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Exam 2 study

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Which of the following components of the nursing process is formed after completing a comprehensive nursing assessment? Hypothesis Implementation Assessment Diagnosis Signs and Symptoms Situation

Diagnosis: Diagnostic-computerThe nursing diagnosis is formed after completions of a comprehensive nursing assessment. Nursing diagnosis' are developed by NANDA (North American Nursing Diagnosis Association) and should be prioritized based on Maslow's

Quality process review recognizes that _____________ is the primary source of evidence used to continuously measure performance outcomes against predetermined standards. Diagnosing Documentation Communication Evaluating

Documentation

Which one of the following acronyms/mnemonics is most closely associated with the nursing process? APGAR ADPIE 5 W's I-SBAR-R BUBBLE - LE ape

ADPIE Add (+) Pie The nursing process can be remembered by the common mnemonic ADPIE. [Asses/Diagnosis/Planning/implementing/Evaluation ]

An _________ is a set of steps, typically embedded in a branching flow chart, that approximates the decision-making process of an expert clinician. Standard Clinical practice Algorithm Procedure

Algorithm

Which of the following is a characteristic most likely associated with I-SBAR-R? Base Bladder Backdrop Background Balance

B- Back-ground stands for background which can include a brief history of the patient or precipitating factors to the current situation at hand.

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? A. "The client reports nausea following eating." B. "The client's right leg is cold to the touch, from the knee to the foot." C."The client's sister reports that the client has unrelieved pain." D. "The client reports having heartburn after breakfast."

B. "The client's right leg is cold to the touch, from the knee to the foot."

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client? A. Risk for Loneliness B. Risk for Impaired Parenting C. Ineffective Infant Feeding Pattern D. Ineffective Breastfeeding E. Acute Pain

B. Risk for Impaired Parenting

Avoiding information contrary to one's opinion is an example of _____, an approach that leads to potential errors in clinical decision making

Bias

In order for a communication process to occur, three components are needed: a source or sender, the message, and the __________, the medium the sender selects to send the message. Feedback Channel Encoder

Channel

A data ____________ is a grouping of patient data or cues that point to the existence of a patient health problem. Cue Cluster Strength Evidence

Cluster

Interventions performed jointly or interdependently by nurses and other members of the health care team are called _____________ interventions. Interpersonal Collaborative Partnership Consult

Collaborative

Using physician-prescribed and nursing-prescribed interventions are examples of ______________ problems that are managed by nurses to minimize the complications of an event. Medical Collaborative Patient Health

Collaborative

Evaluation that is conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met is known as ___________ evaluation. Concurrent Process Retrospective Outcome

Concurrent

The evaluation of one staff member by another staff member on the same level in the hierarchy of an organization is known as ________ review. Collaborative Peer Staff Performance

PEER

A _________________ nursing diagnosis is a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community.. Standard Problem-Focused Health Promotion Risk Medical

Problem-Focused

Written plans, known as __________, detail the nursing activities to be executed in specific situations. Standing Orders Delegation Protocols Research

Protocols

When preparing for data collection, identify the ___________ of the nursing assessment first, then gather the appropriate data. Outcome Purpose Potential errors Cues

Purpose

Which of the following is a characteristic most likely associated with I-SBAR-R? Readback Review Role Resolve Rate Retrospect

R- Reading back order for readback is an important step to verify any direction given and confirm orders to minimize errors.

Which of the following is a characteristic most likely associated with I-SBAR-R? Rate Retrospect Review Role Recommendation Reassess

R- Recommending for recommendation involves making suggestions for what action should be taken or an explanation of what you require and how urgent this need is.

Which of the following is most important when developing a plan of care using the nursing process? Rate Recommendation Relevance Risk Rights Realistic

Realistic Realistic-reelGoals should be realistic to the individual patient. This implies that the patient will actually be able to achieve the goals you outline within the time period specified. NEXT QUESTION

T/F The focus of a process evaluation is the nature and sequence of activities carried out by nurses who are implementing the nursing process.

T/F Unless specified otherwise, the data recorded in the nursing history are assumed to have been collected from the patient.

T/F the patient record is the only permanent legal document that details the nurse's interactions with the patient.

The Nursing Interventions Classification (NIC) report of research provides a ______________ structure of nursing interventions.

Taxonomy

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? A. No action is necessary as this is a normal finding during sleep. B. Call the primary care provider to report possible neurologic deficit. C. Lower the temperature in the patient's room. D. Awaken the patient as this is an indication of night terrors.

a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? Thank the wife for being present. Ask the wife if she wants to remain. Ask the wife to leave. Ask the patient if he would like the wife to stay.

*Ask the patient if he would like the wife to stay. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? -"You need to speak to the patient quietly so you don't disturb the other patients." -"Let me help you with your transfer technique." -"When you are finished, be sure to apologize for your rough demeanor." -"When your patient is safe and comfortable, meet me at the desk."

- "When your patient is safe and comfortable, meet me at the desk." The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? Inform the charge nurse. Inform the surgeon. Validate the finding. Document the finding.

- validate the finding The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? -"I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." -"I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" -"I will need to call in on the 8th of August because I have a doctor's appointment." -"Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

-"I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time.

A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? -"You know your personal situation better than I do, so I will respect your wishes." -"If you don't accept these services, your baby's health will suffer." -"Let's take a look at the plan again and see if we can adjust it to fit your needs." -"I'm going to assign your case to a social worker who can explain the services better."

-"Let's take a look at the plan again and see if we can adjust it to fit your needs." When a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? -"Would you prefer a bath or a shower?" -"May I help you with a bed bath now or later this morning?" -"I will be giving you your bath. Do you use soap or shower gel?" -"I prefer a shower in the evening. When would you like your bath?"

-"May I help you with a bed bath now or later this morning?" The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones.

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? -"I'm just the IV therapist checking your IV." -"I've been transferred to this division and will be caring for you." -"I'm sorry, my name is John Smith and I am your nurse." -"My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

-"My name is John Smith, I am your nurse and I'll be caring for you until 11 PM." The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient.

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? -"New mothers need support." -"The lack of a father is difficult." -"How are you today?" -"It is a very sad situation."

-"New mothers need support." The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles.

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? -"Do you take two injections of insulin to decrease the complications?" -"Most health care providers recommend diet and exercise to regulate blood sugar." -"Most complications of diabetes are related to neuropathy." -"What specific complications have you experienced?"

-"What specific complications have you experienced?" Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? -"You made an inference that she is fine because she has no complaints. How did you validate this?" -"She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." -"Sometimes everyone gets lucky. Why don't you try to help another patient?" -"Maybe you should reassess the patient. She has to have a problem why else would she be here?"

-"You made an inference that she is fine because she has no complaints. How did you validate this?" The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

Which are examples of objective data? Select all that apply. -A client's report of being unable to breathe -Breath sounds on auscultation -A client's temperature -A client's report of pain -Laboratory test results

-Laboratory test results -A client's temperature -Breath sounds on auscultation

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

-"You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.

Which are examples of subjective data? Select all that apply. -A client describes pain as an 8 on the pain assessment scale. -A client's blood pressure is elevated following physical activity. -A nurse observes redness and swelling at an intravenous site. -A client reports being cold and requests an extra blanket. -A client feels nauseated after eating breakfast. -A nurse observes a client wringing the hands before signing a consent for surgery.

-A client describes pain as an 8 on the pain assessment scale -A client reports being cold and requests an extra blanket. -A client feels nauseated after eating breakfast.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. -A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. -A nurse consults with a psychiatrist for a patient who abuses pain killers. -A nurse checks the skin of bedridden patients for skin breakdown. -A nurse orders a kosher meal for an orthodox Jewish patient. -A nurse records the I&O of a patient as prescribed by his health care provider. -A nurse prepares a patient for minor surgery according to facility protocol.

-A nurse prepares a patient for minor surgery according to facility protocol. -A nurse checks the skin of bedridden patients for skin breakdown. -A nurse orders a kosher meal for an orthodox Jewish patient. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? -Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. -Schedule the testing and meal planning first and complete hygiene as time permits. -Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. -Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

-Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? -Cliché -Giving advice -Being judgmental -Changing the subject

-Cliché Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition.

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? -Determining the progress made in achieving established goals -Clarifying when the patient should take medications -Reporting the progress made in teaching to the staff -Including all family members in the teaching session

-Determining the progress made in achieving established goals The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care.

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? -Determining the established goals of the institution -Ensuring that verbal and nonverbal communication is congruent -Engaging in self-talk to plan the day and decrease fear -Speaking with fellow colleagues about how they feel

-Engaging in self-talk to plan the day and decrease fear By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety.

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? -A closed-ended answer -Information clarification -The nurse to give advice -Assertive behavior

-Information clarification The patient's question allows the nurse to clarify information that is new to the patient or that requires further explanation.

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. -Performing the initial patient assessments -Making patient beds -Giving patients bed baths -Administering patient medications -Ambulating patients -Assisting patients with meals

-Making patient beds -Giving patients bed baths -Ambulating patients -Assisting patients with meals Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

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

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

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? -Pain -Anxiety -Depression -Fluid volume deficit

-Pain A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior.

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

-Quick priority Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

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

-Reassess the patient. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. The

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? -Tell the RN that he or she lacks the technical competencies to change the dressing independently. -Assemble the equipment for the procedure and follow the steps in the procedure manual. -Ask another student nurse to work collaboratively with him or her to change the dressing. -Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses

-Tell the RN that he or she lacks the technical competencies to change the dressing independently. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? -Allow the UAPs to do the admission assessment and report the findings to the RN. -Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. -Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. -Contact his or her labor representative to report this practice to the state board of nursing

-Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. -The nurse carefully removes the bandages from a burn victim's arm. -The nurse assesses a patient to check nutritional status. -The nurse formulates a nursing diagnosis for a patient with epilepsy. -The nurse turns a patient in bed every 2 hours to prevent pressure injuries. -The nurse checks a patient's insurance coverage at the initial interview. -The nurse checks for community resources for a patient with dementia.

-The nurse carefully removes the bandages from a burn victim's arm. -The nurse turns a patient in bed every 2 hours to prevent pressure injuries. -The nurse checks for community resources for a patient with dementia. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? -The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." -The nurse places a hand on the patient's arm and states, "You feel so alone." -The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." -The nurse holds the patient's hand and asks, "What makes you feel so alone?"

-The nurse holds the patient's hand and asks, "What makes you feel so alone?" The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? -The use of reflective questions -The use of closed questions -The use of assertive questions -The use of clarifying questions

-The use of clarifying questions The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication.

In the nursing process, evaluative criteria are the patient _______ developed during the planning step. Diagnosis Outcomes Assessments

Outcomes

T/F Nurse-initiated interventions do not require a health care provider's (or other team member's) order.

T/F Nursing diagnoses focus on unhealthy responses to health and illness.

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. A patient tells the nurse that she is feeling nauseous. A patient's ankles are swollen. A patient tells the nurse that she is nervous about her test results. A patient complains that the skin on her arms is tingling. A patient rates his pain as a 7 on a scale of 1 to 10. A patient vomits after eating supper.

A,C,D,E Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. -Group decision making -Group leadership -Group power -Group identity -Group patterns of interaction -Group cohesiveness

A,D,E,F Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes.

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

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

Which of the following is a characteristic most likely associated with I-SBAR-R? Analyze Advocate Assign Activity Assessment

A- [Assess-man] A stands for assessment. Vital signs, physical assessment, mental state, or precipitating factors to current situation.

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

A. Perform the focused assessment as this is an independent nurse-initiated intervention. Performing a focused assessment is an independent nurse-initiated intervention; thus the nurse does not need an order from the physician or the nutritionist.

Which of the following nursing process components involves collecting data about the patient? Administration Diagnosis Implementation Active listening Assessment Attention

Assessment: (Assess-man) The assessment portion of the nursing process is where the nurse will collect data about the patient. This information will encompass physical findings, psychological, cultural, social, family, and nursing histories as well as accessing the medical record and obtaining diagnostic test results.A nurse should not implement interventions until a complete assessment has been done. Exceptions are only in scenarios where the patient will be at risk of immediate injury or death.

T/F Rapport refers to a feeling of mutual trust experienced by people in a satisfactory relationship.

The therapeutic communication technique known as ___________ is the skill of identifying with the way another person feels. Assertive Empathy Behaviors

Empathy

A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history? A. Old chart B. Social worker C Family D. Physician

C Family

The process of ____________occurs when two or more people with varying degrees of experience and expertise discuss a problem and its solution. Planning Consultation Outcomes Intervention

Consultation

Computer-based records, or ____________ health records (EHRs), allow data to be distributed among many caregivers in a standardized format.

Electronic

Which component of the nursing process includes determining reasons for unmet goals and providing modifications to ensure future goal completion? Implementation Timed Diagnosis Evaluation Assessment Emotional Support

Evaluation Evaluator Evaluation is the step where the nurse determines if the patient has met the goals in the patient's plan of care. If the patient did not meet the goals, then the nursing process would begin over and reassessment of the client is completed. Be sure to include reasons why the goals were not previously met and modifications to the plan of care to ensure new goals would be completed.

The documentation of a judgment summarizing data interpretation and patient outcome achievement is an _____________ statement. Pt Document Evaluative Diagnosis Assessment

Evaluative

it is critical that every nursing intervention is supported by a sound scientific rationale, as demanded by ____________-based practice. Patient Centered Evidence Nursing

Evidence

Charting by ____________ is a shorthand documentation method in which only deviations from well-defined standards of practice are documented in narrative notes. Exception Variance Hand PIE

Exception

Carrying out a physician-initiated order is an example of an independent nursing action.

T/F During the implementation step of the nursing process, patient outcomes are identified

T/F Interpersonal communication, or self-talk, is the communication that happens within the individual.

T/F Most experienced nurses begin the work of interpreting and analyzing data after they have finished collecting it.

T/F Nursing assessments have the same components as medical assessments, but with less detail

T/F Quality by inspection focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork.

T/F Subjective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing it.

T/F The chief purpose of ongoing planning is to teach the patient to competently carry out necessary self-care behaviors at home.

T/F The following would be considered an example of a psychomotor outcome: "Before discharge, patient will verbalize the need to quit smoking cigarettes."

T/F The phase expected outcomes is used to refer to the less-specific, hard-to-measure criteria for measuring whether a goal has been met.

T/F An example of a helpful and accurate nursing note is: "The patient appears to be resting more comfortably today than yesterday."

F Although is it nice to know that the pt is resting better this gives you no measurable data or data to compare to.

T/F Clearly identifying patient strengths and actual and potential problems is a part of the nursing process known as assessing.

F Diagnosis

T/F An example of an open-ended question is: "What medicines have you been taking at home?"

F Why? Only allowing pt to list off items [Static response]not allowing pt to give you a free formed answer

T/F The Nursing Interventions Classification (NIC) project defines an indirect care intervention as any nursing activity

F reports of research to construct a taxonomy of nursing interventions

T/F Accurate documentation for a patient given Diovan, 10 mg, once daily is: "Diovan, 10 mg, Q.D."

F What is Wrong/missing? -10mg of what -At What time -What date _First initial, full last name [Physican name if needed] - What is your title[RN, Physician... etc]

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

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

The __________________record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics. Electronic Health record Graphic record Patient record Problem oriented medical record

Graphic

4 The nursing _____________ identifies the patient's health status, strengths, health problems, health risks, and need for nursing care. Skill History Process

History

Which of the following is a characteristic most likely associated with I-SBAR-R? Instigate Implement Interview Intervention Isolate Identify

I-stands for identify which can include information such as who you are, the patient you are referring to, their age, gender, and any other important identifying factors. NEXT QUESTION

Which component of the nursing process involves engaging the patient and family with therapeutic communication to execute the nursing plan? Support Implementation Individualized to the Patient Evaluation Interview Action

Implementation: Implementation is the step of the nursing process where your prioritized plans are carried out. Be sure to involve both the patient and family in active care. The nurse should always use therapeutic communication techniques for communication during implementation.(Notes: This is the step where we actually intervene to help them, give drugs, educate, monitor.) Individualized to the Pati

Which of the following is the most important characteristic regarding the planning component of the nursing process? Aggressive Observation Standard Goals Rate Early Diagnosis Individualized to the Patient

Individualized to the Patient: Specific face of the Patient The planning stage involves setting goals that are individualized for the patient based on assessment data. Some examples of specificity include modifying goals for age, communication ability, mobility, mentality, or any other assessment related data.

Problem solving that is ___________ refers to a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible. Trial an error Scientific Intuitive

Intuitive

The outcome of critical thinking or clinical reasoning is known as clinical__________ , the conclusion, decision, or opinion the nurse makes Reasoning or Judgement

Judgement

Most schools of nursing and health care institutions establish a _____________data set that specifies the information that must be collected from every patient.

Minimum

A ________-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way. Patient Nurse Physician Medical

Nurse

A key nursing skill when performing both the nursing history and the physical examination is ____________, the conscious and deliberate use of the five senses to gather data. Interview Observations Physical Assessment

Observations

During the ____________ phase of the helping relationship, the tone and guidelines for the relationship are established. Orientation Working Termination

Orientation

A patient ___________ is an expected conclusion to a patient's health expectation. Plan Outcome Consult Risk

Outcome

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

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

Patient safety and transparency of information are two principles of ________ centered care that can be used by every organization.

Person / Patient

An intimate communication zone occurs during interaction between parents and children, whereas a ___________ zone occurs when people interact with close friends. Comfortable Personal Safe

Personal

Initial ___________ addresses each problem listed in the prioritized list of nursing diagnoses and identifies appropriate patient goals and related nursing care. Care planning Outcome

Planning

Which component of the nursing process involves setting goals? Production Implementation Assessment Mapping Evaluation Planning

Planning Planning for Treatment The planning step of the nursing process includes developing an individualized care plan, setting goals, and identifying expected outcomes. Setting priorities of the nursing diagnosis' is an important step in the plan of care. Outcomes of planning should be individualized to the client, realistic and measurable, and include a time frame.

A health ____________ is a condition that necessitates intervention to prevent or resolve disease or illness, or to promote coping and wellness. Condition Problem Diagnosis Promotion

Problem

Which of the following is a characteristic most likely associated with I-SBAR-R? Scene Story Setting Situation Suggestion Safety

S-The Situation stands for situation which includes information, such as the reason for contact, diagnosis, or changing conditions.

T/F Risk nursing diagnoses are statements that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

T/F Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician

A _______-oriented patient record is one in which each health care group keeps data on its own separate form. Problem Source Variance

Source

A _____________ or a norm is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. Risk Standard Plan Cue

Standard

A _____________ of nursing practice is established by authority, custom, or consent, and reflects a level of performance accepted by and expected of nursing staff. Protocol Standard Criteria

Standards

T/F A comprehensive care plan specifies any routine nursing assistance that the patient needs to meet basic human needs and describes appropriate nursing responsibilities for fulfilling the collaborative and medical care plan.

T/F A focused assessment is conducted to gather data about a specific problem that has already been identified.

T/F A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.

T/F A national study of more than 1,700 health care professionals found that the majority of physicians and nurses surveyed had seen coworkers take shortcuts that could have been dangerous to patients.

T/F Actual or potential health problems that can be prevented or resolved by independent nursing interventions are termed nursing diagnoses.

T/F An example of a cognitive outcome is: "Within one day after teaching, the patient will list three benefits of quitting smoking."

T/F Communication is influenced by the way people value themselves, one another, and the purpose of any human interaction.

T/F Concept mapping---an instructional strategy to identify, graphically display and link key concepts---is an example of a critical-thinking approach to care planning.

T/F Critical pathways or care maps, used in the case management model, specify the care plan that is linked to expected outcomes projected along a timeline.

T/F Critical thinking is defined as "a systematic way to form and shape one's thinking."

T/F Delegation is the transfer of responsibility for the performance of an activity to another person while retaining accountability for the outcome.

T/F Evaluative criteria are measurable qualities, attributes, or characteristics that specify skills, knowledge, or health status.

T/F Hypothesis formation and testing are two steps in the scientific problem-solving method used by health care professionals as they work with patients.

T/F In most facilities, the only circumstance in which orders may be issued verbally is in a medical emergency.

T/F Incivility is rude, disruptive, intimidating, and undesirable behavior directed at another person

T/F Maslow's Human Needs Model can be used to organize or cluster data.

When the relationship between the care and the cared for is used for promoting or restoring the health and well-being of people within the relationship, it becomes a_______________ relationship.

Therapeutic Relationship

The purpose of _______________ data is to keep information, an important part of assessment, free from error, bias, and misinterpretation as much as possible Validating Documenting Reporting Collecting

Validating

Which of the following is most important when planning goals for a patient in the nursing process? Minimize Contact Close Observation Open-Ended High Mortality Rate Prevalence Timed

Timed: Timer Goals must always be timed. The nurse places a realistic time on the goal so that it can be measured..

Staff who are trained to function in an assistive role to the registered nurse (RN) in the provision of patient activities, as delegated by and under the supervision of the RN, are called ___________ assistive personnel Licensed Certified Unlicensed Assistant

Unlicensed

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A. A patient who has uncontrolled hypothyroidism. B. A patient with coronary artery disease. C. A patient who has GERD. D. A patient who is HIV positive. E. A patient who is taking corticosteroids for arthritis. F. A patient with a urinary tract infection.

a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has GERD may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns.

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. A. Arrange for assessment for depression and treatment. B. Discourage napping during the day. C. Decrease fluids during the evening. D. Administer diuretics in the morning. E. Encourage patient to engage in some type of physical activity. F. Assess medication for side effects of sleep pattern disturbances.

a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep.

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. A. Daily mental activities B. Daily physical activities C. Morning and evening body temperature D. Daily measurement of fluid intake and output E. Presence of anxiety or worries affecting sleep F. Morning and evening blood pressure readings

a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary.

After instituting a new system for recording patient data, a nurse evaluates the "usability" of the system. Which actions by the nurse BEST reflect this goal? Select all that apply. A. The nurse checks that the screens are formatted to allow for ease of data entry. B. The nurse reorders the screen sequencing to maximize effective use of the system. C. The nurse ensures that the computers can be used by specified users effectively. D. The nurse checks that the system is intuitive, and supportive of nurses. E. The nurse improves end-user skills and satisfaction with the new system. F. The nurse ensures patient data is able to be shared across health care systems.

a, c, d. Usability refers to the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use. Checking that screens are formatted to allow ease of data entry, ensuring that computers can be used by specified users effectively, and checking that the system is intuitive and supportive of nurses are all tasks related to the "usability" of the system. Reordering screen sequencing to maximize use and improving end-user skills and satisfaction with the new system refers to optimization. The ability to share patient data across health care systems is termed interoperability.

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. A. Basing patient care on continuous healing relationships B. Customizing care to reflect the competencies of the staff C. Using evidence-based decision making D. Having a charge nurse as the source of control E. Using safety as a system priority F. Recognizing the need for secrecy to protect patient privacy

a, c, e. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. A. Monitoring patient status every hour B. Using intuition to troubleshoot patient problems C. Turning a patient on bed rest every 2 hours D. Becoming a nurse mentor to a student nurse E. Administering pain medication ordered by the physician F. Becoming involved in community nursing events

a, c, e. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, turning a patient on bed rest every 2 hours, and administering pain medication ordered by the physician. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not patient care standards.

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

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

A nurse is using the steps in informatics evaluation to evaluate the use of a portal as a patient resource. What are examples of activities that might occur in the "determining the question" step? Select all that apply. A. The nurse develops a clear, focused question to determine the data to be collected. B. The nurse determines what to evaluate. C. The nurse determines how the data ultimately should be reported. D. The nurse decides what specific data elements need to be collected. E. The nurse clarifies exactly how the data will be collected. F. The nurse performs comprehensive documentation of the data collected.

a, c. The nurse develops a clear, focused question to determine the data to be collected and the nurse determines how the data ultimately should be reported during the "determine the question" step. The nurse determines what to evaluate during the step "determine what will be evaluated." The nurse decides what specific data elements need to be collected during the "determine the needed data" step. The nurse clarifies exactly how the data will be collected during the "determine the data collection method and sample size" step. The nurse performs comprehensive documentation of the data collected during the "document your outcome evaluation" step.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. A. The nurse uses critical thinking skills to plan care for a patient. The nurse correctly administers IV saline to a patient who is dehydrated. B. The nurse assists a patient to fill out an informed consent form. C. The nurse learns the correct dosages for patient pain medications. D. The nurse comforts a mother whose baby was born with Down syndrome. E. The nurse uses the proper procedure to catheterize a female patient.

a, d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? A. 2, 4, 1, 3 B. 3, 1, 4, 2 C. 2, 4, 3, 1 D. 3, 2, 4, 1

a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? A. Compare this reading to standards. B. Check the taxonomy of nursing diagnoses for a pertinent label. C. Check a medical text for the signs and symptoms of high blood pressure. D. Consult with colleagues.

a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: A. Clinical judgment B. Clinical reasoning C. Critical thinking D. Blended competencies

a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: A. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice B. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice C. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice D. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? A. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. B. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. C. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! D. It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? A. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. B. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. C. Following physical therapy, patient will begin to gradually participate in walking/running events. D. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

a. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which action is recommended for these patients? A. Increase physical activities during the day. B. Encourage short periods of napping during the day. C. Increase fluids during the evening. D. Dispense diuretics during the afternoon hours.

a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening.

Population health addresses the health status and health issues of aggregate populations and addresses ways in which resources may be allocated to address these concerns. What is the driving force behind the use by health corporations of analytics and big data to support population health? A. The transition from fee-for-service models to value-based payment models B. A growing older population with more complicated health needs C. The overcrowding and understaffing of hospitals D. The shortage of health care professionals, particularly nurses

a. Information technology is a part of the core infrastructure on which population health can be assessed and addressed. As organizations transition from the traditional fee-for-service model to value-based payment models (including ACOs), data, information, and knowledge about populations rather than individual patients will be required. A growing older population with more complicated health needs, the overcrowding and understaffing of hospitals, and the shortage of health care professionals, particularly nurses, may be affected by population health assessment, but are not the driving force for the development of this technology.

To promote sleep in a patient, a nurse suggests what intervention? A. Follow the usual bedtime routine if possible. B. Drink two or three glasses of water at bedtime. C. Have a large snack at bedtime. D. Take a sedative-hypnotic every night at bedtime.

a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly.

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the people responsible for these errors and see if we can replace them." This is an example of: A. Quality by inspection B. Quality by punishment C. Quality by surveillance D. Quality by opportunity

a. Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by punishment and quality by surveillance are not quality-assurance methods used in the health care field.

A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? A. A patient problem list B. Narrative notes describing the patient's condition C. Overall trends in patient status D.Planned interventions and patient outcomes

a. The SOAP format (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, not SOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model.

When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. A. News media are preparing a report on the condition of a patient who is a public figure. B. Data are needed for the tracking and notification of disease outbreaks. C. Protected health information is needed by a coroner. D. Child abuse and neglect are suspected. E. Protected health information is needed to facilitate organ donation. F. The sister of a patient with Alzheimer's disease wants to help provide care.

b, c, d, e. According to the HIPAA, a health institution is not required to obtain written patient authorization to release PHI for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, medical records released according to a valid subpoena, PHI needed by coroners, medical examiners, and funeral directors, PHI provided to law enforcement in the case of a death from a potential crime, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease.

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

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

Nurses incorporate telecare in patient care plans. Which services are MOST representative of this technologic advance? Select all that apply. A. Diagnostic testing B. Easy access to specialists C. Health and fitness apps D. Early warning and detection technologies E. Digital medication reminder systems F. Monitoring of progress following treatment

b, c, d. Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes. It may include consumer-oriented health and fitness apps, sensors and tools that connect consumers with family members or other caregivers, exercise tracking tools, digital medication reminder systems, and early warning and detection technologies. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Examples include conducting diagnostic tests, monitoring a patient's progress after treatment or therapy, and facilitating access to specialists that are not located in the same place as the patient.

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. A. It functions independently of nursing standards, ethics, and state practice acts. B. It is based on the principles of the nursing process, problem solving, and the scientific method. C. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. D. It is not designed to compensate for problems created by human nature, such as medication errors. E. It is constantly re-evaluating, self-correcting, and striving for improvement. F. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A. A patient who is taking iron supplements for anemia. B. A patient with Parkinson's disease who is taking dopamine. C. An older adult taking diuretics for congestive heart failure. D. A patient who is taking antibiotics for an ear infection. E. A patient who is prescribed antidepressants. F. A patient who is taking low-dose aspirin prophylactically.

b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems.

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

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

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

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

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

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

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

b. "Related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? 1. Disabled Family Coping related to lack of knowledge about home care of child on ventilator 2. Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height-weight charts 3. Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" 4. Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" 5. Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression A. (1) and (3) B. (2) and (4) C. (1), (2), and (3) D. (1), (2), (3), (4), and (5)

b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement which blames home health aides for the patient's problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic.

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? A. "Was this diagnosis derived from a cluster of significant data or a single clue?" B. "This early diagnosis will help us manage the problem before it becomes more acute." C. "Have you determined if this is an actual or a possible diagnosis?" D. "This condition is a medical problem that should not have a nursing diagnosis."

b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? A. Actual B. Possible C. Risk D. Collaborative

b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? A. "I can expect my newborn to sleep an average of 16 to 24 hours a day." B. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." C. "I will place my infant on his back to sleep." D."I will not place pillows or blankets in the crib to prevent suffocation."

b. Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? A. Systematic B. Interpersonal C. Dynamic D. Universally applicable in nursing situations

b. Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? A. Circadian rhythm sleep-wake disorder B. Narcolepsy C. Enuresis D. Sleep apnea

b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

A nurse is using informatics technology to decide which patients may be at risk for readmission. What is the term for this type of analytic? A. Data visualization B, Predictive analytics C. Big data D. Data recall

b. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, this is used by organizations to attempt to identify patients who are at risk for readmission so case managers can intervene. Data visualization is the presentation of data in a pictorial or graphical format for analysis. Big data comprises the accumulation of health care-related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. Data recall is not a technical term for analytics.

A home health care nurse is using the steps of the SDLC, to design a new system for home health care documentation. The nurse analyzes the old system and develops plans for the new system. What is the next step of the nurse in this process? A. Test B. Design C. Implement D. Evaluate

b. The SDLC requires focus in the areas of Analyze and Plan, Design and Build, Test, Train, Implement, Maintain, and Evaluate. After analyzing and planning the new system, the nurse would move on to the design step in which the basic design of the new system is developed. The nurse would then test the system, train employees, and implement, maintain, and evaluate the new system in that order.

A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? A. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." B. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." C. "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" D. "Why do you think Sue isn't talking about her worries?"

b. The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mentioning the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do.

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? A. Keep the room light dimmed during the day. B. Keep the room cool. C. Keep the door of the room open. D. Offer a sleep aid medication to patients on a regular basis.

b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed.

A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? A. Erase or use correcting fluid to completely delete the error. B. Mark the entry "mistaken entry"; add correct information; date and initial. C. Use a permanent marker to block out the mistaken entry and rewrite it. D. Remove the page with the error and rewrite the data on that page correctly.

b. The nurse should not use dittos, erasures, or correcting fluids when correcting documentation; block out a mistake with a permanent marker; or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered, the nurse should mark the entry "mistaken entry," add the correct information, and date and initial the entry. If the nurse records information in the wrong chart, the nurse should write "mistaken entry—wrong chart" and sign off. The nurse should follow similar guidelines in electronic records.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? A. Offer the patient 60-mL fluid every 2 hours while awake. B. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. C. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. D, At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60-mL fluid every 2 hours while awake." Correct: "The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20." The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: A. Quality assurance B. Quality improvement C. Process evaluation D. Outcome evaluation

b. Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation are types of quality-assurance programs.

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? A. No problem B. Possible problem C. Actual nursing diagnosis D. Clinical problem other than nursing diagnosis

b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? A. The use of a central nervous system stimulant B. Continuous positive airway pressure machine (CPAP) C. Chronotherapy D. The application of heat or cold therapy to promote sleep

c. Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. b. Use the time to perform the care that is needed uninterrupted. c. Discuss the silence with the patient to ascertain its meaning. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. e. Arrange for a counselor to help the patient cope with emotional issues.

c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. A. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN B.6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN C. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN D, 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN E. 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick,RN F. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "patient's response to pain appears to be exaggerated" or "seems to be comfortable." The nurse should never document an intervention before carrying it out.

A nurse designing a new EHR system for a pediatric office follows usability concepts in system design. Which concepts are recommended in system design? Select all that apply. A. Users should not explore with forgiveness for unintended consequences. B. Shortcuts for frequent users should not be incorporated into the system. C. Content emphasis should be on information needed for decision making. D. The less times users need to apply prior experience to a new system the better. E. All the information needed should be presented to reduce cognitive load. F. The number of steps it takes to complete tasks should be minimized.

c, e, f. When designing a system, content emphasis should be on information needed for decision making. All the information needed should be presented to reduce cognitive load. The number of steps it takes to complete tasks should be minimized. The more users can apply prior experience to a new system, the lower the learning curve, the more effective their usage, and the fewer their errors. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. This approach accelerates learning while building in protections against unintended consequences. One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users.

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. A. He is aware of his surroundings at this point. B. He is in delta sleep at this time. C. It would be most difficult to awaken him at this time. D. This is most likely an NREM stage. E. This stage constitutes around 20% to 25% of total sleep. F. The muscles are relaxed in this stage.

c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep.

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

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

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

c. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

Nurses test new technology in phases. In which phase would the nurse "test drive" the new system? A. Unit B. Function C. User acceptance D. Integration

c. During the phase "user acceptance," the nurse would "test drive" the new system to ensure it's working as designed. Unit testing is basic testing that occurs initially. Function testing uses test scripts to validate that a system is working as designed for one particular function. Integration testing uses test script to validate that a system is working as designed for an entire workflow that integrates multiple components of the system.

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? A. State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." B. Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. C. State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." D. Try calling another resident for the order or wait until the next shift.

c. In most facilities, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician or nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Trying to call another resident for the order or waiting until the next shift would be inappropriate; the patient should not have to wait for the pain medication, and a resident is available who can immediately write the order.

A nurse is using information from informatics technology that is synthesized so that relationships between lung cancer diagnoses and smoking are identified. What part of "DIKW" does this represent? A. Data B. Information C. Knowledge D. Wisdom

c. Knowledge is Information that is synthesized so that relationships are identified. Data refer to discrete entities that are described without interpretation. Information is data that have been interpreted, organized, or structured. Wisdom is the appropriate use of knowledge to manage and solve human problems.

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? A. Preparing the family for a diagnosis of insomnia and related treatments. B. Preparing the family for a diagnosis of narcolepsy and related treatments. C. Anticipating the scheduling of polysomnography to confirm OSA. D. No action would be taken, as this is a normal finding for hospitalized children.

c. OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? A. Initial planning B. Standardized planning C. Ongoing planning D. Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? A. Patient-centered care B. Evidence-based practice C. Quality improvement D. Informatics

c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? A. The nurse judges whether the patient database is adequate to address the problem. B. The nurse considers whether or not to suggest a counseling session for the patient. C.The nurse reassesses the patient and decides how best to intervene in her care. D. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes) Which item below places them in their correct sequence? A. 1, 2, 3, 4, 5 B. 3, 2, 1, 4, 5 C. 5, 2, 1, 3, 4 D. 2, 3, 1, 4, 5

c. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes); (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; and (5) terminating, continuing, or modifying the plan.

A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? A. Drinking a cup of regular tea at night induces sleep. B. Using alcohol moderately promotes a deep sleep. C. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. D. Exercising right before bedtime can hinder sleep.

c. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. A. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." B. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." C. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." D. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." E. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." F. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read-back.

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. A. REM sleep constitutes much of the sleep cycle of a preschool child. B. By the age of 8 years, most children no longer take naps. C. Sleep needs usually decrease when physical growth peaks. D. Many adolescents do not get enough sleep. E. Total sleep decreases in adults with a decrease in stage IV sleep. Sleep is less sound in older adults and stage IV sleep may be absent.

d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks.

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? A. "I'm sorry, but patients are not allowed to copy their medical records." B. "I can make a copy of your record for you right now." C. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." D. "I will need to check with our records department to get you a copy."

d. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? A. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. B. By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. C. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). D. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? A. Collaborative problem B. Interdisciplinary problem C. Medical problem D. Nursing problem

d. Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studie

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1. Ineffective Coping related to inability to maintain marriage 2. Defensive Coping related to loss of job and economic security 3. Altered Thought Processes related to panic state 4. Decisional Conflict related to placement of parent in a long-term care facility A. (1) and (2) B. (3) and (4) C. (1), (2), and (3) D. (1), (2), (3), and (4)

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

A nurse is testing a new computer program designed to store patient data. In what phase of testing would the nurse determine if the system can handle high volumes of end-users or care providers using the system at the same time? A. Unit B. Function C. Integration D. Performance

d. Performance testing is more technical and ensures proper functioning of the system when there are high volumes of end-users or care providers using the system at the same time, ensuring it can handle the load. Unit testing is basic testing that occurs initially. Function testing uses test scripts to validate that a system is working as designed for one particular function. Integration testing uses test script to validate that a system is working as designed for an entire workflow that integrates multiple components of the system.

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

d. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the care plan since the student has not met her targeted outcome. The student may need more than just additional time to reach her outcome.

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? A. "Outcome not met." B. "1/21/20—Patient reports no change in diet." C. "Outcome not met. Patient reports no change in diet or activity level." D."1/21/20—Outcome not met. Patient reports no change in diet or activity level."

d. The evaluative statement must contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? A. The nurse collects data to identify health problems. B. The nurse collects data to identify patient strengths. C. The nurse collects data to justify terminating the care plan. D. The nurse collects data to measure outcome achievement.

d. The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? A. Admission sheet B. Admission nursing assessment C. Flow sheet D. Graphic record

d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the flow sheet.

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