Unit 4 Chapters 10-15 The Nursing Process

¡Supera tus tareas y exámenes ahora con Quizwiz!

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? A: "What did the doctor tell you about your diagnosis?" B: "Are you worried about how the diagnosis will affect you in the future?" C: "Tell me about your reactions to the diagnosis" D: "How is your family responding to the diagnosis?"

C: "Tell me about your reactions to the diagnosis"

The nurse is admitting the client to an acute care facility, beginning with the initial assessment, when the client states: "I don't know why you need to know so much about me." The nurse explains that the purpose of the assessment is: (select all that apply) A: "To develop a plan of care for your stay in the hospital" B: "The select nursing interventions that will assist you to obtain your goals" C: "To supply a comprehensive understanding of your health needs" D: "To collect information about your past and present health status" E: "To understand your needs related to taking care of yourself at home after discharge"

C: "To supply a comprehensive understanding of your health needs" D: "To collect information about your past and present health status" E: "To understand your needs related to taking care of yourself at home after discharge"

The nurse is admitting the client to the unit and asks the client questions related to his food preference. What type of interview is the nurse performing? A: Nondirective B: Open C: Directive D: Rapport

C: Directive

The nurse is repositioning the client to avoid skin breakdown, which is an example of what phase of the nursing process? A: Evaluation B: Diagnosis C: Implementation D: Assessment

C: Implementation

The nurse conducts a time-lapsed reassessment in what setting? A: While the client is being admitted B: Community health screening event C: In a home care setting D: In the urgent care center

C: In a home care setting

Subjective data is important to the nurse's assessment because: A: It provides the nurse with overt data B: It contributes secondary information C: It provides the nurse with information that no one else can offer D: It provides the most accurate data

C: It provides the nurse with information that no one else can offer

The client states, "Blood oozes out of the wound every time I go for a walk." Is this: A: Subjective, Primary B: Subjective, Secondary C: Objective, Primary D: Objective, Secondary

C: Objective, Primary

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing proess to provide nursing care? A: Proposes hypotheses B: Generates desired outcomes C: Reviews results of laboratory tests D: Documents care

C: Reviews results of laboratory tests

Indicator

Specific patient state that is most sensitive to nursing interventions and measurable

Wellness diagnosis

(NANDA) describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement

Objective Data

(SIGNS) or overt data, are detectable by an observer or can be measured or tested against an accepted standard. Can be seen, heard, felt, smelled, and are obtained by observation or physical examination.

Subjective Data

(SYMPTOMS) or Covert Data, apparent only to the person affected and can be described or verified only by that person

Roy's Adaptation Model

-Adaptive Modes 1. Physiological Needs -activity & rest -nutrition -elimination -fluid & electrolytes -oxygenation -protection -regulation of temperature -regulation of senses -regulation of endocrine system 2. Self Concept -physical self -personal self 3. Role Function 4. Interdependence

Assessment as the first phase of the nursing process

-Assessing: -collecting, organizing, validating, & documenting client data -systematic & continuous process carried out during all phases -purpose: establish database about client's response to health concerns or illness & ability to manage health care needs

Assessment Phase

-Collect patient data -Identify priority areas to be assessed -Determine types of data needed -Establish a database -Analyze data & patient's symptoms

Collecting Subjective Data

-Sources of Subjective Data: 1. Patient 2. Significant Others 3. Health Care Providers -Physicians -Colleagues -CNAs -Allied health -Methods of Collecting Subjective Data: 1. Active Listening 2. Interviewing 3. Active Processing -Analyze Information -Use Intuition -Validate

Clinical Decision Making ,Phase One: Assessment

-What data needs collecting? -What data is relevant to patient's problem? -What does the normal or abnormal data mean? -What action should the nurse take based on the data collected?

Non Directive Interview

-also known as rapport building interview -nurse allows client to control purpose, subject matter, & pacing

Non Nursing Models

-are narrower than model required in nursing -nurse usually needs to combine these with other approaches to obtain complete history 1. Body Systems Model 2. Maslow's Hierarchy of Needs 3. Developmental Theories

Open Ended Questions

-associated with non directive interview -invite clients to discover & explore, elaborate, clarify, or illustrate their thoughts & feelings -specifies one broad topic to be discussed -gives clients freedom to give information they are ready to disclose -is useful at beginning of interview or to change topics & elicit attitudes

Maslow's Hierarchy of Needs

-clusters data pertaining to following: 1. Physiological Needs (Survival Needs) 2. Safety & Security Needs 3. Love & Belonging Needs 4. Self Esteem Needs 5. Self Actualization Needs

Database

-contains all information about client -includes: -nursing health history -physical assessment -primary care provider's history -primary care provider's physical examination -results of laboratory & diagnostic tests -material contributed by other health personnel

Collecting Data

-data collection is the process of gathering information about client's health status -must be systematic & continuous to prevent excluded significant data -refer to client's changing health status -client data should include past history as well as current problems -to collect data accurately, client & nurse must actively participate

Orem

-describes eight universal self care requisites of humans

Body Systems Model

-focuses on abnormalities of following anatomic systems: 1. Integumentary System 2. Respiratory System 3. Cardiovascular System 4. Nervous System 5. Musculoskeletal System 6. Gastrointestinal System 7. Genitourinary System 8. Reproductive System 9. Immune System

Directive Interview

-highly structured & evokes specific information -nurse establishes purpose of interview & controls interview -nurses use directive interviews to gather & give information when time is limited

Interviewing

-interview: planned communicating or conversation with purpose -used mainly while taking nursing health history -combination of directive & non directive approaches is usually appropriate during information gathering interview -nurse begins by determining areas of concern for client -two approaches to interviewing: 1. directive interview: 2. non directive interview:

Examining

-major method used in physical health assessment -systematic data collection method using observation to detect health problems -uses techniques of inspection, auscultation, palpation, & percussion -carried out systematically -nurse first records general impression about client's overall appearance & health status -during physical examination, nurse assesses all body parts & compares findings on each side of body -may be organized according to examiner's preference in head to toe approach or body systems approach -instead of complete examination, nurse may focus on specific problem area noted -data obtained from examination are measured against norms or standards -nurse may perform screening examination: also called review of systems, brief review of essential functioning of various body parts or systems 1. cephalocaudal examination approach: -known as head to toe approach -begins examination at head, progresses to neck, thorax, abdomen, & ends at toes 2. body systems examination approach -nurse investigates each system individually

Methods of Data Collection

-nurse uses all three methods simultaneously when assessing client 1. Observing 2. Interviewing 3. Examining

Wellness Models

-nurses use wellness models to assist clients to identify health risks & to explore lifestyle habits -such models generally include: 1. health history 2. physical fitness evaluation 3. nutritional assessment 4. life stress analysis 5. lifestyle & health habits 6. health beliefs 7. sexual health 8. spiritual health 9. relationships 10. health risk appraisal

Organizing the Data

-nurses uses written or electric format that organizes assessment data systematically -often referred to as nursing health history, nursing assessment, or nursing database form -nurse is not limited to exact framework provided by data collection tool 1. Conceptual Models/Frameworks -Gordon's functional health pattern framework -Orem's self care model -Roy's adaptation model 2. Wellness Models 3. Non nursing Models

Observing

-observe: gather data by using senses -occurs whenever nurse is in contact with client or support persons -conscious, deliberate skill that is developed through effort & with an organized approach -involves distinguishing data in meaningful manner -nurses observe mainly through sight -has two aspects: 1. noticing data 2. selecting, organizing, & interpreting data

Roy

-outlines data to be collected & classifies observable behavior into four categories: 1. physiological 2. self concept 3. role function 4. interdependence

Gordon

-provides a framework of 11 functional health patterns -uses the word pattern to signify a sequence of recurring behavior -nurse collects data about dysfunctional & functional behavior -by using this framework, nurses are able to recognize emerging patterns

Neutral Question

-question client can answer without direction or pressure from nurse -is open ended -used in non directive interviews

Developmental Theories

-several physical, psychosocial, cognitive, & moral developmental theories may be used by nurse in specific situations 1. Havighurst's age periods & developmental tasks 2. Freud's five stages of development 3. Erikson's eight stages of development 4. Piaget's phases of cognitive development 5. Kohlberg's stages of moral development

Assessing

-systematic & continuous collection, organization, validation, & documentation of data (information) -continuous process carried out during all phases of nursing process -all phases depend on accurate & complete collection of data -focus on client's responses to health problem -nurses should think critically about what to assess

Documenting Data

-to complete assessment phase, nurse records client data -accurate documentation is essential & should include all data collected about client's health status -data recorded in factual manner & not interpreted by nurse -nurse records subjective data in client's own words, using quotations

Types of Interview Questions

-type of question nurse chooses depends on needs of client at the time -nurses find it necessary to use combination of closed & open ended questions 1. Closed Questions -Leading Question 2. Open Ended Questions -Neutral Question

Rapport

-understanding between two or more people

Orem's Self Care Model

-universal self care requisites 1. maintenance of sufficient intake of air 2. maintenance of sufficient intake of water 3. maintenance of sufficient intake of food 4. provision of care associated with elimination processes & excrement 5. maintenance of balance between activity & rest 6. maintenance of balance between being alone & social interaction 7. prevention of hazards to human life, human functioning, & human well being 8. promotion of human functioning & development within social groups

Closed Questions

-used in directive interview -restrictive & generally require only yes, no or short answers giving specific information -often used when information is needed quickly, such as in an emergency

Leading Question

-usually closed -used in directive interview -directs client's answer

The nurse considers advantages of asking open-ended questions are: (select all that apply) A: They are easy to answer and are nonthreatening B: They can convey interest and trust C: They can provide information this interviewer may not ask for D: They may reveal the interviewee's lack of information, misunderstanding of words, prejudices, or sterotypes E: They may inhibit communication and convey lack of interest by the interviewer

A: They are easy to answer and are nonthreatening B: They can convey interest and trust C: They can provide information this interviewer may not ask for D: They may reveal the interviewee's lack of information, misunderstanding of words, prejudices, or sterotypes

Problem Statement

AKA diagnosis label. It is title used in writing nursing Dx. Includes diagnostic label and etiology.

Which of the following behaviors is most representative of the "nursing diagnosis" phase of the nursing process? A: Identifying major problems or needs B: Organizing data in the client's family history C: Establishing short-term and long-term goals D: Administering an antibiotic

A: Identifying major problems or needs

The nurse determines the status of a specific problem identified earlier in the shift during: A: Problem-focused assessment B: The initial assessment C: Emergency assessment D: Time-lapsed reassessment

A: Problem-focused assessment

During the nursing history and physical, the nurse obtains: (select all that apply) A: Subjective data B: Objective data C: Prioritized data D: Directed interview data E: Primary data

A: Subjective data B: Objective data E: Primary data

The nurse assesses the client and learns the client has been experiencing frequent headaches. The nurse sees the client's past blood pressure measurements have consistently been less than 120/80 mmHg. Upon measuring blood pressure on this occasion, the client's blood pressure is 152/94 mmHg. The nurse has collected: (select all that apply) A: Subjective data B: Primary data C: Secondary data D: Initial interview data E: Objective data

A: Subjective data B: Primary data C: Secondary data E: Objective data

The client states, "I feel overwhelmed by all the new information you have given me that I need to remember." Is this: A: Subjective, Primary B: Subjective, Secondary C: Objective, Primary D: Objective, Secondary

A: Subjective, Primary

The nurse identifies that the client is experiencing chest pain, shortness of breath, nausea, and diaphoresis. This is an example of which phase of the nursing process? A: Evaluation B: Planning C: Assessment D: Diagnosis

C: Assessment

In order to facilitate an easy exchange of information, the nurse arranges the environment for the interview with: A: The client in bed and the nurse standing at the foot of the bed B: The client in bed and the nurse standing at the side of the bed C: The client in bed and the nurse sitting on a chair at a 45-degree angle to the head of the bed D: Both the nurse and client seated and chairs at right angles to one another, about a foot apart

C: The client in bed and the nurse sitting on a chair at a 45-degree angle to the head of the bed

A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do? 1. Follow the physician's orders as written and give the medication. 2. Call the pharmacy and do further investigating before administering the medication. 3. Ask the client about this medication. 4. Call the physician and ask what the medication is and what it is for.

Call the pharmacy and do further investigating before administering the medication. : The nurse should clearly understand all nursing interventions to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of medical and surgical plans of care. The pharmacist would be the most appropriate reference point for this nurse to begin to research this problem.

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. Collects subjective data. 2. Applies a framework to the collected data. 3. Confirms data is complete and accurate. 4. Records data in the client record.

Confirms data is complete and accurate.

What are the characteristics of the nursing process?

Cyclic and dynamic nature, client centeredness, focus on problem solving and decision making, interpersonal and collaborative style, universal applicability, and use of critical thinking

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? A: "What did the doctor tell you about your diagnosis?" B: "How is your family responding to the diagnosis?" C: "Are you worried about how the diagnosis will affect you in the future?" D: "Tell me about your reactions to the diagnosis."

D: "Tell me about your reactions to the diagnosis."

Two hours after administration of blood pressure medication, the nurse takes the client's blood pressure. This is an example of what phase of the nursing process? A: Diagnosis B: Planning C: Implementation D: Evaluation

D: Evaluation

The nurse is asking the client how often the nausea occurs and if there is anything that alleviates the problem. This is an example of what method of data collection? A: Secondary B: Examining C: Observation D: Interviewing

D: Interviewing

The client's sister states, "He lives at 402 S Oak St." Is this: A: Subjective, Primary B: Subjective, Secondary C: Objective, Primary D: Objective, Secondary

D: Objective Secondary

The nursing process is primarily used by nurses to guide them in: A: Learning about the client B: Communicating C: Managing time appropriately D: Problem solving

D: Problem solving

The nurse is reviewing the client's history in the medical record and recognizes this type of data source as: A: Parallel B: Primary C: Constant D: Secondary

D: Secondary

The client is brought to the hospital after experiencing a seizure and the nurse collects data from the husband regarding the witnessed seizure activity. This is an example of what type of data? A: Inaccurate B: Primary C: Objective D: Support

D: Support

Which of the following represents application of the components of evaluating? 1. Goal achievement must be written as either completely met or unmet. 2. Data related to expected outcomes must be collected. 3. If the outcome was achieved, conclude that the plan was effective. 4. After determining that the outcome was not met, start over with a new nursing care plan.

Data related to expected outcomes must be collected.

The care plan call for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most? 1. Cognitive 2. Intellectual 3. Interpersonal 4. Psychomotor

Interpersonal

The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior. Which skill should the nurse use when caring for these clients? 1. Cognitive 2. Interpersonal 3. Technical 4. Therapeutic

Interpersonal : Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurse's ability to communicate with others. Interpersonal skills are necessary for all nursing activities, including comforting, counseling, and supporting—all of which are extremely important in the acute psychiatric setting.

A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation, what should the nurse do? 1. Review the data and make sure that the diagnosis is relevant. 2. Investigate whether the best nursing interventions were selected. 3. Modify the whole nursing plan. 4. Discard the nursing plan and start over from the assessment phase.

Investigate whether the best nursing interventions were selected.: Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with goal achievement. The nurse needs to check and see if the interventions were appropriate for the client. If the interventions selected did not help the client achieve the goal, then rearranging or implementing new ones may be necessary.

When is a "problem-focused assessment" performed?

It is an ongoing process integrated with nursing care

Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? 1. When the activity is routine (e.g., raising the bed rails). 2. When the activity occurs at regular intervals (e.g., turning the client in bed). 3. When the activity is to be carried out immediately (e.g., a stat medication). 4. It is never acceptable.

It is never acceptable.

When is an "initial assessment" performed?

It is performed within specified time after admission to a health care agency

Diagnostic label

It is the title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association's (NANDA) standardized taxonomy of terms

The client has a high priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? 1. Delete the diagnosis since the problem has not occured. 2. Keep the diagnosis since the risk factors are still present. 3. Modify the nursing diagnosis to Impaired Mobility. 4. Demote the nursing diagnosis to a lower priority.

Keep the diagnosis since the risk factors are still present.

Multidisciplinary Care Plan

Outlines care required for clients to include nursing interventions as well as medical treatments to be performed by other members of the health care team

Progress note

PQRM chart entry; made by all health professionals involved in client care; they all use the same type of sheet for notes

Initial Assessment

Performed within specified time after admission to a health care agency. To establish a complete database for problem identification, reference, and future comparison

Maslow's Hierarchy of Needs

Physiological Needs Safety and Security Needs Love and Belonging Needs Self esteem Needs Self-actualization Needs

Which of the following nursing diagnoses contains the proper components? 1. Risk for Caregiver Role Strain related to unpredictable illness course. 2. Risk for Falls related to tendency to collapse when having difficulty breathing. 3. Impaired Communication related to stroke. 4. Sleep Deprivation secondary to fatigue and a noisy environment.

Risk for Caregiver Role Strain related to unpredictable illness course.

Place the following activities of planning in the correct order of their use. 1. Establish goals/outcomes. 2. Write the care plan. 3. Set priorities. 4. Choose interventions.

Set priorities Establish goals/outcomes Choose interventions. Write the care plan.

When is a "time-lapsed assessment performed?"

Several months after initial assessment

Time-lapsed Reassessment

Several months after the initial assessment, to compare the clients current status to baseline data previously obtained

What is "assessing?"

The systematic and continuous collection, organization, validation, and documentation of data (information).

Cognitive Processes

The thinking processes based on the knowledge of aspects of client care.

The nurse reviews clients' records and the care they received while in the hospital for an insurance company. Part of the job description requires the nurse to make sure that the client and insurance company were billed for services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse completing? 1. Concurrent 2. Peer review 3. Nursing audit 4. Retrospective

Retrospective: A retrospective audit is the evaluation of a client's record after discharge from an agency. The word retrospective means "relating to the past." If the nurse is reviewing records after the client has been discharged, the information being examined is in the past.

Which if the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1. Purposes hypotheses. 2. Generates desired outcomes. 3. Reviews results of laboratory tests. 4. Documents care.

Reviews results of laboratory tests.

One of the primary advantages of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which if the following? 1. Decreases the cost of health care. 2. Improves communication between nurse and client. 3. Helps the nurse focus on health and wellness elements. 4. Standardizes organization of client data.

Standardizes organization of client data.

After being admitted directly to the surgery unit, a 75 year old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1. Initial. 2. Ongoing. 3. Discharge. 4. Strategic.

Strategic.

Informal Nursing Care Plan

Strategy for actions that exists in the nurse's mind

A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be evaluated? 1. Management 2. Structure 3. Process 4. Outcome

Structure: Structure evaluation focuses on the setting in which care is given. Structural standards describe desirable environmental and organizational characteristics that influence care, such as equipment and staffing. Process evaluation focuses on how the care was given.

Individualized Care Plans

Tailored to meet unique needs or a specific client

A home care client must correctly self-administer insulin injections before being discharged from the agency. On what skill is this client being evaluated? 1. Technical 2. Cognitive 3. Interpersonal 4. Academic

Technical : Technical skills are "hands-on" skills such as manipulating equipment, giving injections, bandaging, and moving, lifting, and repositioning clients. These skills can also be called tasks, procedures, or psychomotor skills.

Which of the following is likely to occur if the goal statement is poorly written? 1. There is no standard against which to compare outcomes. 2. The nursing diagnoses cannot be prioritized. 3. Only dependent nursing interventions can be used. 4. It is difficult to determine which nursing interventions can be delegated.

There is no standard against which to compare outcomes.

Creativity

Thinking that results in the development of new ideas and products.

The care plan includes a nursing intervention "4/2/11 Measure client's fluid intake and output. F. Jenkins, RN." What element of proper nursing intervention has been omitted? 1. Action verb 2. Content 3. Time 4. None

Time

Emergency Assessment

Time Performed: -during any physiological or psychological crisis of client Purpose: -identify life threatening problems -identify new or overlooked problems Example: -rapid assessment of person's airways, breathing status, & circulation during cardiac arrest -assessment of suicidal tendencies or potential for violence

Problem Focused Assessment

Time Performed: -ongoing process integrated with nursing care Purpose: -determine status of specific problem identified in earlier assessment Example: -hourly assessment of client's fluid intake & urinary output in an ICU -assessment of client's ability to perform self care while assisting a client to bathe

Initial Assessment

Time Performed: -performed within specified time after admission to an agency Purpose: -establish complete database for problem identification, reference, & future comparison Example: -nursing admission assessment

Time Lapsed Reassessment

Time Performed: -several months after initial assessment Purpose: -compare client's current status to baseline data previously obtained Example: -reassessment of client's functional health patterns in a home care, outpatient setting, or hospital, at shift change

What is the purpose of a "time-lapsed assessment?"

To compare the client's current status to baseline data previously obtained.

What is the purpose of a "problem-focused assessment?"

To determine the status of a specific problem identified in an earlier assessment

What is the purpose of an "initial assessment?"

To establish a complete database for a problem identification, reference, and future comparison.

What is the purpose of assessing?

To establish a database about the client's response to health concerns or illness and the ability to manage health care needs

What is the purpose of an "emergency assessment?"

To identify life-threatening problems; to identify new or overlooked problems.

SOAP

acronym for subjective data, objective data, assessment, and planning

Independent functions

an activity that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills

Norm

an ideal or fixed standard; an expected standard of behavior of group members

discussion

an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.

3 activities that take place in the diagnostic phase of the nursing process

analyzing data, identifying health problems/risks/strengths, formulating diagnostic statements

Cues

are subjective or objective data that can be directly observed by the nurse

Inferences

are the nurses interpretation or conclusion based on the cues

Opened-ended Question

associated with the nondirective interview, invited clients to discover and explore, elaborate, clarify, or illustrate their thoughts and feelings.

Screening Examination

brief review of essentials functioning of various body parts or systems.

Defining characteristics

client signs and symptoms that must be present to validate a nursing diagnosis

Risk nursing diagnosis

clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene

3 ways nurses analyze data

compare data against standards, cluster the cues, identify gaps & inconsistancies

Database

contains all of the information about a client it includes the nursing health history , physical assessment, primary care providers history of physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel

POMR (problem oriented medical record) / POR (problem oriented record)

data arranged according to the problems the client has rather than the source of the information

PIE

documentation model that groups information into three categories;acronym for problems, interventions and evaluation of nursing care

Risk Factors

factors that cause a client to be vulnerable to devloping a health problem

Secondary Sources of Data (Indirect)

family members, support persons, health professionals, records and reports, laboratory and diagnostic analysis, and relevant literature.

chart

formal legal document that provides evidence of a client's care and can be written or computer based. also see record or client record

variance

goal not met

Directive Interview

high structured and elicits specific information

Variable Data

information that does change over time such as blood pressure, level of pain, age

Constant Data

information that does not change over time such as race or blood type

focus charting

intended to make the client and client concerns and strengths of care

Neutral Question

is a question the client can answer without direction or pressure from the nurse

Nondirective Interview

or rapport (understanding between two people) building interview the nurse allows the client to control the purpose, subject matter, and pacing.

report

oral, written, or computer-based communication intended to convey information to others

Interview

planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate, change, teach, provide support, or provide counseling or therapy

Collaborative problems

potential problems that nurses manage using both independent and physician-prescribed interventions

3 components of an actual nursing diagnosis

problem & definition, etiology, defining characteristics (symptoms)

"handoff" communication

process in which information about patient/client/resident is communicated in a consistent manner including an opportunity to ask and respond to questions

charting

process of making an entry on a client's record. also see recording or documenting.

record

see chart or client record; formal legal document that provides evidence of a client's care and can be written or computer based.

client record

see chart; formal legal document that provides evidence of a client's care and can be written or computer based. also see record or client record

documenting

see charting or recording; process of making an entry on a client's record.

recording

see charting; process of making an entry on a client's record.

Assessing

systematic and continuous collection, organization, validation, and documentation of data (information)

Nursing Process

systematic, rational method of planning and providing individualized nursing care.

Etiology

the casual relationship between a problem and its related or risk factors

Focused Interview

the nurse asks the client specific questions to collect information related to the clients problems

Nursing diagnosis

the nurse's clinical judgment about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable

The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occuring in other postions. This decision is an example of? 1. The research method. 2. The trial-and-error method. 3. Intuition. 4. The nursing process. .

the research method

Why is it important for the nurse to identify patients strengths?

to help client develop a more well-rounded self concept and self image

source oriented records

traditional client record; each person or department makes notation in a separate section or sections of the patient's chart

Closed Question

used in directive interviews, are restrictive and generally require only yes or no answers, or short factual answers that provide specific information

flowsheet

uses specific assessment criteria in a particular format, such as human needs or functional health patterns

Leading Question

usually closed, used in directive interview, and thus directs the clients answer.

How can a nurse avoid making errors when creating a nursing diagnosis?

verify, build a good knowledge base & clinical experience, have working knowledge of what is normal, consult resources, base Dx on patterns, improve critical thinking skills.

Kardex

widely used consise method of organizing and recording data about a client, making information quickly accessible to all health care professionals

Dependent functions

with regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out

Diagnosis

a statement or conclusion concerning the nature of some phenomenon

narrative charting

a traditional part of source oriented record; consists of written notes that include routine care, normal findings, and client problems.

When the client reports experiencing nausea, the nurse recognizes this data as: A: Subjective B: Alternate C: Objective D: Secondary

A: Subjective

5 Phases of the Nursing Process

Assessing Diagnosis Planning Implementing Evaluating

The nurse notes that a client has the outcome goal "Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic." Which client statement should the nurse use to evaluate this goal? 1. "I'm getting really sleepy from that medication. I think I'll take a nap." 2. "My pain is a 4." 3. "I still have some pain." 4. "Will the pain ever go away?"

"My pain is a 4.": The nurse collects data so that conclusions can be drawn about whether goals have been met. If the goal is clearly stated, precise, and measurable, it will be easy to evaluate. If the goal was a pain level of 3, the client should be able to give a numerical rating to the pain in order for the nurse to evaluate it.

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. "What did the doctor tell you about your diagnosis?" 2. "Are you worried about how the diagnosis will affect you in the future?" 3. "Tell me about your reactions to this diagnosis." 4. "How is your family responding to the diagnosis?"

"Tell me about your reactions to this diagnosis."

A client in a cardiac rehabilitation program says to the nurse, "I have to eat a low sodium diet for the rest of my life, and I hate it!" Which is the most appropriate response by the nurse? 1. "I will get a dietary consultant to talk to you before next week." 2. "What do you think is so difficult about following a low sodium diet?" 3. "At least you survived a heart attack and are able to return to work." 4. "You may not need to follow a low sodium diet for as long as you think."

"What do you think is so difficult about following a low sodium diet?"

Validating Data

-validation: act of double checking or verifying data to confirm it is accurate & factual -nurses need to be aware of their won opinions -validating data helps nurse complete these tasks: 1. ensure assessment information is complete 2. ensure objective & related subjective data agree 3. obtain additional overlooked information 4. differentiate cues & inferences -cues: subjective or objective data that can be directly observed by nurse -inferences: nurse's interpretation or conclusions made based on cues 5. avoid jumping to conclusions & focusing in wrong direction to identify problems

A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality improvement actions should the nurse manager expect to complete for this client occurrence? Standard Text: Select all that apply. 1. A root cause analysis 2. Paperwork about a sentinel event 3. Analysis of the nurse assigned to the client 4. Number of times the client was observed on the night shift 5. Number of hours since the client last received pain medication

1. A root cause analysis 2. Paperwork about a sentinel event Rationale 1: Root cause analysis is a process for identifying the factors that bring about deviations in practices that lead to the event. It focuses primarily on systems and processes, not individual performance. Rationale 2: A sentinel event is an unexpected occurrence involving death. Such events are called "sentinel" because they signal the need for immediate investigation and response.

Sources of Data

1. Client 2. Support People 3. Client Records 4. Health Care Professionals 5. Literature -primary & secondary -primary source of data: client -secondary source of data (indirect source): all sources other than client -all data from secondary sources should be validated

The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation were completed by the nurse appropriately? Standard Text: Select all that apply. 1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan 5. Physician notified of changes in the care plan

1. Client problems updated 2. Data linked to NOC indicators 3. Data compared to desired outcomes 4. Interventions changed on the care plan Rationale 1: The evaluation phase has five components. Updating the client problems indicates that the plan of care was modified. Rationale 2: The evaluation phase has five components. One phase is ensuring that the collected data are related to the NOC indicators. Rationale 3: The evaluation phase has five components. One phase is comparing the data with desired outcomes. Rationale 4: The evaluation phase has five components. One phase is changing the interventions on the care plan to meet the client's needs or changes in health status.

Guidelines for Validating Assessment Data

1. Compare subjective & objective data to verify client's statements with your observations 2. Clarify any unclear or vague statements 3. Be sure your data consist of cues, not inferences 4. Double check extreme abnormal data 5. Determine factors that may interfere with accuracy 6. Use references

The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that show an understanding of the relationship of evaluation to the other phases of the nursing process? Standard Text: Select all that apply. 1. Effectively assessing the client's needs 2. Selecting the appropriate nursing diagnosis related to the client's needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes 5. Basing evaluation on assessment data collected during the admission phase

1. Effectively assessing the client's needs 2. Selecting the appropriate nursing diagnosis related to the client's needs 3. Collecting client-focused data with a specific need in mind 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes: Rationale 1: Successful evaluation depends on the effectiveness of the steps that precede it. Assessment data must be accurate and complete so that the nurse can proceed with the nursing process. Rationale 2: Successful evaluation depends on the effectiveness of the steps that precede it so that the nurse can formulate appropriate nursing diagnoses. Rationale 3: Data are collected for different purposes at different points in the nursing process. Rationale 4: During the evaluation step, the nurse collects data for the purpose of comparing it with preselected goals/outcomes and judging the effectiveness of the nursing care.

Organizing the Data: Body Systems Approach

1. Eyes, Ears, Nose, Throat 2. Neurological 3. Musculoskeletal 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Skin and wounds

Organizing the Data: Functional Health Patterns

1. Health Perception-Health Maintenance 2. Nutritional-Metabolic 3. Elimination 4. Activity-Exercise 5. Sleep-Rest 6. Cognitive-Perceptual 7. Self-Perception—Self-Concept 8. Role-Relationship 9. Sexuality-Reproductive 10. Coping-Stress Tolerance 11. Value-Belief

Gordon's Typology of 11 Functional Health Patterns

1. Health Perception-Health Management: -describes client's perceived pattern of health & well being & how health is managed 2. Nutritional-Metabolic: -describes client's pattern of food & fluid consumption relative to metabolic need & pattern indicators of local nutrient supply 3. Elimination: -describes patterns of excretory function -(bowel, bladder, & skin) 4. Activity-Exercise: -describes pattern of exercise, activity, leisure, & recreation 5. Sleep: -describes patterns of sleep & relaxation 6. Cognitive-Perceptual: -describes sensory perceptual & cognitive patterns 7. Self Perception-Self Concept: -describes client's self concept pattern & perceptions of self -(worth, body image, feeling state) 8. Role-Relationship: -describes client's pattern of role participation & relationships 9. Sexuality-Reproductive: -describes client's patterns of satisfaction & dissatisfaction with sexuality pattern -describes reproductive patterns 10. Coping-Stress Tolerance: -describes client's general coping pattern & effectiveness of pattern in terms of stress tolerance 11. Value-Belief: -describes pattern of values, beliefs, & goals that guide client's choices or decisions

Types of Assessment

1. Initial Nursing Assessment 2. Problem Focused Assessment 3. Emergency Assessment 4. Time Lapsed Reassessment

Collecting Objective Data

1. Medical Records 2. Physical Exam 3. Data that can be observed or verified

Organizing the Data: Concept Mapping

1. Oxygenation 2. Nutrition 3. Cognition 4. Comfort 5. Mobility 6. Elimination 7. Psychosocial

After implementing interventions and reassessing the client's response, the nurse completes the process by evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing process? Standard Text: Select all that apply. 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinion

1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments: Rationale 1: Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client's progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan. Rationale 2: Through evaluating, nurses demonstrate responsibility and accountability for their actions. Rationale 3: Evaluation is continuous and done while or immediately after implementing a nursing order. Rationale 4: To evaluate is to judge or appraise. Through evaluation, the nurse is able to establish whether nursing interventions should be terminated, continued, or changed.

Types of Data

1. Subjective Data: -referred to as symptoms or covert data -what the patient tells you -can only be described & verified by person affected 2. Objective Data: -referred to as signs or overt data -what nurse observes -detectable by observer -can be measured or tested against accepted standard -obtained by observation or physical examination -nurse obtains objective data to validate subject data -constant data is information that does not change over time (race, blood type) -variable data can change quickly, frequently, rarely (blood pressure, pain, age)

The nurse notes that assessment data indicate a change in a client's condition. What should the nurse ask before changing this client's plan of care? Standard Text: Select all that apply. 1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan? 5. Will the primary medical provider agree with the need to alter the care plan?

2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan?: Rationale 2: This condition must be met before consideration is given to altering a client's care plan. Rationale 3: This condition must be met before consideration is given to altering a client's care plan. Rationale 4: This condition must be met before consideration is given to altering a client's care plan.

The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process? Standard Text: Select all that apply. 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing intervention

2. Reassessing the client 4. Supervising delegated care 5. Implementing the nursing intervention: Rationale 2: This is a component of the implementation process. Rationale 4: This is a component of the implementation process. Rationale 5: This is a component of the implementation process.

The nurse is preparing to provide care planned for a client. What actions should the nurse complete during this phase of client care? 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing interventions

2. Reassessing the client 4. Supervising delegated care 5. Implementing the nursing interventions: Rationale 2: Other components of the implementation process include reassessing the client. Rationale 4: Other components of the implementation process include supervising delegated care. Rationale 5: Other components of the implementation process include implementing the nursing interventions.

The nurse manager has been appointed to implement a quality assurance program at the hospital. Which components should the manager prepare to evaluate for this program? 1. Methods 2. Structure 3. Finances 4. Process 5. Outcome

2. Structure 4. Process 5. Outcome Rationale 2: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care, with structure being one of them. Rationale 4: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care, with process being one of them. Rationale 5: Quality assurance is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. It requires evaluation of three components of care, with outcome being one of them.

The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch. Which skill did the nurse use for this situation? 1. Technical 2. Interpersonal 3. Creativity 4. Cognitive

4. Cognitive : Cognitive skills include problem solving, decision making, critical thinking, and creativity. Finding a unique way to provide the treatment while keeping the client's wishes in mind is an example of the nurse using cognitive abilities.

One nurse expresses that the manager prepared the holiday work schedule unfairly. The manager states that it is the same type of schedule used in the past and other nurses have no problems with it. Which response indicates the nurse is displaying an attitude of critical thinking? 1. Accepting the preferences of the other nurses since there are several of them. 2. Recognizing that the nurse must have reached a false conclusion. 3. Considering going to a higher authority than the manager for an explanation. 4. Continuing to query the manager until the nurse understands the explanation.

4.Continuing to query the manager until the nurse understands the explanation.

Collaborative Care Plans

A critical pathway that sequences care required for client with common conditions

Decision Making

A critical thinking process for choosing the best actions to meet a desired goal.

Clinical Judgement

A decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the client's care.

A major characteristic of the nursing process is which of the following? 1. A focus on client needs. 2. It's static nature. 3. An emphasis on physiology and illness. 4. It's exclusive use by and with nurses.

A focus on client needs.

What is a "directive interview?"

A highly structured interview that elicits specific information.

Trial and Error

A number of approaches are tried until a solution is found.

Problem Solving

A process for clarifying the nature of a problem, suggesting possible solutions, and evaluating the solutions for the best possible choice to implement.

What is a "nondirective interview?"

A rapport-building interview; the nurse allows the client to control the purpose, subject matter, and pacing.

In the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis status? 1. A risk nursing diagnosis. 2. A wellness nursing diagnosis. 3. A health promotion nursing diagnosis. 4. An actual nursing diagnosis.

A risk nursing diagnosis.

Nursing Process

A systematic client-centered method for structuring nursing care.

Nursing Interventions Classification (NIC)

A taxonomy of nursing interventions

Nursing Outcomes Classifications (NOC)

A taxonomy of nursing outcome statements

Socratic Questioning

A technique one can use to look below the surface to differentiate what one knows from what one merely believes.

The client has had a stroke and has difficulty speaking. An example of the most appropriate form of communication the nurse can use is: A: "Are you having pain?" B: "Tell me about your family." C: "Tell me about your health history." D: "Count backwards from 100."

A: "Are you having pain?"

The nurse's use of a conceptual or theorectical framework for collecting and organizing assessment data ensures: A: Collection of all necessary information for a thorough appraisal B: Utilization of creativity and intuition in creaing a plan of care C: Correlation of the data with other members of the health care team D: Demonstration of cost-effective care

A: Collection of all necessary information for a thorough appraisal

During assessment, the nurse: (select all that apply) A: Collects data B: Organizes data C: Documents data D: Validates data E: Prioritizes data

A: Collects data B: Organizes data C: Documents data D: Validates data

The nurse is admitting the client to the unit and is asking very specific questions related to the client's health history. What type of interview is the nurse performing? A: Directive B: Rapport C: Open D: Nondirective

A: Directive

Protocols

Actions commonly required for a particular group of clients

Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis. 2. Always select independent interventions when possible. 3. There is one best intervention for each goal/outcome. 4. Interventions should be "doing." not just "monitoring."

Actions should address the etiology of the nursing diagnosis.

Nursing Interventions

Actions that a nurse performs to enhance client outcomes

Collaborative Interventions

Actions the nurse carrier out in conjunction with other health team members

Independent Interventions

Actives that nurses are licensed to initiate on the basis of their knowledge and skills

Dependent Interventions

Activities carried out under the orders or supervision of a licensed physician or other health care provider

The nurse is providing care to an assigned client. Which action indicates that the nurse supports the client's respect for dignity? 1. Allowing the client to complete hygienic care when possible 2. Providing all care to the client whenever possible 3. Telling the other staff that the client is demanding, so they are able to meet the client's needs 4. Presenting information to the client's family about the client's condition

Allowing the client to complete hygienic care when possible: Respecting the dignity of each client enhances their self-esteem and is an important aspect of implementing interventions. Providing privacy and allowing clients to make their own decisions, or do their own care when possible, is a way of respecting dignity and increasing self-esteem.

What is "objective data?"

Also referred to as signs or OVERT data; are detectable by an observer or can be measured or tested against an accepted standard.

What is "subjective data?"

Also referred to as symptoms or COVERT data; only apparent to the person affected and can be described or verified only by that person.

A client with diarrhea also has a primary care providers order for bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, "the primary care provider does not know the client has diarrhea." This statement is an example of? 1. A fact. 2. An inference. 3. A judgement. 4. An opinion.

An inference

Critical Thinking

An intentional higher level reasoning that is delineated by several factors as a guide for rational judgement and action.

The nurse is teaching a client about wound care during a follow-up visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence-based practice when the client states, "I just don't know how I can afford these dressings"? 1. Integrity 2. Intellectual humility 3. Confidence 4. Independence

Answer 1 Rationale: By reconsidering the type of dressing used based on research, the nurse is using integrity. Options 2 and 3 are critical thinking attitudes characterized by an awareness of the limits of one's own knowledge, and being trustworthy. Option 4 indicates an attitude of not being easily swayed by the opinions of others.

Which of the following is true regarding the relationship of implementing to the other phases of the nursing process? 1. The findings from the assessing phase are reconfirmed in the implementing phase. 2. After implementing, the nurse moves to the diagnosing phase. 3. The nurse's need for involvement of other health care team members in implementing occurs during the planning phase. 4. Once all interventions have been completed, evaluating can begin.

Answer 1 Rationale: During implementing, the nurse also assesses and compares with the initial assessment. Evaluating follows implementing (option 2), mobilization of other health care teams is a part of implementing (option 3), and evaluating occurs during or immediately after each intervention, not waiting for all interventions to be completed (option 4).

Answer 1 Rationale: Goal statements provide the standard against which outcomes are measured. Nursing diagnoses are prioritized before goals are written (option 2). Both independent and dependent interventions may be appropriate for any goal (option 3). Clarity of the goal does not influence delegation of the intervention (option 4).

Answer 1 Rationale: Interventions should address the etiology of the nursing diagnosis. Both independent and dependent interventions should be selected if appropriate (option 2) and several interventions may be needed for a single outcome (option 3). Both action and assessment-type interventions can be used (options 4).

When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing? 1. Creating environments that support critical thinking 2. Tolerating dissonance and ambiguity 3. Self-assessment 4. Seeking situations where good thinking is practiced

Answer 1 Rationale: Nurses must embrace exploration of the perspectives of persons from different ages, cultures, religions, socioeconomic levels, and family structures to create environments that support critical thinking. Option 2 relates to nurses who should increase their tolerance for ideas that contradict previously held beliefs. Option 3 is conducted when a nurse benefits from a rigorous personal assessment to determine which attitudes he or she already possesses and which need to be cultivated. Option 4 occurs when nurses find it valuable to attend conferences in clinical or educational settings that support open examination of all sides of issues and respect for opposing viewpoints.

The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1. Hospital policies 2. Standardized care plans 3. Orthopedic protocols 4. Standards of care

Answer 1 Rationale: Policy and procedure documents provide data about how certain situations are handled. Standardized care plans (option 2) and standards of care (option 4) are written for groups of clients with similar medical or nursing diagnoses. They generally do not address questions such as hospital routines and nonmedical client needs. Note: Even hospital policies are not absolute. Each situation must be analyzed and responded to individually. Orthopedic protocols (option 3) would address elements specifically associated with the surgery, not whether the family slept in the room.

The primary purpose of the evaluating phase of the care planning process is to determine whether 1. Desired outcomes have been met. 2. Nursing activities were carried out. 3. Nursing activities were effective. 4. Client's condition has changed.

Answer 1 Rationale: The desired outcomes and indicator statements reflect the parameters by which success will be measured. The goal can be met even if the nursing activities were not carried out or were ineffective. Although the desired outcome, by definition, indicates a change in the client's condition (behavior, knowledge, or attitude), only specific changes (desired outcomes) reflect the success of the care plan.

A client reports feeling hungry, but does not eat when food is served. Using critical thinking skills, the nurse should perform which of the following? 1. Assess why the client is not ingesting the food provided. 2. Continue to leave the food at the bedside until the client is hungry enough to eat. 3. Notify the primary care provider that tube feeding may be indicated soon. 4. Believe the client is not really hungry.

Answer 1 Rationale: The nurse recognizes that many assumptions (beliefs) could interfere with the client eating - such as that the food presented is not culturally appropriate. These assumptions must be clarified. Options 2 and 3 reach conclusions not supported by the facts. In option 4, the nurse has made a judgement or has an opinion that may not be accurate. Also, the nurse is acting without assessment. Implementation should not be preceded by assessment.

The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. This decision is an example of 1. The research method. 2. The trial-and-error method. 3. Intuition. 4. The nursing process.

Answer 1 Rationale: The research method uses a research study based approach to problem solving. Trial and error (option 2) and intuition (option 3) would involve unstructured approaches resulting in less predictable results. The nursing process generally uses application of known interventions, previously determined by the scientific (research) process (option 4).

Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply. 1. No interventions should be carried out without the nurse having clear rationales. 2. Always follow the primary care provider's orders exactly, without variation. 3. Encourage all clients to be as dependent as desired and allow the nurse to perform care for them. 4. When possible, give the client options in how interventions will be implemented. 5. Each intervention should be accompanied by client teaching.

Answer 1, 4, and 5 Rationale: Nurses should always have clear rationales for their actions, clients should be given options whenever possible, and client teaching is a constant, integral part of implementing. Primary care provider orders must be critically evaluated and modified to meet individual client needs (option 2). Clients may have nurses provide needed care but should take care of themselves whenever possible since dependency has its own complications (option 3).

If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift which process does this reflect? 1. Structure evaluation 2. Process evaluation 3. Outcome evaluation 4. Audit

Answer 2 Rationale: Because this assessment focuses on how care is provided, it is a process evaluation. A structure evaluation would focus on the setting (e.g., how well equipment functions), and outcome evaluations focus on changes in client status (e.g., whether reported satisfaction levels vary with type of person who answers the call light). An audit would be a chart or document review.

Answer 2 Rationale: Evaluating requires that client behaving be compared to expected outcomes. Goals may be partially met in addition to completely met or unmet (option 1). An outcome may be achieved but not be a direct result of the plan or interventions (option 3). A care plan should be continued, modified, or terminated based on achievement of outcomes (option 4).

The nurse recognizes which of the following as a benefit of using a standardized care plan? 1. No individualization is needed. 2. The nurse chooses from a list of interventions. 3. They are much shorter than nurse-authored care plans. 4. They have been approved by accrediting agencies.

Answer 2 Rationale: Standardized care plans provide a list of interventions from which the nurse can choose. The plan must still be individualized (option 1). Standardized plans could be longer or shorter than nurse-authored ones (option 3), but have not been approved by any outside accreditor (option 4).

A client with diarrhea also has a primary care provider's order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, "The primary care provider does not know the client has diarrhea." This statement is an example of 1. A fact. 2. An inference. 3. A judgment. 4. An opinion.

Answer 2 Rationale: The nurse has inferred and concluded something that is beyond the available information (and in this case may not be accurate). The prescription and the diarrhea are facts (option 1). It would be judgement and opinion if the nurse stated that the laxatives would make the diarrhea worse and should not be given (options 3 and 4).

A client in a cardiac rehabilitation program says to the nurse, "I have to eat a low-sodium diet for the rest of my life, and I hate it!" Which is the most appropriate response by the nurse? 1. "I will get a dietary consult to talk to you before next week." 2. "What do you think is so difficult about following a low-sodium diet?" 3. "At least you survived a heart attack and are able to return to work." 4. "You may not need to follow a low-sodium diet for as long as you think."

Answer 2 Rationale: The nurse recognizes the need to obtain further information from the client in order to respond directly to the client's statement. Option 1 passes off the client's educational needs to another practitioner. Options 3 and 4 are non therapeutic.

The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects critical thinking? 1. Notify the primary care provider. 2. Obtain vital signs and oxygen saturation. 3. Request a chest x-ray. 4. Call the rapid response team.

Answer 2 Rationale: The nurse's intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client's clinical picture more fully. Option 1 supports appropriate nursing actions, but the client's respiratory status should be assessed first. Usually, a physician must order a chest x-ray (option 3). The rapid response team (option 4) may be needed if the client's condition becomes more critical.

The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? 1. Delete the diagnosis since the problem has not occurred. 2. Keep the diagnosis since the risk factors are still present. 3. Modify the nursing diagnosis to Impaired Mobility. 4. Demote the nursing diagnosis to a lower priority.

Answer 2 Rationale: There is no reason to delete or modify the nursing diagnosis or demote its priority because the risk factors that prompted it are still present.

When written properly, NOC outcomes and indicators 1. Do not require customization. 2. Address several nursing diagnoses. 3. Are broad statements of desired end points. 4. Reflect both the nurse's and the client's values.

Answer 4 Rationale: NOC outcomes should reflect both the nurse's and the client's values of what is trying to be achieved. The outcomes still must be customized (option 1), but address only one nursing diagnosis at a time (option 2). Outcomes are narrow/specific end points, not broad (option 3).

An element of quality improvement, rather than quality assurance, is which of the following? 1. Focus is on individual outcomes 2. Evaluates organizational structures 3. Aims to confirm that quality exists 4. Plans corrective actions for problems

Answer 4 Rationale: Quality improvement plans corrective actions for problems. QI focuses on process rather than outcomes (option 1), client care rather than confirmation of quality (option 3).

The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but very dry skin. The client declines oral fluid due to nausea, and reports no bowl movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1. Pain 2. Nausea 3. Constipation 4. Potential for wound infection

Answer 2 Rationale: More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority. Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. The client's pain level is not extreme considering the recency of the surgery, and pain intervention can be assumed to be effective (option 1). Although the constipation is probably bordering on abnormal, a nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. More invasive interventions such as an enema or suppository would not be commonly administered the first day postoperative (option 3). Wound infection can occur, but there is no data to indicate that this requires a change in the current plan (option 4).

The care plan includes a nursing intervention "4/2/11 Measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? 1. Action verb 2. Content 3. Time 4. None

Answer 3 Rationale: Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done "routinely" or at specific intervals (e.g., q4h). The nurse is also aware, however, that critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings.

When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? 1. Carrying out nursing interventions 2. Determining the need for assistance 3. Reassessing the client 4. Documenting interventions

Answer 3 Rationale: The first step of implementing is reassessing the client to determine that the activity is still indicated and safe. The next action would be to determine if assistance is required, and then implement the intervention (delegating if appropriate), and last document the intervention.

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? 1. Turn in bed q2h. 2. Report the importance of applying lotion to skin daily. 3. Have intact skin during hospitalization. 4. Use a pressure-reducing mattress.

Answer 3 Rationale: The goal or outcome should state the opposite of the nursing diagnosis stem, and thus healthy intact skin is the reverse condition of impaired skin integrity. Turning in bed, applying lotion, and using a special mattress are all interventions that may result in achieving the goal (options 1, 2, and 4).

The care plan calls for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most? 1. Cognitive 2. Intellectual 3. Interpersonal 4. Psychomotor

Answer 3 Rationale: This client needs psychosocial support rather than skills related to knowledge (options 1 and 2) or hands on activity (option 4).

Place the following activities of planning in the correct order of their use. 1. Establish goals/outcomes. 2. Write the care plan. 3. Set priorities. 4. Choose interventions.

Answer 3, 1, 4, and 2 Rationale: In planning, first the nurse sets priorities and then writes goals/outcomes, selects interventions, and then writes the nursing care plan.

Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? 1. When the activity is routine (e.g., raising the bed rails) 2. When the activity occurs at regular intervals (e.g., turning the client in bed) 3. When the activity is to be carried out immediately (e.g., a stat medication) 4. It is never acceptable

Answer 4 Rationale: It is never acceptable practice for the nurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading, and potentially dangerous. In a few situations, it may be permissible to chart frequent or routine activities some time following the activities such as at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately following the activity.

Which reasoning process describes the nurse's actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? 1. Intuition 2. Research process 3. Trial and error 4. Problem solving

Answer 4 Rationale: A nurse thinks critically, evaluates possible solutions, and uses problem solving. Intuition (option 1) is not a sufficient basis for implementing wound care when significant data on alternative care strategies are available. Research (option 2) is a more comprehensive rigorous process and not typically implemented while caring for an infected wound. Trial and error (option 3) is unsafe and inappropriate for care of an infected wound.

In the decision-making process, the nurse sets and weights the criteria, examines alternatives, and performs which of the following before implementing the plan? 1. Reexamines the purpose for making the decision 2. Consults the client and family members to determine their view of the criteria 3. Identifies and considers various means for reaching the outcomes 4. Determines the logical course of action should intervening problems arise.

Answer 4 Rationale: It is important to project what problems might interfere with the plan and have appropriate responses prepared to prevent the interferences. The purpose for the decision should have been clear enough at the outset as to not require reexamination at this point (option 1). Clients and families should be consulted early - in the purpose setting and criteria setting steps. Criteria should not be set until all significant participants have an opportunity to present their point of view (option 2). Considering various means for reaching the outcomes is the same as examining alternatives (option 3).

After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be the least useful during the first shift on the orthopedic unit? 1. Initial 2. Ongoing 3. Discharge 4. Strategic

Answer 4 Rationale: Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least useful and not relevant in this case. The client requires initial planning because he has just arrived on the orthopedic unit for the first time (option 1). Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires the ongoing type of planning necessary to determine the care appropriate for this shift (option 2). Discharge planning needs to start on admission to ensure adequate client preparation for management of health needs outside the health agency (option 3).

One nurse expresses that the manager prepared the holiday work schedule unfairly. The manager states that it is the same type of schedule used in the past and other nurses have no problems with it. Which response indicates the nurse is displaying an attitude of critical thinking? 1. Accepting the preferences f the other nurses since there are several of them 2. Recognizing that the nurse must have reached a false conclusion 3. Considering going to a higher authority than the manager for an explanation 4. Continuing to query the manager until the nurse understands the explanation

Answer 4 Rationale: The critical thinking approach should include perseverance until a reasonable solution or answer is determined. Giving in (option 1), overquestioning self, poor trust in one's own beliefs (option 2), or bypassing normal routes of authority (option 3) violates the desirable attitudes of integrity, intellectual courage, and confidence in reason.

Critical Analysis

Application of a set of questions to a particular situation to determine essential information and discard unneeded information.

The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out? 1. Delegating to the appropriate staff 2. Delegating the appropriate task 3. Selecting the appropriate client 4. Appropriately supervising care

Appropriately supervising care: The nurse has two responsibilities in delegating and assigning duties: (1) appropriate delegation of duties (that is, giving people duties within their scope of practice) and (2) adequate supervision of personnel to whom work is delegated or assigned. In this situation, the nurse gave an unlicensed person a duty that was appropriate. Unlicensed assistive personnel completed the duty and documented the findings. The nurse is still responsible for analyzing data, planning care, and evaluating outcomes. In this case, the nurse failed to follow up (supervise) after the duty was performed and analyze the findings.

A client has the goal statement "Client will have clear lung sounds bilaterally within 3 days." One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. What should the nurse do to relate the intervention to the outcome? 1. Ask how many times per day the client practiced the coughing and deep breathing exercises. 2. Tell the client that the lungs are clear. 3. Document the assessment findings to show the effectiveness of the intervention. 4. Write this evaluation statement: Goal met, lung sounds clear by third day.

Ask how many times per day the client practiced the coughing and deep breathing exercises.: Part of the evaluating process is determining whether the nursing activities had any relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep breathing? In order to know for sure, the nurse must collect more data and not assume that this particular nursing intervention had any relation to the outcome.

On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take? 1. Ask the nurse mentor to assist with the teaching after reviewing the procedure. 2. Read the policy and procedure manual before the teaching session. 3. Do the best the nurse can by remembering what was taught in nursing school. 4. Ask for a different assignment until the nurse feels comfortable with this one.

Ask the nurse mentor to assist with the teaching after reviewing the procedure.: When implementing some nursing interventions, the nurse may require assistance. In this case, the nurse lacks the knowledge or skills to implement a particular nursing activity (teaching).

A client reports feeling hungry, but does not eat when food is served. Using critical thinking skills, the nurse should perform? 1. Asses why the client is not ingesting the food provided. 2. Continue to leave the food at the bedside until the client is hungry enough to eat. 3. Notify the primary care provider that tube feeding may be indicated soon. 4. Believe the client is not really hungry.

Assess why the client is not ingesting the food provided.

The client is having chest pain. The nurse most appropriately asks: A: "Is your pain sharp or dull? B: "Please describe your pain." C: "Are you having pain?" D: "Are you having pain in your left arm?"

B: "Please describe your pain."

The nurse asks a client, "What happened to your leg?" This is an example of: A: A closed-ended question B: An open-ended question C: A neutral question D: A leading question

B: An open-ended question

During which stage of the interview should the nurse ask, "How long have you had this symptom?" A: Closing B: Body C: Opening D: Examination

B: Body

The most important component to the effective use of the nursing process is: A: Collaboration B: Critical thinking C: Client compliance with the plan D: Nursing theory

B: Critical thinking

What nursing framework is based on 11 functional health patterns and collects data about dysfunctional and functional behavior? A: Roy's adaptation model B: Gordon's functional health patterns C: The wellness model D: Orem's self-care model

B: Gordon's functional health patterns

The nurse collects subjective data when learning that the client is experiencing: A: Vomiting B: Headache C: Bleeding D: Diarrhea

B: Headache

B: Interviewing

Characteristics of the nursing process include: (select all that apply) A: It is nursing centered B: It is universally applicable in all settings C: It is individual and autonomous D: Decision making is involved in each phase of the nursing process E: Data from each phase is used in the next phase

B: It is universally applicable in all settings D: Decision making is involved in each phase of the nursing process E: Data from each phase is used in the next phase

Which of the following elements is best characterized as secondary subjective data? A: The nurse measures a weight loss of 10 lbs since the last clinic visit B: Spouse states the client has lost all appetite C: The nurse palpates edema in lower extremities D: Client states severe pain when walking up stairs

B: Spouse states the client has lost all appetite

The client's significant other states, "He says it feels like spiders are crawling on his legs, but I don't see them." Is this: A: Subjective, Primary B: Subjective, Secondary C: Objective, Primary D: Objective, Secondary

B: Subjective, Secondary

Primary Source of Data

Client

Critical Pathways

Collaborative care plan that sequences care that must be given

How does a nursing diagnosis differ from collaborative problems?

Collaborative problems are potential problems that nurses manage using independent and physician prescribed interventions. Nursing diagnosis involve human responses which vary greatly.

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. Correlation of the data with other members of the health care team. 2. Demonstration of cost-effective care. 3. Utilization of creativity and intuition of creating a plan of care. 4. Collection of all necessary information for a thorough appraisal.

Collection of all necessary information for a thorough appraisal.

When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing? 1. Creating environments that support critical thinking. 2. Tolerating dissonance and ambiguity. 3. Self-assessment. 4. Seeking situations where good thinking is practiced.

Creating environments that support critical thinking.

In the diagnostic statement "Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following? 1. Excess fluid volume. 2. Decreased venous return. 3. Edema 4. Unknown

Decreased venous return.

The nurse is conducting the diagnosing phase (nursing diagnosis) of the nusing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement? 1. Assess the client's needs. 2. Delineate the client's problems and strengths. 3. Determine which interventions are most likely to succeed. 4. Estimate the cost of several different approaches.

Delineate the client's problems and strengths.

Goals/Desired Outcomes

Describe what the nurse hopes to achieve by implementing the nursing interventions

The primary purpose of the evaluating phase of the care planning process is to determine whether 1. Desired outcomes have been met. 2. Nursing activites were carried out. 3. Nursing activities were effective. 4. Client's condition has changed.

Desired outcomes have been met.

In the decision making process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the following before implementing the plan? 1. Reexamines the purpose for making the decision. 2. Consults the client and family members to determine their view of the criteria. 3. Identifies and considers various means for reaching the outcomes. 4. Determines the logical course of action should intervening problems arise.

Determines the logical course of action should intervening problems arise.

Policies

Developed to govern the handling of frequently occurring situations

The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next? 1. Move on to the next assignment to increase the nurse's efficiency. 2. Report this to the charge nurse. 3. Document all care in the progress notes. 4. Get supplies organized for the next client's medications and treatments.

Document all care in the progress notes.: After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the progress notes.

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the nurse do? 1. Keep the problem on the care plan, in case the symptoms return. 2. Document that the problem has been resolved and discontinue the care for the problem. 3. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. 4. Document that the potential problem is being prevented because the symptoms have stopped.

Document that the problem has been resolved and discontinue the care for the problem.: In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time.

When is an "emergency assessment" performed?

During any physiological or psychological crisis of the client

Emergency Assessment

During any psychological or physiological crisis of the client, to identify life-threatening problems, to identify new or overlooked problems

Which of the following represent effective planning of the interview setting? Select all that apply. 1. Keep the lighting dimmed so as not to stress the client's eyes. 2. Ensure that no one can overhear the interview conversation. 3. Stand near the client's head while he or she is in the bed or chair. 4. Keep approximately 3 feet from the client during the interview. 5. Use a standard form to be sure all relevant data are covered in the interview.

Ensure that no one can overhear the interview conversation. Keep approximately 3 feet from the client during the interview. Use a standard form to be sure all relevant data are covered in the interview.

Which of the following is the purpose of assessing? 1. Establish a database of client responses to his or her health status. 2. Identify client strengths and problems. 3. Develop an individualized plan of care. 4. Implement care, prevent illness, and promote wellness.

Establish a database of client responses to his or her health status.

What are the activities performed during the assessment phase of the nursing process?

Establishing a database by: Obtaining a nursing health history, Conducting a physical assessment, Review client records, Review nursing literature, Consult support persons, Consult health professionals. Update data as needed. Organize data. Validate data. Communicate/document data.

Rationale

Evidence-based principle given as the reason for selecting a particular nursing intervention

Assessing is the systematic collection of data by the nurse that occurs only within 24 hours of the client's inpatient admission: True or False?

False

Standardized Care Plan

Formal plan that specifies the nursing care for groups of clients with common needs

Inductive Reasoning

Generalizations are formed from a set of facts or observations.

Standing Order

Gives the nurse authority to carry out specific actions under certain circumstances

A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." What statement demonstrates that the nurse appropriately evaluated this goal? 1. Goal not met, client able to state one positive aspect by the end of the week. 2. Goal met, client able to state one positive aspect by the end of the week. 3. Goal met, client able to state two positive aspects of therapy by week's end. 4. Goal incomplete, client not able to positively state anything about rehab.

Goal met, client able to state two positive aspects of therapy by week's end.: An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of the client responses that support the conclusion. In this situation, the goal was met if the client was able to state two positive aspects of rehab by the end of the week, and the evaluation statement should reveal that.

Concept Map

Graphic representation of linear and nonlinear relationships for representing critical care.

change of shift report

Hand off communication given to all nurses on next shift

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? The client will 1. Turn in bed q2h. 2. Report the importance of applying lotion to dry skin daily. 3. Have intact skin during hospitalization. 4. Use a pressure-reducing mattress.

Have intact skin during hospitalization.

Cephalocaudal

Head-to-toe approach begins examination at the head and ends at the toes

The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether of not this request can be honored, the nurse should consult which of the following? 1. Hospital policies. 2. Standardized care plans. 3. Orthopedic protocols. 4. Standards of care.

Hospital policies.

What is an example of a "problem-focused assessment?"

Hourly assessment of client's fluid intake and urinary output in an ICU

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs. 2. Organizing data in the client's family history. 3. Establishing short-term and long-term goals. 4. Adminstering and antibiotic.

Identifying major problems or needs.

A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis 1. If both medical and nursing intervention are required to treat the problem. 2. When independent nursing actions can be utilized to treat the problem. 3. In cases where nursing intervention are the primary actions required to treat the problem. 4. When no medical diagnosis (disease) can be determined.

If both medical and nursing intervention are required to treat the problem.

During teaching, the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin. Which guideline of implementing interventions is the nurse using? 1. Adapt activities to the individual client. 2. Encourage clients to participate actively in implementing nursing interventions. 3. Base nursing interventions on scientific knowledge, research, and standards of care. 4. Implement safe care.

Implement safe care.: Showing the client how to avoid injury with injections is part of implementing safe care.

Metacognitive Processes

Include reflective thinking and awareness of the skills learned by the nurse in caring for the client.

The nurse is teaching a client about wound care during a follow up visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence based practice when the client states, "I just don't know how I can afford these dressings"? 1. Integrity. 2. Intellectual humility. 3. Confidence. 4. Independence

Integrity

The nurse is caring for a new mother and infant. Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant? 1. Telling the parents everything the nurse is doing and why 2. Letting the parents watch a video after the bath 3. Letting the parents bathe the baby with direction and guidance from the nurse 4. Giving lots of advice and suggestions about different methods

Letting the parents bathe the baby with direction and guidance from the nurse : Active participation enhances a client's sense of independence and control. In this situation, the baby and parents will do best with future bathing times if they are allowed to complete the bath themselves.

Problem-Focused Assessment

Ongoing process integrated with nursing care, to determine a status of a specific problem identified in an earlier assessment.

Which of the following is true regarding the state of the science in regards to nursing diagnosis? 1. The original taxonomy has proven to be adequate in scope. 2. The organizing framework of the taxonomy is based on the work of Florence Nightingale. 3. More research is needed to validate and refine the diagnostic labels. 4. New diagnostic labels are approved by means of a vote of registered nurses.

More research is needed to validate and refine the diagnostic labels.

The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but very dry skin. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered high priority for a change in the current care plan? 1. Pain 2. Nausea 3. Constipation 4. Potential for wound infection

Nausea

Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply. 1. No interventions should be carried out without the nurse having clear rationales. 2. Always follow the primary care provider's orders exactly, without variation. 3. Encourage all clients to be as independent as desired and allow the nurse to perform care for them. 4. When possible, give the client options on how the interventions will be implemented. 5. Each intervention should be accompanied by client teaching.

No interventions should be carried out without the nurse having clear rationales. When possible, give the client options on how the interventions will be implemented. Each intervention should be accompanied by client teaching.

What is an example of an "initial assessment?"

Nursing admission assessment

A nursing unit's records of client care have been reviewed for accuracy in documentation. Which type of review is being completed on these records? 1. Nursing audit 2. Peer review 3. Individual audit 4. Concurrent audit

Nursing audit: An audit is an examination or review of records. A nursing audit is a type of peer review that focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation.

Which if the following would be true regarding use of the observing method of data collection? 1. When observing, the nurse uses only the visual sense. 2. Observing is done only when no other nursing interventions are being performed at the same time. 3. Data should be gathered as it occurs, rather than in any particular order. 4. Observed data should be interpreted in relation to other sources of collected data.

Observed data should be interpreted in relation to other sources of collected data.

The nurse is concerned about a client who begins to breath very rapidly. Which action by the nurse reflects critical thinking? 1. Notify the primary care provider. 2. Obtain vital signs and oxygen saturation. 3. Request a chest x-ray. 4. Call the rapid response team.

Obtain vital signs and oxygen saturation.

An element of quality improvement, rather than quality assurance, is which of the following? 1. Focus is on individual outcomes. 2. Evaluates organizational structures. 3. Aims to confirm that quality exists. 4. Plans corrective actions for problems.

Plans corrective actions for problems.

Significant Cues

Point to a change in a client's health status or patter. Vary from norms of the client population. Indicate a developmental delay.`

2 parts of a basic nursing diagnosis

Problem (P) statement & Etiology (E) factors

Which reasoning process describes the nurse's actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? 1. Intuition. 2. Research process. 3. Trial and error. 4. Problem solving.

Problem solving

If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift, which process does this reflect? 1. Structure evaluation 2. Process evaluation 3. Outcome evaluation 4. Audit

Process evaluation

Discharge Planning

Process of anticipating and planning for release from a facility

Priority Setting

Process of establishing a preferential sequence for addressing nursing diagnoses and interventions

Deductive Reasoning

Process of working from a general premises to reach a specific conclusion.

A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. When evaluating this care area, on which care component should the quality assurance officer focus? 1. Competency 2. Structure 3. Process 4. Outcome

Process: Process evaluation focuses on how the care was given. Is the care relevant to the clients' needs? Is it appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process.

When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? 1. Carrying out nurses interventions. 2. Determining the need for assistance. 3. Reassessing the client. 4. Documenting interventions.

Reassessing the client.

What is an example of an "emergency assessment?"

Rapid assessment of a person's airway, breathing status, and circulation during a cardiac arrest. Assessment of suicidal tendencies or potential for violence.

Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform? 1. Implementing nursing intervention 2. Determining the nurse's need for assistance 3. Supervising delegated care 4. Reassessing the client

Reassessing the client: Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed or to discover if there are new data that indicate a need to change the priorities of care. In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of teaching/learning experience. Instead, the nurse reassesses the situation and implements a more appropriate intervention.

What is an example of a "time-lapsed assessment?"

Reassessment of a client's functional health patterns in a home care or outpatient setting or, in a hospital, at shift change.

Reflect both the nurse's and the client's values.

Procedures

Similar to protocols specify what is to be done

Which of the following elements is best catergorized as secondary subjective data? 1. The nurse measures a weight loss of 10 pounds since the last clinic visit. 2. Spouse states the client has lost all appetite. 3. The nurse palpates edema in lower extremitites. 4. Client states severe pain when walking upstairs.

Spouse states the client has lost all appetite.

Validation

The act of double-checking or verifying data to confirm that it is accurate and factual

Clinical Reasoning

The analysis of a clinical situation as it unfolds or develops.

Which if the following would indicate a significant cue when comparing data to standards? Select all that apply. 1. The client has moved partway toward a set goal (e/g/, weight loss). 2. The client's vision is within normal range only when wearing glasses. 3. A child is able to control bladder and bowels at age 18 months. 4. A woman widowed recently states she is "unable to cry." 5. A 16 year old high school student reports spending 6 hours doing homework five nights per week.

The client has moved partway toward a set goal (e/g/, weight loss). A woman widowed recently states she is "unable to cry." A 16 year old high school student reports spending 6 hours doing homework five nights per week.

A teenage client has been having problems with peer support, school performance, and parental expectations, all of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis? 1. The data collected would support the diagnosis. 2. The diagnosis is directly related to the data presented. 3. The nursing diagnosis is not relevant to the data. 4. The data are not sufficient enough to support this diagnosis.

The data are not sufficient enough to support this diagnosis.: An incomplete database influences all steps of the nursing process and care plan. The nurse must complete the assessment before formulating a diagnosis about weakness and fatigue. Perhaps this diagnosis is appropriate for this client, but there are not enough data presented to know that for sure.

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? 1. Assessment is done at the beginning of the process. 2. Evaluation is completed at the end of the process. 3. They are the same and there is no need to differentiate. 4. The difference is in how the data are used.

The difference is in how the data are used. : Although the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care.

The findings from the assessing phase are reconfirmed in the implementing phase.

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan? 1. The goal statement is written inaccurately. 2. The interventions are dependent of nursing. 3. The goal is unrealistic. 4. The interventions are not clear enough.

The goal is unrealistic.:When a care plan needs to be modified, discontinued, or changed in some manner, several decisions need to be made. If the nursing diagnosis is accurate, as it is in this case, the nurse should check to see if the goals are attainable and realistic—the flaw in this plan. A client with terminal cancer is not going to be pain-free, regardless of the amount of medication delivered. To think otherwise is inappropriate.

The nurse chooses from a list of interventions.

Intuition

Understanding of things without conscious use of reasoning.

Concept Map

Visual tool in which ideas or data are enclosed in circles or boxes connected buy lines or arrows to indicate relationships

Client's Strength

Weight that is normal range, nonsmoker, immunized, no allergies could be considered to be __________ for client.

Formal Nursing Care Plan

Written or computerized guide that organizes information

Taxonomy

a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles

Syndrome diagnosis

a diagnosis that is associated with a cluster of other diagnoses

charting by exception (CBE)

a documentation system in which all abnormal or significant findings or exceptions to the norm are recorded.

Unit 4 Chapters 10-15 The Nursing Process

Conjuntos de estudio relacionados

APA Quiz- Chapter 6

Ch 26 & 27

MKT Ch 8

Chapter 14 and 16

CH 14

8B 2.8 Post Test Review

Norbery Eco: 5 & 6

Biology UNIT 9 TEST

Clinical Treatment

Gov Chapter 17

Amsco Ch. 21

MCC Psychology Ch. 5

Peds end of chapter questions

Nutrition Exam 3 Final

Week 4 - Chapter 3 and 4

final exam mgmt 3013

study guide for macro midterm

Basic Care and Prevention of Athletic Injuries Final Review

Psych CBA 2 (updated)

Cognitive Psychology Exam 3