Unit 1: Foundations of Nursing Practice

Subjective

-"I haven't slept in days." -"I follow my diabetic diet all the time." -What the client tells the nurse

Standards of Nursing Practice

-Comprehensive nursing care -Knowledgable nursing care

Medical Assessment

-Does the chest x-ray look suspicious for pneumonia? -Should the patient be started on antibiotic therapy?

Nursing Assessment

-Does the patient understand how and when to take their medications? -Can the patient perform the activities of daily living?

Place the steps of the nursing activities in the correct order as they are most likely to occur when a nurse uses the nursing process.

-Establishing priorities -Carrying out the plan of care -Determining how well the client has achieved desired outcomes -Modifying the plan of care if necessary

Nursing Process

-Implementing -Evaluating

Code of Ethics

-Integrity -Altruism

Objective

-Right lower are with redness, edema, and firm to light palpation. -Blood pressure 180/90 mm/Hg -Signs

Place the following basic needs from Maslow's hierarchy of human needs in the correct order.

-self-actualization needs -self-esteem needs -love and belonging needs -safety needs -physiologic needs

Place the steps of data collection and analysis in the correct order.

1.Recognize Significant Data 2.Recognize Patterns or Clusters of Data 3.Identifying Strengths and Problems 4.Identifying Potential Complications 5.Reaching Conclusions

Which of the following is a correct evaluative statement?

3/1/20 - Outcome met. Client reported 3 lb weight loss.

What type of assessment is performed to obtain data about an actual, potential, or possible problem the has already been identified or is suspected?

A focused assessment

Which of the following best identifies the nursing process?

A problem-solving approach to nursing care.

Problem-focused nursing diagnosis example

Acute pain related to trauma of surgical incision

The nurse protects human or legal rights.

Advocate

Establishes quality education standards that influences the nursing profession and the public.

American Association of Colleges of Nursing

Fosters high standard of nursing practice and advocates on health care issues that affects nurses and the public.

American Nurses Association

During which phase of the nursing process does the nurse complete data and information gathering?

Assessment

Florence Nightingale is known for which of the following?

Being a nurse and abolitionist.

The _____________ of Nursing allows students from approved schools of nursing to take the licensing examination.

Board

The nurse provides care to the client using all of the roles of the nurse.

Caregiver

Assess client's ability to understand the plan of care

Client

Nurse Variables

Client Variables Available time Creativity

An actual or potential client problem in which nurses intervene in cooperation with personnel from other health care providers.

Collaborative problem

The nurse uses effective skills to organize, communicate, and advocate for clients to provide care involving all members of the health care team.

Collaborator

Sense of mental, physical, or social well-being or ease

Comfort

The use of effective interpersonal skills to establish and maintain relationships with clients of all ages.

Communicator

Identify all patient data needed to understand the patient health problem.

Complete

Research Findings

Continuing education workshops

The use of therapeutic interpersonal communication skills to provide information, make appropriate referrals, and facilitate the client's problem-solving skills.

Counselor

Measurable qualities, attributes, and/or characteristics

Criteria

Significant data or data that influences analysis and "raises a red flag" for the nurse.

Cue

Considers race, ethnicity, religious beliefs, and socioeconomic factors.

Culture

Place the following parts of SBAR format for reporting in the correct order. All options must be used.

Current vital signs Pertinent history Client's present problem What the client needs

May include a focus on growth, feeding, and elimination in an infant.

Developmental Stage

Which of the following actions is considered a direct care intervention?

Discussing advanced directives with a client with end-stage breast cancer (Providing supportive interventions and counselling, to the client, are considered direct care interventions.)

Utilizing all five steps of the nursing process at one time.

Dynamic

When Mrs. Barclay, an older client with pneumonia was admitted, her status was rapidly changing. The nurse moved quickly from assessing to planning to implementing and back to assessing. Which characteristic of the nursing process does this demonstrate?

Dynamic

Which of the following is correct regarding the nursing process?

Enables nurses to efficiently use time and resources benefit of client and nurses.

Which of the following should the nurse try to accomplish when planning care and identifying outcomes with the client and the family?

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

Factors that cause, contribute to, or create a risk for the problem.

Etiology

Which step of the nursing process addresses outcomes and identifying evaluative criteria?

Evaluation

Desired changes in health or knowledge statu

Expected Outcomes

Depends upon the reliability of the patient or caregiver who is supplying the data.

Factual & Accurate

True or False: When establishing priorities for nursing diagnosis, the nurse must consider Maslow's hierarchy of human needs, client preference, and expected outcomes.

False

True or False: Evaluating a client's knowledge of foods to avoid 24 hours after the dietary teaching was completed is an example of an affective outcome

False, Affective describes changes in beliefs and attitudes.

True or False: Evaluating a client's knowledge about foods to avoid as a newly diagnosed diabetic 24 hours after the dietary teaching was given is an example of an affective outcome.

False, Affective outcomes describe changes in beliefs and attitudes, not knowledge about information that was taught.

True or False: A prescription for pain management detailing the strength of the medication to be given to a client, based on assessment, using a pain assessment scale, is an example of a protocol.

False, Protocols are detailed plans to be executed based on a specific situation.

True or False: The nurse should wait until the day the client is being discharged to evaluate outcome achievement.

False, The nurse should evaluate client outcome achievement as early as possible.

True or False: Identifying a medical condition, illness, or disease is the purpose of determining a nursing diagnosis.

False, it is not the purpose

True or False: The legal scope of nursing practice is regulated by the National Advisory Council on Nurse Education and Practice.

False: the Nurse Practice Act legally regulates nursing practice.

Age-appropriate increase in physical dimensions, maturation of organ systems, and/or progression through the developmental milestones.

Growth & Development

Helps patients explore the habits, behaviors, beliefs, attitudes, and values that influence their wellness.

Health Orientation

The awareness of well-being or normality of function and the strategies used to maintain control of and enhance that well-being or normality of function.

Health Promotion

Concern with motivation and desire to increase well-being and to actualize human health potential.

Health promotion nursing diagnosis

Speak slowly and softly; approach patient gently.

High Anxiety

A nurse notes a client's refusal to stop smoking will adversely affect recovery from cardiac surgery.

Identifying strengths and problems

Which of the following actions should the nurse use to improve the care of the client?

Include cultural assessment in developing the plan of care, Culturally-relevant holistic care is important in meeting the specific needs of the client

Carried out during admission using the history and physical assessment.

Initial planning

Nursing processes are person-centered rather than task centered.

Interpersonal

Will impact the patient's initial impression of the nurse.

Interpersonal Competence

Which of the following interventions are related to actual nursing diagnosis?

Interventions that promote higher level wellness

Used to obtain the patient's nursing history.

Interview

Vital patient data may be miscommunicated.

Language Difficulty

The nurse acts assertive, self-confident when providing care, effecting change, and functioning with groups.

Leader

Describes a disease, illness, or injury to identify a pathology.

Medical diagnosis

The nurse notes the client is having difficulty achieving goals that were set in the care plan. The nurse should ____________ the care plan.

Modify

Fosters the development and improvement of all nursing services and nursing education.

National League for Nurses

Voluntary accreditation for educational programs in nursing is provided by which of the following?

National League for Nurses

Examines the specific purpose of nursing interventions to influence the type of care provided.

Need for Nursing

Match the client's needs with specific nursing strategies

Nurse

Which of the following best describes something written to describe client problems or issues that nurses can treat independently?

Nursing diagnoses

Nurse-initiated interventions are derived from which of the following?

Nursing diagnosis

Used to evaluate the patient for signs of distress, ability to manage their own care, and the patient's immediate environment each time the nurse encounters the patient.

Observation

Carried out by any nurse caring for the client to keep the plan up to date.

Ongoing planning

Nursing interventions are planned based on specific desired results.

Outcome Oriented

Provide comfort measures or defer remainder of interview.

Pain

Might include healthy physiologic functioning, emotional health, cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths.

Patient Strengths

A terminal degree educational program in nursing that prepares nurses to implement the research conducted to advance nursing theory and practice is:

PhD

Focuses primarily on the patient's functional abilities.

Physical Examination

Patient is unwilling to participate in interview

Previous Negative Experience with Healthcare

Concerned with an undesirable human response to a health condition/life process that exists in an individual, family, group, or community.

Problem-focused nursing diagnosis

Identify whether or not the nursing assessment is comprehensive, focused, emergency, or time lapsed in order to gather the appropriate data.

Purposeful

A nurse identifies that a client receiving an antibiotic has an adverse reaction to the medication and consult the health care provider.

Reaching conclusions

Health promotion nursing diagnosis example

Readiness for enhanced nutritio

Identifying a grouping of client data or cues that point to the existence of a health problem.

Recognizing clusters

A nurse in a pediatric clinic compares an 18-month-old child's height and weight with the norms for that age group.

Recognizing significant data

Using comparative standards to determine the significance of a piece of dat

Recognizing significant data

Record data according to the facility's policy so that all caregivers can easily access what has been learned.

Recorded in a Standard Manner

Recording only the data that is important to providing appropriate care.

Relevant

Assess number of incoming nurses before making the shift assignment.

Resources

Risk nursing diagnosis example

Risk for infection

Concerned with the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.

Risk nursing diagnosis

Freedom from danger, physical injury, or immune system damage; preservation from loss; and protection of safety and security.

Safety & Protection

Awareness about the self.

Self-Perception

A society that recognizes the value of scholarship and excellence in nursing practice.

Sigma Theta Tau International

Generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category.

Standard or Norm

Level of performance accepted by and expected of the healthcare team

Standards

A measurable outcome should include which of the following?

Subject, Verb, Conditions,Performance criteria, Target time

____ is an important strategy to prevent errors and omissions in implementing the plan of care.

Surveillance

Each nursing activity is part of an ordered sequence of activities

Systematic

Gathering data in this way allows the nurse to know if something important has been missed.

Systematic

The nurse can use the word _____________ to remember how to write goals and outcomes.

S—specific M—measurable A—attainable R—realistic T—time-bound

Which of the following trends in nursing and healthcare were identified by both the NLN and ANA?

Technology

The nurse should ensure which of the following when implementing care?

The scientific rationale for the intervention is understood. Standards of care are followed. Nursing actions are individualized for the client's preferences. Prescriptions that are questionable are clarified. Nursing interventions are consistent with protocols and policies of the facility. Nursing actions are safe for the client. All equipment and supplies are ready.

Which of the following is the primary purpose of outcome identification and the planning phase of the nursing process?

To design a plan of care with the client.

True or False: A benefit of the outcome identification and planning phase of the nursing process is that the outcomes will contribute to the prevention, resolution, or reduction of the client's problems.

True

True or False: A nurse will need at least a master's degree in nursing in order to practice as a family nurse practitioner.

True

True or False: A nursing care plan can be developed from a medical and interdisciplinary care plans.

True

True or False: A record that can be used for research and reimbursement should be created during the outcome identification and planning phase of the nursing process.

True

True or False: As part of comprehensive planning, a discharge plan should be initiated when a client is admitted to the hospital.

True

True or False: Computerized nursing care plans are part of the client's electronic medical record.

True

True or False: NANDA-I provides a list of approved nursing diagnoses for clinical use and testing.

True

True or False: Nursing diagnoses focus on the client's response to the health condition and are written to describe client problems or issues that nurses can treat independently.

True

True or False: Short and long-term outcomes should support the treatment plan and the client's overall goals.

True

True or False: The American Association of Colleges of Nursing advocates that the entry level education in nursing is a baccalaureate degree.

True

True or False: The nurse in a long-term care facility is turning a client every two hours to prevent tissue injury. This action by the nurse would be an intervention to help achieve a long-term outcome established in the plan of care.

True

True or False: The nurse should consider available resources when implementing a client's plan of care.

True

True or False: The purpose of evaluation is to allow the client's achievement of expected outcomes to direct future nurse-client interactions.

True

True or False: Unless specified otherwise, the data recorded in the nursing history are assumed to have been collected from the patient.

True

True or False: When interpreting evaluative data and summarizing the findings, the nurse should consider factors that influence outcome achievement.

True

The nursing process is a valuable tool that can be used in any situation.

Universally Applicable

Patient expects nurses to magically know everything about them and "surrenders" self to the system.

Unrealistic Expectations of Health Care Professionals

The nurse is identifying outcomes for a client placed on a low sodium diet for high blood pressure. Which of the following is a cognitive outcome for this client?

Within one month, the client will be able identify foods that are appropriate to eat.

Which of the following actions would be appropriate after the nurse identifies the factors contributing to the client's outcomes are not being achieved?

change nursing interventions make the outcome statement more realistic adjust the time criteria in outcome statements delete the nursing diagnosis modify the nursing diagnosis

Formats for Care Plans

computerized concept map multidisciplinary

A plan of care that illustrates a client's problems and proposed interventions is a ___________ map.

concept

Which activities are associated with the assessment phase of the nursing process?

data collection, collects data, identifies clues and makes inferences, validates the data, clusters related data to identify patterns, and reports/records the data.

Factors that should be considered when developing nurse-initiated interventions include which of the following?

desired outcome, identified nursing diagnosis, feasibility of the intervention, evidence-based intervention, capability of the caregiver, and acceptability to the client

Recognizing client changes in client data indicating a further problem is occurring.

identifying potential complications

A _______ initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and projected outcomes.

nurse

Types of Nursing Care

nursing diagnosis /problems basic human needs medical and interdisciplinary care

Place the following activities of the nursing process in the correct order

nursing process are assessing, diagnosing, planning, implementing, and evaluating

In addition to the type of data that needs to be evaluated in determining client ___________ timing criteria should be included.

outcome

A judgment summarizing the findings, by the nurse, of client outcome achievement is called an evaluative _________

statement