NSG 1050 Exam 2 CU

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies:

"Spiritual, mind, and body connections can affect health."

Label each step of the nursing process in its proper order. Step 1-5

1) Assessment 2) Diagnosis 3) Planning 4) Interventions 5) Evaluation

nursing process

A framework that guides nurses in delivering client-focused care that takes the entire person into consideration.A five-step sequential process that guides nurses in assessing and prioritizing care for clients. The five steps are assessment, analysis, planning, implementation, and evaluation.

interprofessional health care team

A group including members from different disciplines who work collaboratively with the client to make decisions and set goals.

Watson's Theory of Human Caring

A model in client care that has a holistic mind-body-spirit healing perspective characterized by caring moments in which the nurse and the client have a human-to-human connection; transpersonal caring and Caritas Processes.

palliative care

A multidisciplinary care approach that is focused on the management of symptoms for chronic or life-threatening illnesses while maintaining the highest level of quality of life possible for the client.

plan of care

A plan including the client problem (analysis), plans and goals, implementation, and responses; it is used by the interprofessional health care team.

Based on the assessment data provided in the care plan on pgs. 792-793, what is the appropriate nursing diagnosis for Mrs. Smith?

Activity Intolerance

doing for

An action, a performance of tasks or activities, or an attitude (Swanson's Theory of Human Caring).

spiritual distress

An uncomfortable feeling related to a questioning of life's meaning, the client's belief system, and anger toward a higher power or the universe. It produces distressing manifestations such as despair, anger, uncertainty, and fear.

An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is:

Asking permission before performing a procedure on a patient.

delegation

Assigning a nursing task or procedure to another person who has the training appropriate for that task or procedure.

Factors that influence RN Decision Making in the acute care setting

Awareness of client status Goals/outcomes Options to meet goals Routines Education Nursing roles Teamwork Resources Support from other staff Patient education

A nurse demonstrated caring by helping family members to: (Select all that apply.)

Become active participants in care. Have unterrupted time for family and patient to be together. Have opportunities for the family to discuss their concerns.

enabling

Being a guide through situations and events (Swanson's theory of human caring)

knowing

Being aware of assessment data, influences on the situation, and even resources, and then translating this knowledge into how the situation fits into the bigger picture (Swanson's Theory of Caring).

being with

Being physically and emotionally present with another person, which provides comfort (Swanson's Theory of Human Caring).

A nurse manager is planning an in-serve about culturally competent care. Which of the following cultural competencies should the manager describe as enabling a nurse to interact with clients from other cultures?

Cultural encounters

objective data

Data that can be observed by the nurse through the senses.

subjective data

Data that is based upon the client's feelings, perception and assumptions.

Providing for another as he or she would do for themselves

Doing for

medically futile

Doing treatments that are not helpful because they will not provide a cure or extend life.

Of the five caring processes described by Swanson, which describes "knowing the patient?"

Establishing an understanding of a specific patient

A nurse is planning an in-service for a group of staff nurses about spiritual care. Which of the following situations should the nurse identify as appropriate for a consultation with pastoral staff?

Ethical dilemma, terminal illness, death of a client, hardship

touch

Expressive touching, including touching the client's hand, forearm or shoulder, relays caring behaviors and compassion on the part of the nurse. The nurse must take into consideration the client's cultural and religious practices when using this caring behavior, as some cultures and religions reserve expressive touching for actions between family members only. the should also obtain the client's permission prior to engaging in expressive touch, as this can be considered battery.

If a woman had a cesarean section (c-section) 15 years ago resulting in the birth of a healthy baby boy, this should be recorded under family history.

False

outcomes

Includes measurable results that may be positive or negative.

process

Measures the mechanisms of the care provided.

Based on your assessment of Mrs. Smith, and the nursing diagnosis of risk for falls, an appropriate goal would be:

Mrs. Smith will always use a walker when out of bed

providing comfort

Providing comfort to clients can take many forms and can help alleviate distress, anxiety, pain, and loneliness in clients. Simple acts, such as placing clean, wrinkle-free sheets on a client's bed, assisting the client to take a drink of water, holding a client's hand during a procedure that can be frightening, and providing a backrub are some examples that are comforting behaviors nurses can easily implement.

quality assurance (QA)

Reactive, problem-driven measures to improve client outcomes and improve healthcare delivery.

advocacy

Speaking up for clients' needs when the clients are unable to speak for themselves, and supporting clients to make choices for their own health. Defending the rights, interests, and safety of someone who is vulnerable.The act of defending the interests, rights, and safety of those who can't do it for themselves.

Caritas Processes (the ten processess)

Sustaining humanistic-altruistic values through the practice of loving-kindness, compassion, and equanimity with self and other. Being authentically present; enabling the faith/hope/belief system; and honoring the subjective inner, lifeworld of self and other. Being sensitive to self and others by cultivating own spiritual practices; moving beyond ego to transpersonal presence. Developing and sustaining loving, trusting-caring relationships. Allowing for expression of positive and negative feelings; authentically listening to another person's story. Creatively problem-solving/"solution-seeking" through the caring process; full use of self and artistry of caring-healing practices via use of all ways of knowing. Engaging in transpersonal teaching and learning within the context of caring relationships; staying within the other's frame of reference. Creating a healing environment at all levels, whereby an authentic caring presence potentiates wholeness, beauty, comfort, dignity, and peace. Reverently assisting with basic needs as sacred acts, touching the mind/body/spirit of the other, and sustaining human dignity. Opening to spiritual, mystery, and unknowns; allowing for miracles.

caring

The act of nurturing another person to whom one feels commitment or responsibility.

analysis

The analysis of assessment data to identify health problems/risks and a client s needs for health intervention. The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care.

culturally competent nursing practice

The application of evidence-based nursing that is congruent to the preferred cultural values, beliefs, worldviews, and practices of the client.

implementation

The application of nursing knowledge to implement interventions to assist a client to promote, maintain, or restore their health. The nurse uses problem-solving skills, clinical judgment, and critical thinking when using interpersonal and technical skills to provide client care. During this step the nurse will also delegate and supervise care and document the care and the client s response.

assessment

The application of nursing knowledge to the collection, organization, validation and documentation of data about a client's health status. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information.

critical thinking

Thought process that is systematic and logical in reviewing information and data, that is open to reflection, inquiry and exploration in order to make informed decisions.

A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective:

Touch forms a connection between nurse and patient.

potentially inappropriate treatment

Treatment that is not appropriate for a client, meaning that it might not be futile, but it also might not be appropriate.

Answer some questions from the Klimek lecture video. An inference is defined as a conclusion reached on the basis of evidence and reasoning.

True

The goals that were identified for Mrs. Smith (according to the care plan in the book) as it related to her activity intolerance included: Achieve a planned moderate-activity exercise program weekly Achieve a 30 lb weight loss in 6 months Activity tolerance will improve above baseline within 2 months

True

True or False? In order for a care plan patient goal to be appropriate, it must be patient-centered, measurable, and have a timeframe.

True

A risk management nurse is providing education to a group of newly hired nurses. Which of the following should the nurse include as QI methods that focus on identifying and correcting problems in an effort to improve care? (Select all that apply.)

Utilizing data-driven decision making, Minimizing the chance of human error, Standardizing processes

listening

an active process that requires the nurse to not only ask questions and provide information, but also to be attentive to the verval and nonverbal messages of the client. It includes allowing for appropriate pauses, as well as being comfortable with silence. With active listening, the nurse focuses on what the client says and how they say it instead of thinking about the next question or comment they wish to make.

A nurse enters a client's room and finds the client crying. The nurse sits beside the bed in silence. Which of Swanson's five categories of caring behaviors is the nurse demonstrating?

being with

A nurse is caring for a client who is emotionally distraught. Which of the following uses of touch should the nurse implement to convey caring?

briefly holding the client's hand

Swanson's Theory of Caring addresses

caring in the profession of nursing and its impact on improving client well-being by assisting nurses to promote the client's empowerment, respect, and dignity.

You are conducting a health history with a patient you are admitting to your medical unit. You ask the question "For what reason did you seek health care services today?" Which part of the health history does this question assess?

chief complaint

mother died of myocardial infarction age 55

family history

received pneumonia vaccine 4 years ago

health maintenance

Maintaining belief

Can be recognition of faith, in others, in God, or in a higher power (Swanson's Theory of Human Caring)

scope of practice

For differences in the scope of practice between RNs and PNs, Engage Fundamentals includes callout boxes focused on PN practice considerations. In addition, PN scope of practice varies by state. For example, some states may allow the PN to contribute directly to a plan of care, while other states limit PN participation in assisting the RN to develop the plan of care. Similarly, most states require the PN to be under the supervision of an RN. As such, PN students should reframe certain discussions in this product to align with their state's scope of practice. Ultimately, the PN is responsible for functioning within their scope by knowing and abiding by state guidelines for safe practice.

Dr. Manchanda told a "parable" (at about the 6-minute mark). By telling this parable, he was showing us why we need to think more "upstream." Identify what each of the 3 friends represented.

Friend 1 Rescue Friend 2 Disease management Friend 3 Prevention

When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: hint: look at table 7-1 for help

Instilling hope and faith

A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch?

Task-oriented touch

A nurse is caring for a client who is postoperative and requests spiritual support. Which of the following statements should the nurse make?

Tell me what I can do to help fulfill your need for support.

Caritas Processes

Ten caring processes that provide a common language to guide nurses in identifying and maximizing the caring moments and occasions in their own practice.

structure

The condition or environment in which the care is provided.

evaluation

The evaluation of a client s response to nursing interventions and to reach a nursing judgment regarding the extent to which the client has met the goals and outcomes. During this step the nurse will also assess client/staff understanding of instruction, the effectiveness of interventions, and identify the need for further intervention or the need to alter the plan.

quality of life

The fulfillment of a client's purpose and meaning of life.

A nurse is caring for an older adult who needs to enter an assisted living facility following discharge from the hospital. Which of the following is an example of listening that displays caring?

The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.

What are some techniques that prove ineffective during an interview? (choose all that apply)

giving your opinion asking closed-ended questions false reassurance asking "why" show approval or disapproval rushing the interview inappropriate self-disclosure

planning

step of the nursing process involves the nurse s ability to make decisions and problem solve. The nurse uses a client s assessment data to develop measurable client goals/outcomes and identify nursing interventions. The nurse uses evidenced based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client to achieve their goals.

Examples of QI processes

studying the prevention of catheter-related infections, reducing nursing fatigue or stress, and decreasing medication errors.

total abdominal hysterectomy in 1995

surgical history

Answer the following questions based on what you learned from watching Dr. Manchanda's TED talk. Which do you think is more important: a comprehensive health history or an in-depth physical exam?

they are equally important

Being emotionally there for another person

Being with

Striving to understand an event as meaning for another person

Knowing

Sustaining faith in one's capacity to get through a situation

Maintaining beleif

Finally, look at the nursing care plan found on pages 792-793 (in the blue boxes). Read through the steps of the nursing process as they relate to Mrs. Smith. Question: What are the symptoms Mrs. Smith is experiencing? (choose all that apply)

easily fatigued (subjective) weight gain (objective) lack of energy (subjective) increased heart rate and respiratory rate with activity (objective)

compassionate care

involves taking action to alleviate pain and suffering in others. It requires the nurse to focus on the humanizing factors in the art of nursing and recognize the human aspect of the client rather than the disease or illness they may have.

quality improvement (QI)

is defined as planning changes in processes or systems that will improve client outcomes, efficacy, and clinical performance of related health care practices.

therapeutic relationships with clients and their caregivers

learning to read cues from both regarding their preferred cultural, religious, and spiritual elements of care.

diagnosed with non-insulin dependent diabetes 2 years ago

medical history

OK, now that you have started to think about the nursing process, let's talk about how to combine safety and the nursing process. The risk for falls is ubiquitous in long-term care settings. Read through this scenario, and then we will ask you some questions stemming from the scenario. You are a student nurse caring for Mrs. Smith, an 87-year-old living in an extended care facility. Today, you are assigned to provide care for Mrs. Smith. You walk into her room and find that she is awake. You greet Mrs. Smith and pull up the chair next to the bed in order to speak at eye level and demonstrate genuine care and concern for her. You spend time talking with her about her life, her husband who passed away 10 years ago, her adult children and many grandchildren and great-grandchildren. You are starting to wrap up your interaction when Mrs. Smith asks you if you will help her to the bathroom. "Of course" you say, "Are you able to walk to the bathroom on your own?" "Yes, I can walk to the bathroom if you just stand next to me while I am walking" responds Mrs. Smith. Mrs. Smith is slow to get up, and asks for help to swing her legs over the side of the bed. Once she is sitting on the side of the bed she stands up immediately and starts to shuffle toward the bathroom. You notice that Mrs. Smith looks pretty unsteady, and you are concerned about her falling. You walk closely next to her and about 2 steps from the bathroom, her legs start to collapse. You quickly move behind her and let her rest against you while you slowly lower her to the floor. Even though Mrs Smith was not hurt, you are shaken up by the "near fall". Using this scenario, answer the next several questions. If you had followed the steps of the nursing process, you may have been able to avoid Mrs. Smith's near fall. Which step of the nursing process did you miss? (choose the best answer)

Assessment Before helping Mrs. Smith out of bed, you could have: asked if she had fallen recently (within the last 12 months) asked if she had difficulty with walking or balance looked at her medication administration record to see if she was taking any narcotics or other high-risk medications. asked her about visual acuity, and checked about her need for glasses or hearing aids. checked her heart rate check her footwear and looked for a walker or cane look for environmental hazards

A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? Protective touch

Caring touch

being present

Clients who are hospitalized or in a long-term care setting may be separated from family and friends. Spending time with a client without performing assessment or other treatments can help alleviate some of the client's loneliness and feelings of isolation, and is considered a form of being present. Other examples of being present involve active listening, focusing on what the client is saying, both verbally and nonverbally.

Presence involves a person-to-person encounter that:

Conveys a closeness and a sense of caring.

A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?"

Gaining an understanding of what a woman's health examination means to the patient

A nurse is caring for a client who has a prescription for opioid analgesia. The client tells the nurse, "I don't want to take that medication because it makes me sleepy." Which of the following responses should the nurse make?

I will speak to your provider to see if there is a different medication to treat your pain.

Listening is not only "taking in" what a patient says, but it also includes:

Interpreting and understanding what the patient means.

Once you have completed your assessment, you find that Mrs. Smith has fallen once in the last 12 months, she is supposed to use a walker when out of bed she is wearing thin white cotton socks her glasses are sitting on the bedside table Based on this assessment, you identify a priority nursing diagnosis as:

Risk for falls

spiritual well-being

Satisfaction and a feeling of contentment with who one is and their belonging in the universe.

standardization

The process of creating and implementing consistent guidelines, methods, steps, processes, or practices that improve the quality of care and client safety.

acculturation

The process of sharing and learning cultural traits or social patterns of another group.

telehealth

The provision of both clinical and nonclinical aspects of health care delivery through the use of telecommunication devices such as the internet and telephone.

telemedicine

The provision of health care which includes diagnostic testing and monitoring through the use of telecommunication devices such as the internet.

A nurse is caring for a client whose religious belief prohibits them from receiving blood products. The client states, "My adult children don't agree with my beliefs and want me to receive a transfusion." Which of the following responses should the nurse make?

You have the right to choose what treatments are best for you."

Patient-centered care

a concept that puts the client at the center of the nurse's care.

works as an elementary school teacher in Xenia Ohio

occupational history

a nurse is caring for a client who states the health care provider recommends treatment to provide comfort because a cure is not possible. To which of the following concepts is the provider referring?

palliative care

Based on Mrs. Smith's risk for falls, and the goal being that she always use a walker when she gets out of bed, what are priority nursing interventions to help meet this goal?

place the walker within Mrs. Smith reach at all times Place a sign in the room reminding Mrs. Smith and visitors that she should always use a walker when out of bed.

As you learned while watching this week's introduction video, many preventable errors are made in the hospital setting. The Joint Commission: Accreditation, Health Care, Certification is an organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. In 2015, the Joint Commission published National Patient Safety goals. These goals represented areas where errors frequently occurred. Question: Identify which of the following were included in the 2015 Joint Commission National Patient Safety Goals.

prevent mistakes in surgery, use medicines safety, use alarms safely, identify patients correctly, improve staff communication, prevent infection

Which of the following nursing-sensitive quality indicators are categorized as an outcome indicator? (Select all that apply.)

readmissions to the hospital, catheter-associated urinary track infections (CAUTIs)

Smoked for 20 years, stopped 5 years ago

social history

What are the components of a health history? (choose all that apply)

social history surgical history sexual history chief complaint occupational history health maintenance history of present illness family history medical history

a nurse is caring for a client who tells the nurse, "something is wrong, i feel like God is so far away from me and I don't know what to do." which of the flowing is the client experiencing?

spiritual distress

A nurse is providing information to a client who is from the Baby Boomer generation about a newly prescribed medication. Using information about generational preferences, which of the following methods of teaching should the nurse use?

talk with the client in person