not refer to the provider's needs, but focuses on the needs of the patient and how they are met. Change over time in response to the family's needs - The dynamic nature does not refer to the family's needs, only to the needs of the patient.

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

Correct Answer: Communicating patient needs Explanation: Resolving patient confusion - The purpose of developing the nursing diagnosis is not to resolve patient confusion. The nursing diagnosis will provide greater clarity and universal understanding by all care providers. Communicating patient needs - In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. Meeting accreditation requirements - The nursing diagnosis is not setup to meet accreditation requirements. Articulating the nursing scope of practice - The nursing diagnosis assists in standardizing the nursing scope of practice.

What is the most important aspect of a patient-centered care plan? Implementing teaching early in the patient's recovery Matching the patient's goals and relevant current status Selecting several interventions for each nursing diagnosis Moving the patient from dependence to independence

Correct Answer: Matching the patient's goals and relevant current status Explanation: Implementing teaching early in the patient's recovery Implementing patient teaching early is important but patient centered plans must be in place before teaching can proceed. This is not the most important aspect of patient-centered care planning. Matching the patient's goals and relevant current status Goals must match patients' status and be based on current evidence in order for nurses to develop plans that effectively move patients toward meeting those goals and achieving desired outcomes. This is the most important aspect of patient-centered care plans. Selecting several interventions for each nursing diagnosis Selecting interventions that best address selected diagnoses and meet patient needs are more important than the number of interventions selected. This is not the most important aspect of patient-centered care planning. Moving the patient from dependence to independence Not every patient can move from dependence to independence, and the plan must be patient-centered. This is important, but not the most important aspect of patient-centered care planning.

Match the nursing process characteristics to the definition. Nurses use critical thinking for each step of the nursing process. The nursing process changes over time in response to patient needs. The nursing process helps ensure that patient care is well planned. Nurses evaluate patient outcomes to determine effectiveness. Outcome-oriented Organized Dynamic Analytical

Correct Answer: Nurses use critical thinking for each step of the nursing process. = Analytical The nursing process changes over time in response to patient needs. = Dynamic The nursing process helps ensure that patient care is well planned. = Organized Nurses evaluate patient outcomes to determine effectiveness. = Outcome-oriented

Match the category with its corresponding data source. Obtained directly from patient Obtained from other healthcare professionals, medical records, test results Direct quotes describing patient feelings Blood pressure reading and weight Primary Subjective Secondary Objective

Correct Answer: Obtained directly from patient = Primary Obtained from other healthcare professionals, medical records, test results = Secondary Direct quotes describing patient feelings = Subjective Blood pressure reading and weight = Objective

Information received from the patient's family members, friends, or other nurses is what type of data? Select all that apply. Comprehensive Objective Primary Secondary Subjective

Correct Answer: Secondary Subjective Explanation: Comprehensive Assessment does not have a category known as comprehensive data even though data collected is comprehensive, meaning it covers physical, emotional, spiritual and cultural aspects of the patient's health and well-being. Objective Objective data are observable information that can be measured or tested. Primary Primary data are obtained directly from the patient. Secondary Secondary data come from sources other than the patient. Subjective Subjective data may come from either the patient or from family members.

Which best describes the diagnosis step of the nursing process? The nurse gathers patient data through observation, interviews, and physical assessment. The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. The nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused with specific outcomes. The nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.

Correct Answer: The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.The diagnosis step of the nursing process is when the nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. Explanation: The nurse gathers patient data through observation, interviews, and physical assessment.Assessment is when the nurse gathers patient data through observation, interviews, and physical assessment. The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.The diagnosis step of the nursing process is when the nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. The nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused with specific outcomes.Planning is when the nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused with specific outcomes. The nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.Implementation is when the nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.

A patient comes to the emergency department complaining of fever and diarrhea. What should the nurse ask the patient first? "Do you have a family history of diabetes?" "Are you taking any medications?" "Have you had any surgeries in the past?" "What is the severity and duration of your fever and diarrhea?"

Correct Answer: "What is the severity and duration of your fever and diarrhea?" Explanation: "Do you have a family history of diabetes?"Asking the patient about a history of diabetes is additional information, but not the first thing to ask the patient. "Are you taking any medications?"The nurse would ask about the patient's medications after finding out more data about the actual patient complaint. "Have you had any surgeries in the past?"Surgery history is important to know, but not the first thing to ask. "What is the severity and duration of your fever and diarrhea?" Asking about severity and duration of the patient's fever and diarrhea gives more data to the assessment step of the nursing process that is relevant to assisting the patient with the chief complaint of fever and diarrhea.

The _________characteristic of the nursing process is that nursing care plans can be developed for patients in any care setting, as well as for targeted populations and communities. Dynamic Analytical Organized Adaptable

Correct Answer: Adaptable Explanation: Dynamic The dynamic characteristic of the nursing process refers to the changing nature of the nursing process over time in response to patients' individual needs. Analytical The analytical characteristic of the nursing process refers to nurses using critical thinking for each step of the nursing process. Organized The organized characteristic of the nursing process refers to ensuring that patient care is well organized and comprehensive. Adaptable The adaptable characteristic of the nursing process refers to nursing care plans being developed for patients in any care setting, as well as for targeted populations and communities.

A nurse determines the patient's goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised? o Add another pillow wedge at night. o Add a step to avoid eating after 7 p.m. o Increase grapefruit juice taken with meals. o Discontinue the plan.

Correct Answer: Add a step to avoid eating after 7 p.m. Explanation: o Add another pillow wedge at night. A second pillow wedge is often ineffective, as patients tend to slide downhill. o Add a step to avoid eating after 7 p.m. Revising the plan by adding a step is the right strategy. o Increase grapefruit juice taken with meals. Drinking grapefruit juice will only increase the acidity of the gastric contents. · o Discontinue the plan. It is too soon to discontinue the plan as it is somewhat working.

The _____________ characteristic of the nursing process describes when nurses ask questions and demonstrate the use of critical thinking for each step. Organized Outcome-oriented Analytical Dynamic

Correct Answer: Analytical Explanation: Organized The organized characteristic of the nursing process refers to ensuring that patient care is well organized and comprehensive. Outcome-oriented The outcome-oriented characteristic of the nursing process refers to nurses and other health care team members being accountable for their actions with regard to patient care. Analytical The analytical characteristic of the nursing process refers to nurses asking analytical questions throughout the process, which demonstrates the use of critical thinking. Dynamic The dynamic characteristic of the nursing process refers to changing nature of the nursing process over time in response to patients' individual needs.

A nurse is caring for a patient who is cyanotic and has edema. The nurse is making a list of the patient's physical, psychological, emotional, environmental, cultural, and spiritual health. What stage of the nursing process is this? · o Assessment o Diagnosis o Planning o Evaluation

Correct Answer: Assessment Explanation: o Assessment. The correct step in the nursing process is assessment, since the parts of holistic assessment are being considered. · o Diagnosis. The current step in the nursing process is not diagnosis, since the nurse is still listing the patient's holistic elements, which is part of assessment. · o Planning. The current step is not planning, since only signs of cyanosis and edema are known, and no diagnosis has been made. · o Evaluation. The current step is not evaluation. Evaluation is the last step of the nursing process, which comes after the treatment has been implemented.

In which way does the nursing diagnosis provide an effective means of communicating the patient's status? By consolidating a great volume of information into a concise statement. By narrowly defining the patient's illness as explicitly as possible. By clearly identifying the patient's medical diagnosis. By listing all of the patient's responses to medical and nursing care.

Correct Answer: By consolidating a great volume of information into a concise statement. Explanations: By consolidating a great volume of information into a concise statement.Because a nursing diagnosis consolidates a great volume of information into a concise statement, it provides an effective shorthand means of communicating the patient's status to the entire healthcare team. By narrowly defining the patient's illness as explicitly as possible.The scope of medical diagnosis is intentionally narrow to define the patient's illness as explicitly as possible. By clearly identifying the patient's medical diagnosis.The purpose of medical diagnosis is to clearly identify a patient's illness so that appropriate medical treatment can be provided. By listing all of the patient's responses to medical and nursing care.The nursing diagnosis doesn't list out each response to medical diagnoses or care.

What determines if an assessment is primary or secondary? Data source Types of data Categories of data Subjectivity of the data

Correct Answer: Data source Explanation: Data source The source of the data determines whether the assessment is primary (directly from a patient) or secondary (from other places). Types of data The types of data are categorized as either subjective or objective. Categories of data The categories of data are another way of saying "the types of data." Subjectivity of the data The subjective data is a type of data, and it may be either primary or secondary.

The nursing __________ identifies an actual or potential problem or response to a problem. Diagnosis Plan Assessment Outcome

Correct Answer: Diagnosis Explanation: Diagnosis A nursing diagnosis is meant to identify an actual or potential problem, or a response to a problem. Plan A nursing plan includes interventions that address the diagnosis; it does not identify the actual or potential problem. Assessment A nursing assessment gathers all the signs and symptoms, and comes before the diagnosis. Outcome Outcomes depend on whether or not patient goals are achieved during the evaluation step of the nursing process.

In which way is the ICNP® taxonomy valuable to the nursing profession? Documentation of the validity of nursing practice is a result of its use. The ICNP® taxonomy is easier to use than the NANDA-I taxonomy. Only nurses can use the ICNP® taxonomy, giving them ownership of the tool. The ICNP® taxonomy replaces much of the documentation required of nurses in the EMR.

Correct Answer: Documentation of the validity of nursing practice is a result of its use. Explanation: Documentation of the validity of nursing practice is a result of its use.Integration of the ICNP taxonomy into the EMR provides documentation and validation of the contribution of nursing as a valuable health care resource. The ICNP® taxonomy is easier to use than the NANDA-I taxonomy.While different in structure, the ICNP® taxonomy is not necessarily easier to use than the NANDA-I taxonomy. Only nurses can use the ICNP® taxonomy, giving them ownership of the tool.Nurses and other health care providers can use the data-based information from ICNP® for planning and managing nursing care, financial forecasting, analysis of patient outcomes, and health policy development. The ICNP® taxonomy replaces much of the documentation required of nurses in the EMR.The ICNP® taxonomy is embedded within the EMR and enhances nursing documentation, while collecting valuable patient data. It does not eliminate the need for other forms of nursing documentation.

A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits? o Ensure individualized care. o Concern over the baby arriving prematurely. o Facilitate setting patient outcomes. o Determine if the patient has other children.

Correct Answer: Ensure individualized care. Explanation: o Ensure individualized care. During evaluation, nurses need to ask questions where answers help determine how best to proceed with individualized care. · o Concern over the baby arriving prematurely. The nurse does not know if the baby will arrive prematurely. o Facilitate setting patient outcomes. Outcomes are not set during evaluation; evaluation determines if outcomes were met. · o Determine if the patient has other children. The patient's other children are not the reason for the nurse's question.

What is the fifth step of the nursing process that includes a decision point on whether to discontinue, continue, or revise the plan of care? Assessment Planning Evaluation Implementation

Correct Answer: Evaluation Explanation: Assessment Assessment is the first step of the nursing process. The nurse gathers patient data through observation, interviews, and physical assessment. Planning Planning is the third step of the nursing process. The nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused, with specific outcomes. Evaluation Evaluation is the fifth step of the nursing process. The nurse determines if the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised. Implementation Implementation is the fourth step of the nursing process. The nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.

Which step is a part of the nursing process? Preparing Analysis Treatment Evaluation

Correct Answer: Evaluation Explanation: reparing Planning is the third step in the nursing process, not preparing. Analysis Diagnosis is the second step in the nursing process, not analysis. Treatment Treatment is not a part of the nursing process. Evaluation Evaluation is the fifth step in the nursing process.

A patient reports that his pain level is now 6 out of 10. The patient's goal for a pain level of 3-4 out of 10 is not met. Which step of the nursing process does this statement reflect? Planning Diagnosis Implementation Evaluation

Correct Answer: Evaluation - During evaluation, the nurse reviews patient outcomes to determine whether the patient's goals and nursing diagnoses were appropriately met or addressed. Explanation: Planning - During the planning step, the nurse identifies appropriate interventions that will address the patient's goals and nursing diagnoses. Diagnosis - During the diagnosis step, the nurse analyzes assessment data and develops a nursing diagnosis to address identified health problems. Implementation - During the implementation step, the nurse carries out the interventions listed on the nursing care plan and those identified during the planning stage. Evaluation - During evaluation, the nurse reviews patient outcomes to determine whether the patient's goals and nursing diagnoses were appropriately met or addressed.

What type of patient assessment takes into account factors such as the patient's physical, psychological, emotional, environmental, cultural, and spiritual health? Universal General Financial Holistic

Correct Answer: Holistic Explanation: Universal While the word universal would seem to take into account a range of patient factors, a holistic assessment considers the patient's physical, psychological, emotional, environmental, cultural, and spiritual health. General The word general is not the same as holistic. Financial Financial status is not part of the holistic assessment. Holistic A holistic assessment takes into account numerous factors of the patient's health: physical, psychological, emotional, environmental, cultural, and spiritual.

A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard? · o Evaluation o Implementation o Assessment o Planning

Correct Answer: Implementation Explanation: · o Evaluation It is not the evaluation step because at evaluation, a treatment is checked for effectiveness and revised if necessary. In this case, the treatment has not yet taken place. o Implementation Implementation includes initiating specific nursing interventions designed to help achieve established goals. o Assessment It is not the assessment step because the question states that the care plan is already in place. o Planning It is not the planning step because the question states that a care plan is already in place. Since the care plan is developed during the planning step, the planning step has already taken place.

A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen? o The plan of care follows directly from the diagnosis. o Revisions will be avoided until after the evaluation phase of the care plan. o Information from other steps will be used to complete the plan of care. o The patient will improve during each step of the nursing process.

Correct Answer: Information from other steps will be used to complete the plan of care. Explanation: o The plan of care follows directly from the diagnosis. The plan of care does not automatically follow from the diagnosis because such factors as the patient's age and immune status necessarily require the nurse's critical thinking process. · o Revisions will be avoided until after the evaluation phase of the care plan. At each step of the nursing process, revisions to the plan of care may occur. o Information from other steps will be used to complete the plan of care. The steps are interdependent, and information from other steps will be used to complete and implement an effective plan of care. · o The patient will improve during each step of the nursing process. While it is hopeful that the patient will improve as each step of the nursing process moves to the next step, complications and other diagnoses can cause the patient to deteriorate instead of improve.

Where are NANDA-I nursing diagnostic labels selected from? NANDA-I approved list Patient's current medical diagnoses Patient's medical record History and physical

Correct Answer: NANDA-I approved list Explanation: NANDA-I approved list - The nurse selects an appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements. Patient's current medical diagnoses - The patient's current medical diagnoses help drive the selection of the nursing diagnoses. Patient's medical record - Information contained in the medical record helps drive the selection of the nursing diagnoses from the NANDA-I approved list. History and physical - Information contained in the history and physical helps drive the selection of the nursing diagnoses from the NANDA-I approved list.

A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers should initiate the nurse to change the nursing care plan? o new decubitus ulcers have formed o there is no change in decubitus ulcer size o decubitus ulcers are now smaller o color of decubitus ulcers has improved

Correct Answer: New decubitus ulcers have formed Explanation: o new decubitus ulcers have formed If the current treatment has resulted in development of new decubitus ulcers the current treatment is not working and should be reevaluated. o there is no change in decubitus ulcer size Although the size of the decubitus ulcers have remained the same, pressure wounds heal very slowly and the current treatment should be continued at this point. o decubitus ulcers are now smaller If the current treatment has resulted in smaller decubitus ulcers, then the current treatment should be continued. o color of decubitus ulcers has improved If the current treatment has resulted in color improvement of the decubitus ulcers then the current treatment is working and should be continued.

Which method was developed to advance the nursing profession and how nurses provide care to all patients? Nursing care plan Nursing process Nursing diagnoses Patient-centered care

Correct Answer: Nursing process Explanation: Nursing care plan The nursing care plan is a part of the nursing process and outlines the nursing diagnoses and patient specific interventions. This step was developed as a result of the development of the nursing process and its steps. Nursing process The term, nursing process, allowed nursing leaders to develop a formal process for providing nursing care for all patients, and has advanced the professional and autonomous image of the nurse. Nursing diagnoses The concept of nursing diagnoses was developed long after the development of the nursing process. Patient-centered care The formal concept of patient centered care is a relatively new concept, and is not specifically related to nursing care.

A nurse educator is reviewing the steps of the nursing process with the class. While reviewing a case study, the educator asks the students to determine which part of the process a nurse uses when establishing short- and long-term goals with the patient. How should the students respond? Planning Diagnosis Implementation Evaluation

Correct Answer: Planning Explanation: Planning - During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. Diagnosis - In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. Implementation - The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. Evaluation - The evaluation step includes the nurse determining whether the patient's goals are met; examining the effectiveness of interventions; and deciding whether the plan of care should be discontinued, continued, or revised.

A nurse is ready to set goals for a patient who is recovering from a hip replacement. The nurse sets goals for the first three days and for the first three weeks. What part of the nursing process is this? o Planning o Assessment o Diagnosis o Evaluation

Correct Answer: Planning o Planning Planning includes prioritizing nursing diagnoses and setting patient-focused short- and long-term goals. · o Assessment Assessment consists of gathering data. · o Diagnosis Diagnosis consists of analyzing, validating, and clustering data to identify patient problems. · o Evaluation Evaluation includes determining the effectiveness of interventions and deciding if the plan of care needs to be revised.

The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient? · o Respiratory therapist, cardiologist, and nephrologist o Cardiologist, urologist, and pulmonologist o Rheumatologist, respiratory therapist, and cardiologist o Respiratory therapist, cardiologist, and pulmonologist

Correct Answer: Respiratory therapist, cardiologist, and pulmonologist Explanations: o Respiratory therapist, cardiologist, and nephrologist Some, but not all of these team members would be included. o Cardiologist, urologist, and pulmonologist Some, but not all of these team members would be included. o Rheumatologist, respiratory therapist, and cardiologist Some, but not all of these team members would be included. o Respiratory therapist, cardiologist, and pulmonologist A respiratory therapist, a cardiologist, and a pulmonologist are all likely members of a health care team concerning a diagnosis of low blood oxygen.

A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care? · o Risk, since the patient's identified need is the diagnosis of colostomy. o Risk, since the patient is at risk for infection at the site of the surgical incision. o Actual, since the patient is at risk from factors indicating vulnerability. o Actual, since the patient is in need of health-promotion, given the nursing diagnostic label of colostomy.

Correct Answer: Risk, since the patient is at risk for infection at the site of the surgical incision. Explanation: o Risk, since the patient's identified need is the diagnosis of colostomy. Colostomy is the name of a surgical procedure. It cannot be the nursing diagnosis; therefore, the nurse would not select this as an actual or risk nursing diagnosis. o Risk, since the patient is at risk for infection at the site of the surgical incision. The patient does have a risk factor: a surgical incision due to the colostomy. The nurse would select this nursing diagnosis as a risk diagnosis for this patient. · o Actual, since the patient is at risk from factors indicating vulnerability. Considering that the patient is at risk from factors indicating vulnerability, this would be the risk type of nursing diagnosis, not the actual type. · o Actual, since the patient is in need of health-promotion, given the nursing diagnostic label of colostomy. Considering that the patient is in need of health-promotion due to the nursing diagnostic label of colostomy, this should be the health-promotion type of nursing diagnosis, not the actual type.

The nurse establishes the ____ of unlicensed health care team members as a crucial balance between collaboration and overlapping responsibilities. Scope of practice Direct intervention Unique skills Protocols

Correct Answer: Scope of practice Explanation: Scope of practice Because each team member has a defined scope of practice, better collaboration and, therefore, better patient outcomes are expected. Direct intervention The nurse does not establish the direct intervention. Unique skills Unique skills are established prior to unlicensed health care team members seeking employment or by the facility after being hired, not by nurse. Protocols Protocols are rules set by the health care workplace, and not established by one nurse.

The nurse is developing a plan of care for a patient with pulmonary embolism. During which step of the nursing process is the nursing diagnosis formulated? First Second Third Fourth

Correct Answer: Second Explanation: First - Assessment is the first step of the nursing process. Correct Second - Nursing diagnosis is the second step of the nursing process. It is preceded by assessment and followed by planning, implementation, and evaluation. Third - Planning is the third step of the nursing process. Fourth - Implementation is the fourth step of the nursing process.

When a patient reports feeling anxious, what is the subjective data called? > Cluster of symptoms > Diagnosis > Sign > Symptom

Correct Answer: Symptom Cluster of symptoms A cluster of symptoms includes more than one symptom. Diagnosis A diagnosis can be made from a correctly clustered collection of signs and symptoms, but a diagnosis is not the same as a symptom. Sign A sign is taken objectively, such as observing a patient throwing up; the patient feeling nauseated is subjective, not objective. Symptom It can be helpful to remember that symptoms, such as anxiety, may lead a patient to know something is wrong, but signs are objective and taken by the health care professionals.

In which way is the ICNP® taxonomy different from the NANDA-I taxonomy? Data clustering is not a component of identifying a relevant nursing diagnosis within the ICNP® taxonomy. A benefit of the ICNP® taxonomy is that it presents a consistent language for nurses to use, enhancing communication and understanding. The ICNP® taxonomy includes different catalogs of nursing diagnoses, outcomes, and interventions. The ICNP® taxonomy allows a nurse to systematically address a specific patient response to a health problem or life event.

Correct Answer: The ICNP® taxonomy includes different catalogs of nursing diagnoses, outcomes, and interventions. Explanation: Data clustering is not a component of identifying a relevant nursing diagnosis within the ICNP® taxonomy.Both the ICNP® and NANDA-I taxonomies require patient data clustering and interpretation in order to select the most relevant nursing diagnosis/diagnoses. A benefit of the ICNP® taxonomy is that it presents a consistent language for nurses to use, enhancing communication and understanding.Both the ICNP® and NANDA-I taxonomies have a consistent language at their core, the goal of which is to allow nurses from different areas communicate and share information about their patients. In many cases, some of the ICNP® and NANDA-I language are the same or very similar. The ICNP® taxonomy includes different catalogs of nursing diagnoses, outcomes, and interventions.Widespread use of the ICNP® taxonomy by nurses in electronic medical records (EMRs) across a variety of settings has generated large sets of patient data. This data has been organized into relevant nursing subsets, containing diagnoses, patient outcomes, and interventions, which have been organized into catalogs. The NANDA-I taxonomy does not have similar subsets or catalogs. The ICNP® taxonomy allows a nurse to systematically address a specific patient response to a health problem or life event.Both the ICNP® and NANDA-I taxonomies provide a systematic method of identifying patient problems through nursing diagnosis and form the basis for an integrated plan of care.

A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient's wife prepares the family meals. Why is it important to include the patient's wife in the teaching? o She can report when he is not adhering to the care plan. o The wife can learn how to follow his new diet too. o The main person responsible for managing the patient's diabetes may be the wife. o Including a second person in teaching is protocol for the facility.

Correct Answer: The wife can learn how to follow his new diet too. Explanation: o She can report when he is not adhering to the care plan. The wife is not making a report. o The wife can learn how to follow his new diet too. The nurse works with family members to develop patient-centered care plans. o The main person responsible for managing the patient's diabetes may be the wife. The wife is part of the collaborative team, but the patient is the one responsible for managing his diabetes. · o Including a second person in teaching is protocol for the facility. Facility protocol does not take precedence over the needs of the patient or family.

A nurse is caring for a patient at risk for appendicitis. When considering the assessment, why should the nurse use the five-step nursing process? · o To set up the correct surgery time for the health care provider o To carefully match what is done in other hospitals o To systematically identify actual or potential patient problems o To better console families who are anxious about their loved one

Correct Answer: To systematically identify actual or potential patient problems Explanation: o To set up the correct surgery time for the health care provider The nursing process does not focus on the health care provider, but rather the patient. o To carefully match what is done in other hospitals No matter what other hospitals may do, the nurse would follow the five steps of the nursing process. o To systematically identify actual or potential patient problems The nursing process is the method by which professional nurses systematically identify and address actual or potential patient problems. o To better console families who are anxious about their loved one The nursing process focuses on identifying and addressing the problems of the patient rather than on consoling the family.

Use of properly formulated nursing diagnoses promotes which outcome? Select all that apply. Accurate medical diagnoses Accountability in nursing Independent nursing practice Patient care standardization Effective communication

Correct Answers: Accountability in nursing Independent nursing practice Patient care standardization Effective communication Explanations: Accurate medical diagnosesNurses evaluate the patient's physical and psychological responses to medical diagnoses when formulating nursing diagnoses; however, nursing diagnosis does not promote accurate medical diagnoses. Accountability in nursingThe use of nursing diagnosis promotes accountability in nursing care. Independent nursing practiceThe use of nursing diagnosis promotes independent nursing practice. Patient care standardizationThe use of nursing diagnosis establishes a standardization of patient care among nursing professionals. Effective communicationThe use of nursing diagnosis promotes effective communication.

The evaluation phase loops back to which earlier phases of the nursing process when considering new data? Select all that apply. Implementation Assessment Diagnosis Planning Goal setting

Correct Answers: Assessment Diagnosis Planning Explanation: Implementation Implementation data are not identified later during the evaluation phase. Assessment Assessment data do continue to be added to the patient's record to be considered in the evaluation phase. Diagnosis Diagnosis is made in the second phase and may be reconsidered in the evaluation phase. Planning Planning is made in the third phase and is somewhat repeated in the evaluation phase when reassessing. Goal setting Goal setting occurs during the third phase and depends on new assessment data and diagnoses. Evaluation data does not depend on earlier goal setting.

Steps of the nursing process serve which purpose? Select all that apply. Enable organization of patient care Ensure comprehensive patient care Prevent overlap between the steps Facilitate evaluation of patient care

Correct Answers: Enable organization of patient care Ensure comprehensive patient care Facilitate evaluation of patient care Explanation: Enable organization of patient care The steps of the nursing process ensure that patient care is organized. Ensure comprehensive patient care The steps of the nursing process ensure that patient care is comprehensive. Prevent overlap between the steps Overlapping between the steps may occur and is often beneficial. Prevention of overlapping steps is not the purpose of the steps of the nursing process. Facilitate evaluation of patient care Evaluation of goals is important and is the fifth step of the nursing process. Promote interdependency between steps Each step of the nursing process is interdependent of each other but that is not their purpose.

What does the evaluation phase include? Judgment about patient's desire to perform interventions. The patient being discharged from the hospital. The nurse's implementation of the patient's plan of care. Patient's achievement of short- and long-term goals.

Correct Answers: Patient's achievement of short- and long-term goals. Explanation: Judgment about patient's desire to perform interventions. A nurse's job is never to judge the patient as to whether they are working hard enough to get better. Nurses evaluate patient ability and skill when performing interventions but they do not judge patient desire to perform interventions. The patient being discharged from the hospital. Success is not only defined as a patient's discharge from the hospital; evaluation is based on other factors as well. The nurse's implementation of the patient's plan of care. The evaluation phase is based on the effectiveness of interventions not just on implementation of the plan of care. Patient's achievement of short- and long-term goals. The evaluation phase is specifically when the nurse determines whether the patient's short- and long-term goals were met.

What types of care plans are used in implementation? Select all that apply. Standing orders that describe specific actions to be taken by a nurse. General protocols that apply to patients with similar clinical needs. Detailed descriptions of possible actions to be taken by the nurse. Care pathways that combine several areas of health care expertise.

Correct Answers: Standing orders that describe specific actions to be taken by a nurse. General protocols that apply to patients with similar clinical needs. Care pathways that combine several areas of health care expertise. Explanation: Standing orders that describe specific actions to be taken by a nurse. Standing orders are a type of care plan to use in the implementation step. General protocols that apply to patients with similar clinical needs. Protocols that can be generalized to a patient population with similar clinical needs are a type of care plan to use in the implementation step. Detailed descriptions of possible actions to be taken by the nurse. It is unnecessary and unproductive to write out every possible action a nurse may take, based on potential complications that a patient may develop. Care pathways that combine several areas of health care expertise. Care pathways, or clinical pathways, combine several areas of healthcare expertise and are a type of care plan to use in the implementation step.

How are th \7e steps of the nursing process utilized? Select all that apply. Diagnose needs and plan goals Assess individuals, families, and communities Identify outcome criteria and implement interventions Follow physician's orders Identify specific nursing interventions

Correct Answers: Diagnose needs and plan goals Assess individuals, families, and communities Identify outcome criteria and implement interventions Identify specific nursing interventions Explanation: Diagnose needs and plan goals The steps of the nursing process can be used to diagnose needs and plan attainable short-term and long-term goals. Assess individuals, families, and communities The steps of the nursing process can be used to assess individuals, families, and communities. Identify outcome criteria and implement interventions The steps of the nursing process can be used to identify outcome criteria, implement specific interventions, and evaluate degrees of goal attainment. Follow physician's orders The nursing process allows nurses to critically think instead of only following the provider's order. Identify specific nursing interventions The nursing process not only involves the implementation of medical interventions, but the planning and implementation of nursing specific actions.

What questions should the nurse ask when evaluating the effectiveness of nursing interventions? Select all that apply. What is the best nursing diagnosis to cover this cluster of signs and symptoms? What are the signs and symptoms that can be used to diagnose the patient's condition? Did the patient meet the goals established during the planning phase? Should the plan of care be discontinued? Does the care plan need to be modified in response to patient changes?

Correct Answers: Did the patient meet the goals established during the planning phase? Should the plan of care be discontinued? Does the care plan need to be modified in response to patient changes? Explanation: What is the best nursing diagnosis to cover this cluster of signs and symptoms? "What is the best nursing diagnosis to cover this cluster of signs and symptoms?" is a good question for the diagnosis phase, not the evaluation phase. What are the signs and symptoms that can be used to diagnose the patient's condition? "What are the signs and symptoms that can be used to diagnose the patient's condition?" is a good question for the assessment phase, not the evaluation phase. Did the patient meet the goals established during the planning phase? Nurses need to ask, "Did the patient meet the goals established during the planning phase?" during the evaluation phase. Should the plan of care be discontinued? "Should the plan of care be discontinued?" is an essential question to ask during the evaluation phase. Does the care plan need to be modified in response to patient changes? "Does the care plan need to be modified in response to patient changes?" is an essential question to ask during the evaluation phase.

A nurse is caring for a patient with a UTI. The nurse's selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain? o Low back aching o Burning upon urination o Frequency of urination o Urgency of urination o Incontinence of urination

Correct Answers: Low back aching Burning upon urination Explanation: Low back aching Low back aching or acute pain is evidence for the diagnosis of acute pain. Burning upon urination Burning upon urination is evidence for the diagnoses of acute pain. Frequency of urination Inflammation noted by frequency of urination is not evidence for acute pain. Urgency of urination Inflammation noted by urgency of urination is not evidence for acute pain. Incontinence of urination Incontinence of urination is not evidence of acute pain.

Why must nursing diagnoses include up-to-date diagnostic labels as determined by NANDA International? > Patient care depends on knowledge of holistic categories. > Accurate clustering of symptoms requires use of NANDA diagnostic labels. > Standardized language facilitates care recognized by all health care team members. > NANDA diagnostic label usage results in more efficient workflow and organization.

Correct Anwer: Standardized language facilitates care recognized by all health care team members. Explanation: Patient care depends on knowledge of holistic categories. While patient care is aided by knowing what makes up holistic nursing, this fact is not relevant to NANDA diagnostic labels. Accurate clustering of symptoms requires use of NANDA diagnostic labels. Accurate clustering of symptoms is possible either with or without up-to-date NANDA diagnostic labels. Standardized language facilitates care recognized by all health care team members. When health care team members agree on common, standardized terms for diagnoses, patient care is improved. NANDA diagnostic label usage results in more efficient workflow and organization. While NANDA diagnostic labels may make for more efficient workflow, this benefit is not the primary reason of using up-to-date NANDA diagnostic labels.

When formulating a nursing diagnosis, which component would the nurse analyze to identify patient problems and select appropriate nursing diagnoses? Assessment data Care plan Nursing outcomes Nursing taxonomy

Correct Repsonse: Assessment data Explanation: Assessment dataFormulation of nursing diagnoses involves the analysis and clustering of patient assessment data to identify patient problems and select appropriate nursing diagnoses. Care planFormulation of the nursing diagnoses helps create the individualized patient care plan. Nursing outcomesFormulation of the nursing diagnosis helps identify appropriate nursing measures to implement for the patient. Nursing taxonomyNursing diagnoses is a taxonomy specific to nurses.

What type of patient-centered care respects the input of family members and other members of the health care team? Evidence-based Collaborative Communicative Planned

Corrrect Answer: Collaborative Explanation: Evidence-based Collaborative care includes evidence-based care, but evidence-based care does not necessarily respect the input of family members. Collaborative Collaborative care is a crucial component of patient-centered care; bringing together and respecting family members and other health care team members are the hallmarks of collaborative care. Communicative Communication is important, but more is required than simply communicating when providing patient-centered care. Planned Care can be planned without respecting the input of family members and other members of the health care team. More is required than simply planning care.

Evaluation is the fifth and final step of the nursing process.

Evaluation is the fifth and final step of the nursing process. During evaluation, the nurse determines goal attainment, the effectiveness of interventions, and whether the plan of care should be discontinued, continued, or revised. Evaluation focuses on the patient's response to nursing interventions and goal or outcome attainment. Patient Evaluation During the evaluation step of the nursing process, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and desired outcomes were achieved. Evaluating whether the patient's goals were attained is a collaborative process involving the patient. Final Checklist Nurses need to ask some questions when evaluating the effectiveness of provided nursing interventions: Did the patient meet the goals and outcome criteria established during the planning phase? Since care began, have new assessment data been identified that should be taken into consideration? Does the care plan need to be modified in response to patient changes? Based on the patient's response to the implemented interventions, should the plan of care be continued, revised, or discontinued?

NANDA-I members meet every two years. Which initiative is the focus of this meeting? Select all that apply. Taxonomy revision Evaluation of nursing research Generation of diagnostic categories Encouragement of nurses to use taxonomy Expansion of taxonomy to international nurses

Exact Answer: Taxonomy revision Evaluation of nursing research Explanation: Taxonomy revision - Every two years, NANDA-I members meet to focus on the revision of the taxonomy. Evaluation of nursing research - Every two years, NANDA-I members meet to focus on the evaluation of nursing research. Generation of diagnostic categories - An original goal of NANDA was to generate diagnostic categories. Encouragement of nurses to use taxonomy - A goal of NANDA is to encourage all nurses to use the taxonomy. Expansion of taxonomy to international nurses - NANDA became NANDA-I in 2002 to acknowledge the interest in nursing taxonomy worldwide.

What nursing skill is essential when utilizing the nursing process? Critical thinking Analysis Observation Time management

Exactly! Critical thinking Critical thinking requires that the nurse think logically about the patient's health problems and how best to address them. Analysis Analysis of the data is a crucial skill for steps two and three of the nursing process - creating nursing diagnoses, setting measurable patient goals, and planning specific interventions to address those goals. Observation Observation is a skill heavily utilized in step one of the nursing process - assessment of the patient through focused health history and physical exams. Time management Time management, while a valuable skill, is not specific to the needs of the nursing process.

Implementation Overview

Interventions (independent, dependent, collaborative care, direct, indirect), Documentation, NIC, care plans (clinical pathways, protocols, standing orders)

Planning as a Step

Planning is the third step of the nursing process. The nurse prioritizes the nursing diagnoses and identifies goals with specific outcome identification when planning patient care. In the planning step of the nursing process, the nurse prioritizes a patient's various nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals. The order in which nursing diagnoses are addressed depends on factors such as the severity of symptoms and the patient's preference. The development of a patient-centered care plan to address nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the healthcare team. This is also referred to as collaborative care. Nurses need to use critical thinking, creativity, expertise, and communication skills when developing a patient-centered care plan. The plan of care needs to be relevant to the patient's health status and goals, and the plan must be based on the latest evidence-based nursing practices. Setting Goals Depending on the patient's immediate and future needs, nurses need to establish short- and long-term goals. While short-term goals may be achieved in less than a week, long-term goals may extend over weeks or months. Setting short- and long-term goals helps create a structure, or a framework, within which nursing care takes place. And all goals should be patient-focused, realistic, and measurable. An example of a short-term goal is: The patient will walk 10 feet with a cane three times a day within one week. An example of a long-term goal is: The patient will walk unassisted to the dining room for each meal within one month. Goals help to direct the patient's healthcare team and ensure that all members of the team work to achieve the same outcomes. Identifying Outcomes Identifying outcomes as a specific aspect of the nursing process was added by ANA in 1991. It involves listing behaviors or observable actions that indicate attainment of a goal. Interventions to help patients meet goals are identified by the nurse during the planning step. The Nursing Outcomes Classification (NOC) is a standardized classification of patient outcomes that evaluates the effects of interventions. The Nursing Interventions Classification (NIC) is a comprehensive classification of interventions that nurses perform on behalf of patients. Outcome Example Diagnosing a patient with Activity Intolerance could have "Endurance" as a desired outcome classification (from the NOC), with indicators ranging from Uncompromised to Severely compromised activity. The nurse could then select patient interventions (from the NIC) related to "Exercise Therapy: Ambulation."

What are the five steps of the nursing process?

The nursing process involves assessment, diagnosis, planning, implementation, and evaluation. Assessment Gather data through observation, interviews, and physical assessment. Diagnosis Analyze, validate, and cluster data to identify patient problems. Select and identify nursing diagnoses. Planning Prioritize nursing diagnoses and set realistic, measurable, patient-focused short- and long-term goals or outcomes. Implementation Initiate interventions and treatments to help patients achieve established goals or outcomes. Evaluation Evaluate goals, determine effectiveness of interventions, and decide if plan of care needs to be revised.

Communication: Referent

The referent is the event that leads to the communication. This may be a sensation such as pain, a thought or concern, a new strange scent, or any other perceived event. Every event has the possibility to initiate the process of communication.

Describe the Diagnosis Step

The second step of the nursing process is diagnosis. In the diagnosis step, patient data are analyzed to identify patient problems, and then each problem is stated as a specific nursing diagnosis using standardized language. The nursing diagnosis identifies an actual or potential problem or response to a problem. Accurate identification of nursing diagnoses for patients results from carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data. If data collection is inaccurate or inadequate, or if data are not validated or clustered with related information, a patient may be misdiagnosed. Diagnosis in the nursing process requires naming patient problems using nursing diagnostic labels. Nursing diagnoses are established and revised every three years by NANDA International, Inc. (NANDA-I), which provides standardized language to identify patient problems and plan customized care. Nursing diagnoses describe a response to an actual or potential problem. NANDA-I (2012) identifies three types of nursing diagnoses (i.e., actual, risk, and health-promotion) that nurses should use when developing plans of patient care. Actual (3 parts): Patient's identified need or problem Etiology or underlying cause Signs and symptoms Risk (2 parts): Patient's indentified need or problem Factors indicating vulnerability Health Promotion (2 parts) Nursing diagnostic label Defining characters

Assessment is the organized and ongoing appraisal of a patient's well-being. True or False

True. Assessment is the organized and ongoing appraisal of a patient's well-being. Nurses assess the state of a patient's physical, psychological, emotional, environmental, cultural, and spiritual health to gain a better understanding of his or her overall condition. This is known as a holistic approach to patient care. Data collection begins at the first direct or indirect encounter with a patient. The data source determines if it is primary or secondary. Primary data are obtained directly from a patient. Secondary data are collected from family members, friends, other healthcare professionals, and written sources, such as medical records and test results. Data may be categorized as subjective or objective. Subjective data are spoken, either by the patient or someone else, perhaps a family member. Typically documented in direct quotes, subjective data often describe patient feelings. Objective data are observable information that the nurse gathers on the basis of what can be seen, measured, or tested, such as data collected from medical records, test results, or physical assessment.

Diagnosis Overview

Types of Nursing Diagnoses: Actual, risk, health promotion