Foundations Exam 1
Stage __ of therapeutic relationship: -pre-interaction -before you actually meet a client Ex. going over the patient's chart before meeting them
1
The mother brings her infant into the clinic. The infant is two months old and has not been gaining weight appropriately. The outcome statement on the plan of care states "The infant will double birth weight by 6 months of age." This is an example of what type of outcome statement? A. Psychomotor B. Cognitive C. Affective D. Physical changes
D.
The night shift RN is caring for a hospitalized adult client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? A. Social isolation B. Powerlessness C. Chronic pain D. Disturbed sleep pattern E. Hyperthermia
D.
Writing Outcomes: S- M- A- R- T- Ex. During the next 24-hour period, the pt's fluid intake will total at least 2000 mL. At the next visit, 12/23/15, the patient will correctly demonstrate relaxation exersices
specific, measurable, attainable, realistic, time-bound
3 actions based on patient response to plan of care: 1. _______ :when goal is met 2. _________: if the pt is having difficult achieving their outcomes 3. _______: the pt is making progress but slower & needs more time
terminate, continue, modify
Stage __ of therapeutic relationship: -orientation -when meeting a patient -introduction -start establishing trust
2
Stage __ of therapeutic relationship: -longest phase -working ohase -collecting information -keeping interview goal-directed -gather subjective & objective data
3
______ is the state of being free from illness or injury
Health
The NSNA is the professional organization for which of the following? A. Newly licensed nurses B. Student nurses C. Licensed practical nurses D. Certified nursing assistants
B. Student nurses
______ of Care: what a reasonable & prudent nurse would do in a given situation
Standards
What is TJC?
The Joint Commission
Nursing assessment focuses on _____ responses to health problems while medical assessment targets ____ pointing to pathologic conditions
patient data
______ _____ ____ ________ (STTI): -national honor society for nursing -members include those from nursing community, senior level baccalaureate & graduate programs -goal to foster nursing leadership & research
Sigma Theta Tau International
______ Distance: - 4 to 12 feet
Social
________ is the loss of ability to speak or understand speed due to brain injury
Aphasia
The nurse is visiting a hospice client in his home. He is explaining the difficulties he is having with his home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is utilizing which therapeutic nurse-client communication technique? A. Restating B. Clarification C.Reflection D.Encouraging elaboration
D.
What is the most important step of the nursing process? it includes -systematic & continous collection -validation -communication of patient data -allows us to devlop a comprehensive care plan
Assessment
What are the 5 steps of the nursing process?
Assessment, Diagnosis, Outcome, Identification, Implementation, Evaluation
What are the steps of the nursing process?
Assessment, planning, intervention, & evaluation
Principles of Bioethics: -_______ to benefit the patient
Beneficence
The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is most likely the cause of this action by the client? A. Hunger B. Low anxiety C. Pain D. Sleepiness
C.
_______ ________- The Key to Competent Practice
Careful Documentation
______ Questions/Comments include: -allows understanding of patient's comments Ex. "Is this the first health problem you have ever had?"
Clarifying
Chain of _______: -nursing faculty -course coordinator -BSN director -associate dean -dean
Command
Is this an example of a correct or incorrect patient goal/outcome? Before discharge, the pt will demonstrate proper techniques of wound care
Correct
While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take? - Cover the area with a transparent wound barrier -Massage areas surrounding the redness -Wash the area with hot water every 8 hr -Re position the client every 4 hr
Cover the area with a transparent wound barrier
_________: wrong against a person or his or hers property as well as the public
Crime
______ law: concerns state & federal criminal statues
Criminal
A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? -Fissures at eyelid corners -Spongy gums that are receding -Easily plucked hair -Deep reddish-colored tongue
Deep reddish-colored tongue
________: person being accused of a crime
Defendant
A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider? -Unilateral nipple inversion present since menarche -Visible symmetrical venous patterns -Silver-colored striae -Dimpling of the tissue of the upper outer quadrant
Dimpling of the tissue of the upper outer quadrant
______ Questions/Comments include: -introducing new topics or re-visiting a topic that was discussed earlier Ex. "You mentioned your dad earlier. Did he devlop complications related to high blood pressure?"
Directing
A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality & requires intervention by the nurse preceptor? -Discussing changes in a client's plan of care with his friend who is a nurse on another unit - Describing a client's level of independence to the case manager arranging home health services - Faxing laboratory results to a client's provider - Remaining in the room with the client while he reviews his own medical records
Discussing changes in a client's plan of care with his friend who is a nurse on another unit
____-_____ care works with dying individuals, families, & supports persons & organizations that focus on end of life needs
End-of-Life
_____ laws guiding nursing practice: -bill of rights -emergency medical treatment & active labor act -Americans with disabilities Act -HIPAA
Federal
______ ______ promotes the highest state of well being regardless of being sick or well Ex. Prenatal care
Health Promotion
_______ _______ focuses on activities that promote the return of health for those who are ill Ex. administering meds
Health Restoration
______ priority diagnoses: life or death; what is the greatest threat to my patient's health?
High
______ assessment includes: -perfomed on admission -big gather of data (medications, health history, etc.) -purpose -establishes a baseline for future focused assessments -establishes priorities for ongoing focused assessments
Initial
______ diagnosis describes problems that will direct treatment (what have they been diagnosed with?)
Medical
_____-______ Communication includes: -touch -eye contact -facial expressions -posture -gait -gestures -physical appearance -sounds/silence
Non-Verbal
The role of the ____ involing interviewing techniques include: -active participant -informing
Patient
______ law: civil law
Private
______ Law: government is directly involved
Public
________ Distance: -12 feet or more
Public
What is QSEN?
Quality & Safety in Nursing Education
What is QI?
Quality Improvement
A nurse is caring for a client who is receiving intermittent enteral tube feedings & having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? -Chill formula prior to administration -Verify feeding tube placement -Reduce the rate of feedings -Place the client supine during feedings
Reduce the rate of feedings
_______ Questions/Comments include: -repeating what was said or describing the patient's feelings Ex. "Youve been upset..."
Reflective
Types of nursing diagnosis: _____ - cluster of symptoms
Syndrome
True or False: In all healthcare agencies, informed & voluntary consent is needed for admission, for specialized diagnostic procedures or medical surgical treatment, & for any experimental treatments or procedures
True
True or False: Both objective & subjective data should be assessed
True
___________ communication includes: -spoken & written word -influences such as developmental level, education, cultures, language, age, & past experiences -vocabulary (medical term. & jargon) -meaning -pace & speed -tone
Verbal
Of the following statements, which is most true of health & illness? 1. Health & illness are the same for all people 2. Health & illness are individually defined by each person 3. People with acute illnesses are actually healthy 4. People with chronic illnesses have poor health beliefs
2.
A nurse is caring for a client who is diagnosed with an urinary tract infection & is prescribed ciprofloxacin 250 mg PO two times daily. The amount available is 100 mg/tablet. How many tablets should the nurse administer with each dose?
2.5 tablets
A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that has been prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to administer per dose?
2.5 teaspoons
Stage __ of therapeutic relationship: -termination phase -very important -summarize & validate information
4
The nurse will reach 1 of __ basic conclusions: - no problem- no response needed; reinforce health habits; reinforce health promotion (prevent disease) -possible problem- collect more data -actual or potential nursing diagnosis-begin planning, implementing, & evaluating our care; prevent, reduce, & slow our problem -clinical problem other than nursing diagnosis- consult someone to help (physical therapist, neurologist, etc.)
4
Therapeutic Relationships have __ stages
4
The nurse places a heating pad on the leg of a patient with PVD to releive muscle spasms. The pad causes a burn which becomes infected requiring a skin graft. This is an example of: 1. Negligence 2. Fraud 3. Assult 4. Malpractice
4.
A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario? A. The working phase B. The introduction phase C. The orientation phase D. The termination phase
A.
A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief? A.Personal morality B. Professional values C. Ethics D. Legal obligations
A.
A nurse case manager is explaining the role of a case manager to a group of nursing students. One student asks if the case manager misses providing client care. What is the case manager's best response? A. "I provide indirect care to my clients by coordinating their treatment with other disciplines." B. "Even though I do not provide direct care to clients, my work is very important." C. "I provide a critical service that is necessary for financial reimbursement." D. "Moving away from client care is a necessary step to advancing my career."
A.
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? A. Bowel Incontinence B. Ulcerative Colitis C. Irritable Bowel Syndrome D. Small Bowel Obstruction
A.
A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question? A. "I understand you have four kids; how many times have you actually been pregnant?" B."All right, you have four children, is that correct?" C. "How old are your children?" D. "Were these term births?"
A.
A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the atenolol to 12.5 mg. However, since the physician is late for another visit, she requests that the nurse write down the order for her. What should be the appropriate nursing action in this situation? A. The nurse should ask the physician to come back and write the order. B. The nurse should write the order and implement it. C. The nurse should inform the client of the change in medication. D.The nurse should remind the physician later to write the work order.
A.
A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)? A. administering bedside blood glucose testing B. administering blood products C. administering intravenous push medication D. administering chemotherapy
A.
A student nurse understands that the primary aim of the Healthy People 2020 initiative is: A. health promotion. B. illness prevention. C. health restoration. D. coping with disability.
A.
An oncology client in an outpatient chemotherapy clinic asks several questions regarding his care and treatment. The nurse explains the clinic's routine, typical side effects of the chemotherapy, and ways to decrease the number of side effects experienced. Which characteristic is the nurse demonstrating? A. Veracity B. Fidelity C. Justice D. Autonomy
A.
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? A. Go to the client and assess the client's pain. B. Determine the frequency of pain medication. C. Medicate the client with the ordered pain medication. D. Instruct the client in nonpharmacologic pain management.
A.
In which of the following situations would the SBAR technique of communication be most appropriate? A. A nurse is calling a physician to report a client's new onset of chest pain. B. A nurse is facilitating a family meeting in order to coordinate a client's discharge planning. C. A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure. D. A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke.
A.
The nurse is assessing a 3-week-old infant. Which of the following assessment findings would define the priority nursing diagnosis for this patient? The infant has not gained weight since birth. Bowel sounds are present in all quadrants. Breath sounds are clear to auscultation. Mom reports child cries much of the night but sleeps better in the daytime. Mom reports child only breastfeeds about four times in a 24-hour period and she doesn't seem to have much milk. A. Ineffective Breastfeeding B. Disturbed Sleep Pattern C. Impaired Comfort D. Risk for Impaired Parenting E. Readiness for Enhanced Parenting
A.
The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? A. Medicate the client and wait to ambulate later. B. Ambulate the client and medicate later. C.Emphasize to the client the importance of following the treatment plan. D. Explain to the client the benefits of ambulation.
A.
Which ethical principle is related to the idea of self-determination? A. Autonomy B. Beneficence C. Confidentiality D. Nonmaleficence
A.
Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? A. Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners B. Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose C. Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment D. Changing a client's advance directive after his prognosis has significantly worsened
A.
Which scenario is an example of certification? A.A nurse who demonstrates advanced expertise in a content area of nursing through special testing B. A graduate of a nursing education program who passes NCLEX-RN C. An education program that meets standards of the National League for Nursing D.A hospital that meets the standards of the Joint Commission
A.
Which theory of ethics prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? A.Care-based ethics B. Deontology C. Utilitarianism D. Principle-based ethics
A.
_____ code of ethics: -succinct statement of the ethical obligations & duties of every individual who enters the nursing profession -the professions nonnegotiable ethical standard -an expression of nursing own understanding of its commitment to society
ANA
Types of nursing diagnosis: _________ - current health problem that is validated; what is actually wrong with my patient? (ex. Parkinsons)
Actual
________ _____ of nursing: -define the legal scope of nursing practice -establish criteria for RN & LPN to become nurse -determine the scope of practice for nurses -make & enforce rules & regulations -excludes untrained or unlicensed people from practicing nursing -licensing for nurses -disciplinary actions
Alabama board
The _______ ________ of ______ in _______ (AACN): -national voice for baccalaureate & higher degree nursing education programs -focuses on establishing quality educational standards, influencing the nursing profession & to improve healthcare -promotes public support of baccalaureate & graduate education, research, & nursing practice -national accreditation for collegiate nursing programs through the AACN by the commision of collegiate nursing education (CCNE)
American Association of Colleges in Nursing
National nursing organization: The _______ ______ ________ (ANA): -founded in late 1800's -professional organization for RN's -public education -clinical nurse standards -lobbying state & federal lawmakers
American nurses association
Principles of Bioethics: -________ respect the rights of patients to make healthcare decisions
Autonomy
A nurse is caring a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? -Toward the body -To the right -Away from the body -To the left
Away from the body
A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data? A.Test reports B. Client himself C. Client's wife D. Client's friends
B.
A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. The charge nurse appropriately identifies that nurse has committed: A. defamation. B. battery. C. assault. D. fraud.
B.
A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method? A.size of the liver B. presence of peristalsis C. pupil reaction D. skin temperature
B.
After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data? A. Subjective B. Objective C. Physical D. Unreliable
B.
The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome? A. The nurse has not made any error in writing the outcome. B. The nurse has omitted the time frame. C. The nurse omitted the defining characteristics. D. The outcome should indicate what the nurse will do.
B.
The nurse is discussing entry level for professional nursing practices. Which is the most accurate statement by the nurse? A. "ADN programs are the recommended entry level by national nursing organizations." B. "BSN is the recommended entry level by national nursing organization." C. "National nursing organizations are promoting diploma nursing." D. "National nursing organizations are eliminating accelerated programs."
B.
The nursing instructor is discussing communication with a student. The student identifies that a contract is made with the client during which phase of the nurse-client relationship? A.Intimate phase B. Orientation phase C. Working phase D. Termination phase
B.
When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problem seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? A. Physiologic B. Safety and Security C. Love and Belonging D. Self-Esteem E. Self-Actualization
B.
While studying methods of data collection, a nursing student learns that there are many different skills involved. Which action is a key nursing skill that uses all five senses? A. Documentation B. Observation C. Listening D. Caring
B.
A client age 46 years has been diagnosed with cancer. He has met with the oncologist and is now weighing his options to undergo chemotherapy or radiation as his treatment. This client is utilizing which ethical principle in making his decision? A.Beneficence B. Confidentiality C. Autonomy D. Justice
C.
A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? A.Verbally report the finding to the charge nurse at the change of shift. B. Inform the unlicensed assistant personnel to document the finding. C. Verbally report the finding immediately to the client's physician. D. Reassess the client's temperature in 2 hours and chart this data.
C.
A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: A. agrees with each of the client's statements. B. attempts to write down everything the client says. C. uses broad, open statements to communicate with the client. D. reassures the client of good outcomes.
C.
An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective? A. Client has a temperature of 102°F. B. Client has leukoplakia on her oral mucosa. C. Client has generalized myalgia or muscle pain. D. Client is alert and oriented to person and place but not time or situation. E. Client has ptosis, a drooping of the eyelid, on his right side.
C.
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? A. Continue the education and remind the client that it is essential to learn self-care. B. Medicate the client for anxiety and continue the education later. C. Discontinue the education and attempt at another time. D. Discontinue the education and ask the client for permission to teach a family member
C.
The nurse is conducting an interview with a newly admitted client. Which listening behavior guideline should the nurse implement in order to have a successful interview? A. Focus mainly on verbal comments. B. Fill in the words for the client. C. Avoid the impulse to interrupt. D. Fill in quiet spaces and pauses.
C.
The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously? A.It gives the nurse more information to document on the client. B. It makes the client feel as if the nurse is spending more time with him or her. C. The client's health status can change quickly. D. Most facilities require it for reimbursement.
C.
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? A. Maintenance B. Surveillance C. Psychomotor D. Psychosocial
C.
Which cultural group may interpret touch by another as an invasion of privacy? A. Hispanic B. African C. Chinese D. European
C.
Which of the following elements of liability best describes the following situation: A nurse fails to raise the bedside rails for an elderly confused patient who then falls & fractures his wrist trying to got to the bathroom alone. A. Duty B. Breach of Duty C. Causation D. Damages
C.
Which of the following is a characteristic of the care-based approach to bioethics? A.the need to emphasize the relevance of clinical experience B. The rightness or wrongness of an action is independent of its consequences. C. the promotion of the dignity and respect of clients as people D. the need for an orientation toward service
C.
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? -Isopropyl alcohol -Iodophor -Chlorhexidine gluconate -Chlorine (bleach)
Chlorine (bleach)
________ _______ is the conclusion or enlightened opnion at which a nurse arrives following a process of observation, reflexion, & analysis of observable or available information or data
Clinical Judgment
______ _______ is the process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan & implement interventions, evaluate outcomes, & reflect on & learn from the process
Clinical Reasoning
_______ _______ observes, compares, contrasts, & evaluates clients condition
Clinical judgement
________ Questions/Comments include: -provides limited choices & possible responses Ex. 'What medications have you been taking at home?"
Close
The primary purpose of _______________ is to share information & obtain a response
Communication
Most important reason nurses need to be ______ thinkers is that nurses are caring for patients with multiple health problems
Critical
A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information? A. Consult with the client. B. Consult with the client's doctor. C. Read the client's chart. D. Consult nursing and medical literature.
D.
A hospital nurse works collaboratively with a physician, social worker, physical therapist, and home health care nurse to provide nursing care for a patient following a motor vehicle accident. What should be the central focus of this care? A. the nurse B. the physician C. the nursing care plan D. the patient E. the physical therapist
D.
A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's daughter to direct his care, is a(an): A. will. B. standard of care. C. license. D. advance directive.
D.
A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed: A. protocols. B. nursing interventions. C. collaborative orders. D. standing orders.
D.
A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client? A.The student nurse B. The nurse instructor C. The hospital D. The student nurse, the nurse instructor, and the hospital
D.
In the United States, the practice of nursing is regulated by which of the following: A. ANA Code for Nurses with Interpretive Statements B. ANA Nursing's Social Policy Statement C. ANA Standards for Nursing Practice D. State nurse practice acts
D.
The nurse observing an interaction between a mother and her daughter appropriately identifies the interaction as which communication zone? A. Public B. Social C. Personal D.Intimate
D.
The primary purpose for evaluating data about a client's care according to a functional health approach is to: A. meet accreditation standards. B. determine implementation of medical orders. C. evaluate the need for health care consultations. D.revise or modify the patient care plan.
D.
The term metacommunication is best defined as: A.congruent relationships in the spoken topics. B. documenting a conversation between the client and nurse. C. contextual factors that impede communication patterns. D. interpersonal bridge between verbal and nonverbal communication.
D.
What must the nurse do to identify actual or potential health problems? A. call the physician B. meet with significant others C. evaluate care implemented D. gather data from sources
D.
_____ ______ for evoking a License: -notice of investigation -fair & impartial hearing -proper decision based on substantial evidence
Due Cause
Tips for interviewing the _____ patient: -allow additional time -may need to schedule more than 1 interview session -interview family or caregiver
Elderly
________ assessment includes: -identifying a life threatening problem -used when there is a change in patient condition
Emergency
Four Functions of the _______ Committees: 1. Education 2. Policy Making 3. Case Review 4. Consultation
Ethics
What is EBP?
Evidence Based Practice
How is healthcare regulated?
Federal government
_________: punishable by imprisonment for more than 1 year
Felony
Principles of Bioethics: -_______ to keep promises
Fidelity
_____ assesment includes: -gathers data on a specific problem that has already been identified -part of the onging assesment -can flag existing problems & risks -short, focused, prioritized assessments -uses the 7 variables
Focused
_____ violations: -copying records (or taking pictures of patients or records) -discussing patients with others -discussing clinical experience on social media sites (Facebook/twitter)
HIPPA
Professional communication helps us build a trusting relationship with _______ as the base
Honesty
A nurse is caring for a client who is diagnosed with rheumatoid arthritis & is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? -Hyperkalemia -Hyponatremia -Hypomagnesemia -Hyperglycemia
Hyperglycemia
______/_____ _____ focuses on avoiding disease Ex. handwashing
Illness/Health Promotion
A nurse is providing education about a new prescription for nitroglycerin to a client who is diagnosed with angina. Which of the following statements by the client indicated a need for further teaching? -Ill make sure that the medication container is kept tightly sealed -I'll go to the emergency room if my chest pain doesnt go away -Im lucky I have a prescription plan that allows me to buy pills in bulk quantities -Ill keep my pills in the medicine cabinet when Im home
Im lucky I hvae a prescription plan that allows me to buy pills in bulk quantities
Is this an example of a correct or incorrect patient goal/outcome? The pt knows how to change their surgical dressing
Incorrect
Basic stages of a comprehensive plan of care: - ________ planning (nurse with admission history & physical; takes the longest; address each problem the pt has) -_______ planning (update plan of care as needed; carried out by any nurse that interacts with the pt; keep it up to date as pt problems resolve or arise -_________ planning (begins on admissions; typically done in conjugation with a social worker or case manager
Initial, ongoing, discharge
Examples of an _______ tort: -assault & battery -defamation of character -invasion of privacy -false imprisonment -fraud
Intentional
________ ________ of nursing (ICN): -first international organization of professional women -founded in 1899 -shares a commitment to maintain high standards of nursing service & nursing education & promotes ethics
International council
Nursing ________ is any treatments based upon clinical judgement & knowledge that a nurse performs to enhance patient/client outcomes -after writing pt, the nurse then identifies this -they do not require physicians order -they are derived from etiology of nursing diagnosis -actions that the nurse will complete to help the patient achieve their goals
Intervention
_______ Distance: -involves touch -up to 1.5 feet
Intimate
Principles of Bioethics: -_______ give each his or her due & act fairly
Justice
What is KSA's?
Knowledge & Skills Attitude
Definition of ____: -standard or rule of conduct established & enforced by government -designed to protect the rights of the public
Law
Four elements of _________: 1. Duty (responsibility to provide safe, competent care) 2.Breach of Duty (the failure to execute & document use of safety measures) 3. Causation (the failure to use appropriate safety measures that results in injury to a person) 4. Damages (include fractured wrist, pain, & suffering, etc.)
Liability
______ _______ ______ (LPN): -1 year program with classroom & clinical teaching -must pass NCLEX-PN -work under the registered nurse (RN) or physician
Licensed practical nurse
______ responses include: -making observations -restating -clarifying -comparisns -summarizing -facilitation (active listening)
Listening
_________: process of bringing & trying a lawsuit
Litigation
A nurse is assisting with the preperation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills? -Living wills detail treatment wished of the client in the event of terminal illness -Living wills require a written prescription from the provider to be legal -Living wills ensure hospitals provide emergency care regardless of coverage -Living wills allow the client to designate a health care proxy
Living wills detail treatment wishes of the client in the event of terminal illness
______- term goals -require longer periods of time -more broad -may be used as discharge goals Ex. by 12 weeks PO pt will have full range of right shoulder
Long
_______ priority diagnoses: may not be specifically related to current health status; underlying issues
Low
________ _______ __ ______: helps prioritize patient's needs' basic priorities first -self- actualization needs -self-esteem needs -love & belonging needs -Safety needs -physiologic needs
Maslows hierarchy of needs
How is healthcare financed?
Medicare/Medicaid (state-operated)
_____ priority diagnoses: not life threatening
Medium
Evaluative Statements: how well were the outcomes met? -along with pt data & or behaviors that support this decision -out comes may have been 1. ______ 2.______ 3.______
Met, partially met, not met
_________: punishable by fines or less than 1 year imprisonment
Misdemeanor
Principles of Bioethics: -_________ avoid causing harm
Nonmaleficence
Roles & functions of the _______: -promote health (weight/exercise -prevent illness (vaccinations) -restore health (medications/treatments) -facilitate coping with disability or death -practice in a wide variety of settings -conduct & publish research -recognize role in promoting health
Nurse
The role of the _____ involving interviewing techniques include: -accepting -respectful -non-judgemental -proffesional -facilitator of the interview
Nurse
Methods of data collection include _____ _____ & _____ ______
Nurse History Physical Assessment
Define _______: -originated from Latin words "nutrix" (to nourish) -patient is central focus of all definitions -includes physical, emotions, social, & spiritual dimensions of the pt -the protection, promotion, & optimization of health & abilities, prevention of illness & injury, alleviation of suffering through the diagnoses & treatment of human response & advocacy in the car of individuals, families, communities, & populations (ANA)
Nursing
_____ diagnosis describes the patient's problems or issues; the focus is unhealthy responses to health & illness; it changes according to patient's response Ex. pain/activity
Nursing
_______ ________ is a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes; nursing diagnosis provides the basis for selection of nursing interventions to acheive outcomes for which the nurse is accountable (NANDA)
Nursing Diagnosis
Benefits of the_____ ______/ plan of care: -scientifically based -individualized care for the patient as a whole -collaboriation with other nurses -cost effective plan -proffesional growth -mandated by joint-commision
Nursing Process
Characterisitcs of the ______ _____: -dynamic -systemic part of an ordered sequence -interpersonal patient-centered -outcome oriented nurse will work w pt to identify specific outcomes -universally applicable -framework used in any nursing
Nursing Process
How do nurses accomplish health promotion?
Nursing Process
How to work through ethical problems? -Use the _______ _______
Nursing Process
What is the _______ _______? -systematic method that directs the nurse & patient, as together they accomplish the following: assess nursing diagnosis identify & plan implement evaluate
Nursing process
______ data is observable & measurable data that can be seen, heard, felt, or measured by another person Ex. vomiting, elevated blood pressure, amount of meal eaten
Objective
A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measuer tissue perfusion? - Obtaining the client's level of oxygen saturation -Measuring the client's chest diameter -Checking the client's depth of respirations -Determining the client's respiratory rate
Obtaining the client's level of oxygen saturation
_____-_____ questions/comments include: -a wide-range of possible responses -try to start your interview with these Ex. "What medications did your Dr tell you about your need for this hospitilization?" "What brought you in today?"
Open-Ended
When developing & writing ______ each is made of 5 components: 1. subject (pt or part of pt) 2. verb (action the pt will perform Ex. wound care) 3. conditions (how is the outcome going to be achieved?) 4. performance criteria (make sure you describe it; observable measurable terms; specific) 5. target time (when is the pt expected to achieve this goal?)
Outcomes
A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is cause by a reduced amount of oxyhemoglobin? -Erythema -Pallor -Jaundice -Cyanosis
Pallor
________ Distance: -1.5 to 4 feet -may involve some touching -appropriate for interview & when communication concern & care
Personal
________ Space: -person claims ownership -in the hospital: clients room & bathroom -always knock before entering
Personal
_______: person bringing the lawsuit
Plaintiff
Ask these questions when reviewing _____ __ _____: -is each nursing intervention supported by evidence based practice? -is each nursing intervention consistent with professional standards of care & the protocol & policies of the healthcare agency? -are the nursing actions safe for this particular pt? -are the orders clear?
Plan of care
Types of nursing diagnosis: ____- suspected problem
Possible
A nurse is assisting with preperation of a teaching program about healthy nutrition for a group of clients who are tactile learner. Which of the following activities should be included as a learning strategy in the program? -Read pamphlets about preparing a healthy meal -Prepare a healthy meal to serve at the end of class -Watch a video discussing healthy meal preperation -Discuss healthy meal preperation as a class
Prepare a healthy meal to serve at the end of class
Each nursing diagnosis statement is a 2-part statement: 1. ______- what is unhealthy about the patient? 2. ______-identify the factors beleived to be the cause Ex. ineffective airway clearance related to pneumonia
Problem Etiology
______ ______ serve as a foundation for nursing practice. Practicing nursing with an appreciation of respectfulness, caring, & human dignity leads to a sense of honor & fulfillment. (CNHS Handbook)
Professional Values
Types of nursing diagnosis: ______ - a patient is more vulnerable to develop the problem than others; what might they be at risk for? (Ex. falling due to weakness/shakiness)
Risk
_________ preventative care: -goal is to detect & treat illnesses in early stages with screenings (blood pressure/HIV/glaucoma/cholesterol/pap smears/mammograms)
Secondary
______ Questions/Comments include: -place events in chronoligcal order or establish a cause/effect relationship Ex. "Your tiredness began after you started taking your medication?"
Sequencing
_____- term goals -accomplished in a specific period of time -more specific -hours to day Ex. pt voids within 8 hrs of discontinued catheter
Short
______ data can be percieved by the effected person; can not be perceived or verfifed by another person Ex. pain, anxiety, & dizziness
Subjective
A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In what position should the client be placed for insertion of the catheter? -Orthopneic -Supine -Side-lying -Dorsal recumbent
Supine
A nurse is caring for a client who is scheduled for cardiac surgery & tells the nurse, "I dont think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate? -Why have you changed your mind about the surgery? -Tell me more about your concerns -Client having this surgery are always scared -You shouldnt worry, everything will be fine
Tell me more about your concerns
What is communication? -Making observations -Placing events in chronoligical order -Validates what was read or heard -The process of exchanging informations & transmitting meaning between 2 or more individuals
The process of exchanging informations & transmitting meaning between 2 more individuals
A ________ relationship focuses on improving the health of the patient
Therapeutic
Barriers to ______ communication include: -failure to see patient as a human-being -failure to listen -sterotyping -biases & preconceptions -inappropriate questions/comments -gossip/rumors
Therapeutic
Some characteristics of ___________ communication includes: -empathy -genuine -warmth/friendliness -respect -trust -honesty
Therapeutic
______-______ Assessment includes: -scheduled to compare patients current condition to baseline -can be comprehensive or focused -commonly seen in nursing home situations
Time-Lapsed
Which of the following is the correct term for the following nursing action: a nurse falsely imprisons a patient by an unauthorized use of restraints A. Crime B. Tort C. Misdemeanor D. Felony
Tort
_______: a wrong committed by a person against another person or his or her property; tried in civil court (intentional or unintentional)
Tort
True or False: Telling an agitated patient that an oral sedative is a medication for his headache would be considered fraud.
True
True or False: The state nurse practice act is the most important law affecting nursing practice.
True
True or False: just like assessment, there are nursing diagnosis & medical diagnosis & they differ greatly
True
A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? -Standing with feet in a wide stance -Using arms & legs to lift -Twisting at the waist & shoulders -Positioning self close to the client
Twisting at the waist & shoulders
Examples of an _______ tort: -negligence -malpractice
Unintentional
A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indiciates the client is experiencing an adverse effect of the medication? -Urinary retention -Diarrhea -Rapid respirations -Dilated pupils
Urinary retention
_______ Questions/Comments include: -validates what was read or heard Ex. "At home you have been taking both a water pill & blood pressure pill every day. Did you take them today?'
Validating
________ helpful in writing measurable outcomes: -define -prepare -identify -design -list -verbalize -choose -explain
Verbs
Types of nursing diagnosis: _____- clinical judgement about a person thats transitioned from one level of wellness to a higher level of wellness
Wellness
The 4 types of nursing ______ are: -initial -focused -emergency -time-lapsed
assessments
Moral (ethics) Values: -_________ encompasses a number of fields; "life sciences" -_________ ethics are concerned with ethical problems "at the bedside" -__________ ethics are a formal study of ethical issues that arise in the practice of nursing; analysis used by nurses to make ethical judgement
bioethics clinical nursing
_______ ______: collection of information, analyzing information, & available options/actions
critical thinking
The 7 variables of the ______ assessment include: -location "where does it hurt?: -chronology:onset of symptoms "when did your symptoms stop or start?" -setting "where were you when the symptoms occured?" -quality: "what is it like?" -quantity "describe the intensisty" -aggravating/alleviating "what makes it worse? what makes it better?" -associated "what other symptoms have you had with this illness?"
focused
The ______ ______ for nursing (NLN): -open to all people interested in nursing (nurses, non-nurses & agencies) -founded in 1952 -foster the development & improvement of all nursing services & nursing education -conducts the largest professional testing services & nursing education -conducts the largest professional testing services in the US -exams measures student progress
national league
The _______ ________ ________ _______ (NSNA): -established 1952 with assistance of the ANA & NLN -national organization for students enrolled in a nursing program -voluntary participation -practice self-governance -advocate for student & patients rights -take collective, responsible action on social & political issues -publishes "Image" a journal dedicated to nursing student issues
national student nurse association
_______ is generally distinguished from other occupations by: -requirement of prolonged, specialized training -orientation toward service -ongoing research -code of ethics -autonomy - a professional organization
nursing
A nurse is volunteering to give influenza injections at a local clinic. What level of care is the nurse demonstrating?
primary
_________ preventative care: -goal is to prevent/slow onset of disease (immunizations/seat belts/exercise)
primary
A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching? -mcg -PO -q.d. -mL
q.d.
_______ _______ (RN): -diploma (3 yr hospital based program; associates degree (ADN); 2 yr community college) -bachelor degree (BSN) 4 yr university undergraduate program -masters degree (MSN) BSN required; 2 yr graduate program; advanced practice nurses -doctorate: MSN required; PhD- research focused; DNP (advanced clinical practice)
registered nurse
________ preventative care: -goal is to stop disease progression; return to pre-illness state (medications/surgical treatment/physical therapy/rehabilitation)
tertiary
Current _______ in nursing: -nursing shortage -decreased length of hospital stay (average 3 days) -aging population -increase in chronic care conditions -culturally competent care
trends
