pharm 2

Risk/high risk

A clinical judgment that a person is more susceptible to a particular problem than others in the same situation is defined as which type of nursing diagnosis?

Break the teaching content down into manageable sections and present them individually in the days before discharge.

An older adult patient is being prepared for discharge after experiencing a stroke with some residual damage. The patient and family are scheduled to receive a large amount of information from the nurse regarding proper care and safety at home. What is the nurse's best course of action?

Resolution In the resolution and acceptance stages of the grieving process, the patient moves toward accepting responsibility and willingness to learn what is necessary to attain an optimal level of health

Which stage of grief represents when the patient is most willing to learn?

It is a standardized care plan derived from "best practice" patterns. Critical care pathways are standardized plans derived from "best practice" patterns that aid in developing detailed treatment plans for a specific case type or disease process.

Which statement about a critical care pathway is true?

The caregiver and patient have ownership of the goals to be achieved. The CMAG 1 model focuses on the patient to implement actions that result in positive change.

Which statement describes a characteristic of Case Management Adherence Guidelines version 1 (CMAG 1)?

The patient states that his temperature has been 98.8°F. The patient is the primary source of information, and the temperature is an objective measurement.

Which assessment finding is considered primary, objective information?

Nursing diagnosis refers to the patient's ability to function in activities of daily living. Nursing diagnosis refers to clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

Which correctly distinguishes a nursing diagnosis from a medical diagnosis?

Nursing Minimum Data Set

Which correctly identifies the NMDS classification system?

Laboratory results Laboratory results are considered objective data because they are data, signs, or observations made by the healthcare provider that are capable of being verified by another.

Which information is considered objective data?

The patient will be able to self-administer insulin injections 2 weeks after initial training.

Which is a measurable goal statement for a patient taking insulin injections?

The patient will take the medication as prescribed, not changing or discontinuing it without contacting the healthcare provider.

Which is a priority outcome for patient teaching about prescribed drug therapy?

Verifies the correct route of medication administration Rationale: Verification of the correct route of administration is an independent nursing action that is required as part of the "six rights" of administration.

Which is an independent nursing action?

Thinking The cognitive domain of learning is the level at which basic knowledge is learned and stored.

Which portion of the learning process is involved in the cognitive domain?

Nursing Process

What is the foundation for the clinical practice of nursing?

Phases of Planning

- Setting priorities - Developing measurable goal/outcome statements - Formulating nursing interventions - Formulating anticipated therapeutic outcomes

Ethnocentrism

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

Actual

Based on human responses and supported by defining characteristics

Syndrome

Clusters signs and symptoms to predict certain circumstances or events

- Actual - Risk/high-risk - Health promotion and wellness - Syndrome

Four Types of Nursing Diagnosis

collaborative problems

Different from nursing diagnoses when the intervention used is to prevent or treat a problem and is worded with potential complication in the diagnosis

Evaluation

Evaluated by comparison with: - goal statements - planned nursing actions - anticipated therapeutic outcomes - patient, family, and significant others who provide feedback and help determine goals

A nursing diagnosis evaluates a patient's response to actual or potential health problems

How does a nursing diagnosis differ from a medical diagnosis?

Psychomotor Domain

Involves the learning of a new skill or procedure. Usually taught by demonstration.

Health promotion and wellness

Only has a one-part label

Risk/high-risk

Patient may be more susceptible to a particular problem

Definition of Measurable goal statement

Starts with an action word that is followed by behavior or behaviors to be performed by patient or the patient's family within a specific amount of time

Affective Domain

The most intangible portion of the learning process. People often chose to internalize feelings instead of expressing them. In other words, it refers to the feelings and beliefs a patient has about what he or she understands.

Verbal explanations along with drug summary sheets

The nurse is preparing a patient for discharge after a surgical procedure. Which method is best for teaching the patient about his or her prescribed drugs?

Psychomotor

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

Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better.

The nurse is supposed to perform postoperative teaching for a patient who is scheduled to be discharged the next day. The patient appears fatigued, in pain, and irritable. The nurse knows that there will be little time for teaching on the day of discharge. What is the nurse's best course of action?

"A sedentary lifestyle is the best way to live." A sedentary lifestyle has many negative health consequences, such as hypertension and heart disease.

The nurse is teaching a patient who has been diagnosed with hypertension. Which statement by the patient indicates the need for further education?

Develop a plan of care that is individualized to each patient's needs.

The nurse who is new to a large urban hospital has found that many of the hospitalized patients are of different cultural groups in the area. Which approach is best for the nurse to take in caring for these patients?

Unless an assessment of psychosocial needs is performed on the patient, the true meaning of an illness may never be uncovered. Because there are differing beliefs among cultures, it is important that the nurse explore the meaning of an illness with the patient.

Which statement is true about culture and ethnic diversity?

Planning Planning with reference to the prescribed medications includes eight steps, the first of which is identification of the therapeutic intent for each prescribed medication

Which step of the nursing process is used when the nurse identifies the therapeutic intent of a prescribed medication?

Designing a teaching method and pace for each patient It is important to individualize the teaching plan for each patient.

Which teaching method is the most effective when teaching patients about medications?

Incorporating time for practicing Time for practicing should be incorporated because it will give elderly patients an opportunity to master the content.

Which teaching strategy does the nurse use when teaching an elderly patient?

dependent

Which type of nursing action occurs when the nurse administers a medication to a patient?

Assessment

an ongoing process that starts with admission and continues until the patient is discharged from care

nursing classification systems

are designed to provide a standardized language for reporting and analyzing nursing care delivery that has been individualized for the patient.

Interdependent Nursing Action

nurse implements cooperatively with other members of the healthcare team for restoring or maintaining the patient's health ex. monitoring a patient's heart rate and rhythm while the patient is receiving antidysrhythmic therapy

Independent Nursing Action

nursing actions that are NOT PRESCRIBED by a healthcare provider that a nurse can provide by virtue of the education and licensure ex. listening to a patient's lung sounds after a respiratory treatment and monitoring laboratory values

Dependent Nursing Action

performed by the nurse on the basis of the healthcare provider's orders ex. administering an antibiotic every 6 hours as ordered (but can still require the nurse's professional judgment

Focused Assessment

process of collecting additional data specific to a patient or family that validates a suggested problem or nursing diagnosis