NURSING TEST 2
Wellness/Illness Continuum
A concept from the National Wellness Institute that proposes that well-being is more than just whether you have symptoms of an illness.
A nurse is using Maslow's hierarchy to prioritize care for an anxious client that is not eating and will not see family members. Which area should the nurse address first? a) Not seeing family members. b) Not eating (Answer) c) Anxiety. d) Mental health.
According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members (need for love and belonging) are all higher-level needs.
Documentation Definition
Accrediting Bodies - TJC -NPSG #2: Improve the effectiveness of communication amongst caregivers (ex. approved abbreviations list, complete nursing care data). Nursing Practice Standards: "Must be systematic, continuous, accessible, communicated, recorded, & readily available to the members of health care team." HIPAA - Federal legislation enforced by Department of Justice & CMS (Centers for medicare/medicaid)
Nursing Process Steps
Assessment Analysis (Diagnosis) Planning Implementation Evaluation
The nurse is preparing a smoking cessation class for family members of clients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a) Maslow's hierarchy of needs. b) Health promotion model (Correct) c) Health belief model. d) Holistic health model.
B
11 Attitude of Critical Thinking
Confidence. Learn how to introduce yourself to a patient; speak with conviction when you begin a treatment or procedure. Do not lead a patient to think that you are unable to perform care safely. Always be well prepared before performing a nursing activity. Encourage a patient to ask questions. Decrease confidence on nurses=increased your anxiety and prevents you from giving best care to patient. Also causes increase anxiety for the patient. Fairness. Listen to both sides of the discussion. If a patient complains of a co-worker, listen to the story and speak with the co-worker as well. It a staff member label a patient as uncooperative , assume the care of the patient with openness and a desire to meet the pt's needs. Responsibility and Authority. Ask for help if you are uncertain about how to perform a nursing skill. Refer to a policy and procedure manual to review steps of a skill. Report any problems immediately. Follow standards of practice in your care. Not taking shortcuts, following standards of practice, accountable to the consequences. Discipline. Be thorough in whatever you do. Use known scientific and practice-based criteria for activities such as assessment and evaluation. Take time to be thorough and manage your time effectively. Be orderly and systematic ex. Ask LIDQ for pain instead of just I. Curiosity. Always ask why. A clinical sign or symptom often indicates a variety of problems. Explore and learn more about a patient so as to make appropriate clinical judgments. Creativity - look for different approaches if interventions are not working. Ex. A patient in pain may need pain modalities. When appropriate, involve pt and family in making decisions. Integrity. Recognize when your opinions conflict with those of a patient; review your position and decide how best to proceed to reach outcomes that will satisfy everyone. Do not compromise nursing standards or honesty in delivering nursing care. Honesty when mistakes are made, tests own values and beliefs. Humility - recognize when you need more information to make decision, asking for orientation when new to unit/new to using device, ask for RN regularly assigned to unit for assistance with approaches to care. (BP ex - recognize when the situation is challenging, ask for help) Thinking Independently - as you acquire more knowledge and experiences, examine your beliefs under new evidence, be open minded about different interventions, read the scientific literature especially if there are different views on the subject matter, talk to other nurses and share ideas Risk Taking - if your knowledge causes you to question a HCP's order, do so. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients, especially if your ideas are supported with scientific evidence. Perseverance - be cautious of an easy answer that avoids uncomfortable situations. If coworkers give you information about a patient and some facts seem to be missing, clarify the information or talk to the patient directly. If problems of the same type continue to occur on a nursing division, bring coworkers together, look for a pattern, and find a solution.
Primary Prevention
First contact in the given episode of illness that leads to a decision regarding a course of action to prevent worsening of the health problem.
Clinical Decision Making Examples:
Inductive reasoning Knowing the patient Prioritization
What must the nurse remember about EBP?
It is dependent on patient values and expectations
How to make a smart goal
Patient will State/demonstrate As evidenced by In (time frame)
Implementation
Perform nursing actions, delegate tasks, supervise other health care staff, and document the care and client's responses
7 Caring Behaviors
Provide presence-being with/doing for Touch Listening Know the patient Spiritual care Relieving pain & suffering Family care
Nonmodifiable Risk Factors
Risk factors that include age, gender, genetics, and family history.
Assessment
Systematic collection of information about client's present health to identify needs and additional data to collect based on findings Observation, interviews with clients and families, medical history, comprehensive/focused physical exam, diagnostic and laboratory reports, and collaboration with other members of healthcare team Nurse collects objective and subjective data and validates, interprets, and clusters data
A patient is having difficulty reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? a) Confidence b) Creativity (Correct) c) Risk taking d) Humility
The nurse uses creativity in this situation to figure out how the patient can safely get a drink of water. Humility is recognizing when more information is needed to make a decision. Confidence is being well prepared to perform nursing care safely. This question best illustrates the attitude of creativity. Risk taking is demonstrating the courage to speak out or to question orders based on the nurse's own knowledge base.
A nurse is caring for a patient with chronic low back pain. The nurse wants to determine the best EBP regarding clinical guidelines for low back pain. What is the best database for the nurse to access? a. MEDLINE b. EMBASE c. CINAHL d. AHRQ
d. AHRQ (Agency for Healthcare Research and Quality)
Social Determinants of Health
education access and quality health care access and quality neighborhood and built environment social and community context economic stability
Watson's 10 Carative Factors
1)Forming a human-altruistic value system 2) instilling faith-hope 3) cultivating sensitivity to one's self and to others 4) developing a helping, trusting, human caring relationship 5) promoting/expressing positive/negative feelings 6) using creative problem-solving, caring processes 7) promoting trans personal teaching-learning 8) providing for a supportive, protective, and/or corrective mental, physical, societal and spiritual environment 9) meeting human needs 10) allowing for existential-phenomenological-spiritual forces
Documentation Methods
- Narrative (using sentences, time consuming) - SOAP (Subjective, Objective, Assessment, Plan) - PIE (Plan, Intervention, Evaluation) - POMR (Problem-Oriented-Medical-Records. Structured, focused on client and their problems, reflects nursing process)
Healthy People 2030
It's mission is to promote, strengthen, and evaluate the nation's efforts to improve the health and well-being of all people.
Critical Thinking
the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process. It involves open-mindedness, continual inquiry, and perseverance, combined with willingness to look at each unique situation and identify which identified assumptions are true and relevant. The aim of critical thinking is the ability to focus on the important issues at hand in any clinical situation and make decisions that produce desired outcomes.
Clinical Judgement
the observed outcomes of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe, assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.
Information Technology and the Healthcare System
| Support Communication, Education & Research | Better/timely access. Continuity of Care (Collaboration). Speeds up implementation of orders (ex. diagnostic tests). Reduces order & transcription errors. Track trends. 100% legibility. | Supports nursing through | Improved access to information & clinical decision-making tools. Provision of applications that promote client safety and reduce errors. Streamlines documentation - ↑ time to spend with clients. | Challenges | Maintenance of confidentiality Devices & training costs How do you evaluate sources of information for credibility & reliability?
Physical Therapy (LOWER BODY)
Bed mobility training Stair negotiation training Gait training Issue walking devices Sitting/standing balance training Trunk control exercises Cardiopulmonary facilitation Wound care via debridement, pulse lavage, ultrasound, dressing changes in adjunct to the above wound care
Which statement regarding nursing diagnoses is correct? Nursing diagnoses are written to identify diseases. Nursing diagnoses remain the same for as long as the disease is present. Nursing diagnoses describe patient problems that nurses can treat. Nursing diagnoses focus on identifying medical health problems.
C
Weight bearing as tolerated (WBAT)
A patient determines the proper amount of weight bearing based on comfort. The amount of weight bearing can range from minimal to full. An assistive device may or may not be required
Clinical Judgement
A process by which nurses take assessment information, analyze that information, seek improve outcomes for patients through specific interventions and then evaluating how the interventions affected the patient outcomes (Using EBP)
A nurse is caring for a client in pain. Which nursing approach is priority? a) Family-centered. b) Patient-centered. c) Self-centered. d) Hospital-centered.
Answer: B It is important to preserve a patient-centered approach to client care for all aspects of nursing, whether the care focuses on pain management, teaching self-care, or basic hygiene measures.
Which action indicates a nurse is using caring touch with a client? a) Administers an injection. b)Inserts a catheter. c) Rubs a client's back. d) Prevents a client from falling.
Answer: C Caring touch is the way a nurse holds a client's hand, gives a back massage, or gently positions a client. Touch that occurs when tasks are being performed, such as insertion of a catheter or administering an injection, is known as "task-oriented touch." Touch used to protect the client (holding and bracing a client to avoid a fall) or nurse (withdraws from tension-filled situations) is known as "protective touch."
The nurse is caring for a client with a terminal illness. The client states, "I have no energy, and I can't eat or sleep. What's the use?" Which response by the nurse is best? a) It sounds like you have lost hope. b) It sounds like you have lost your appetite. c) It sounds like you have lost the ability to sleep. d) It sounds like you have lost energy.
Answer: A All of the client's descriptions are describing a loss of hope. While losses of energy, appetite, and sleep are indicated, they only address a part of client's problems. A loss of hope encompasses the holistic view of the client.
A nurse is providing spiritual care to clients. Which action is essential for the nurse to take? a) Visit churches, temples, mosques, or synagogues. b) Knowing one's own personal beliefs. c) Learning about other religions. d) Travel to other areas that do not have the same beliefs.
Answer: B Because each person has a unique spirituality, you need to know your own beliefs, so you are able to care for each client without bias. While learning about religions, visiting other religious areas of worship, and traveling to areas that do not have the same beliefs are beneficial, they are not essential.
A nurse contacts the health care provider about a change in a client's condition and receives several new orders for the client over the phone. When documenting telephone orders in the EHR, what should the nurse do? a) Record telephone orders in the EHR but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. b) "Read back" all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR. c) Implement telephone order(s) immediately but insist that the health care provider come to the patient care unit to personally enter the order(s) into the EHR within the next 24 hours. d) Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes.
Answer: B Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order.
When documenting an assessment of a client's cardiac system in an EHR, the nurse selects the "WNL" to document the following findings: "Heart rate 80 beats/min, and regular. Denies chest pain." This is an example of using which of the following documentation formats? a) Focus charting incorporating data, action, and response (DAR). b) Problem-intervention-evaluation (PIE). c) Charting by exception (CBE). d) Narrative documentation.
Answer: C Charting by exception (CBE) is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Many computerized nursing documentation systems have incorporated a CBE design. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WNL (or WDL) statement or to choose other statements from a drop-down menu.
The nurse is changing the dressing over the midline incision of a client who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? a) Health care provider notified about change in assessment of abdominal incision. T. Wright, RN b) 09-3-21: Notified the surgeon by phone that there is a new area of redness around the patient's incision. T. Wright, RN c) 1015: Contacted the surgeon and notified about changes in abdominal incision. T. Wright, RN d) 09-3-21 (1015): Surgeon contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN
Answer: D Statements should include the date and time the health care provider was contacted, the specific name of the health care provider, descriptive details of the changes of concern noted in the patient assessment, whether any orders were received, and the name and credentials of the nurse who contacted the health care provider.
The nurse is caring for a client who claims to be spiritual but does not practice any specific religion. How will the nurse interpret this finding? a) This indicates a strong religious affiliation. b) This statement is contradictory. c) This indicates a lack of hope. d) This statement is reasonable.
Answer: D The client's statement is reasonable and is not contradictory. Many people tend to use the terms spirituality and religion interchangeably. Although closely associated, these terms are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice. When a person has the attitude of something to live for and look forward to, hope is present.
The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contains an inappropriate abbreviation included on TJC's "do not use" list and should be clarified with the health care provider? a) Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. b) Lorazepam 0.5 mg PO every 4 hours PRN anxiety. c) Morphine sulfate 1 mg IVP every 2 hours PRN severe pain. d) Insulin aspart 8u SQ every morning before breakfast.
Answer: D The word "unit(s)" should be written out because the letter "u" can be mistaken for "0," the number "4," or "cc." The other orders are written appropriately.
You are a nurse who is working in an agency that has recently implemented an EHR. Which of the following are acceptable practices for maintaining the security and confidentiality of EHR information? (Select all that apply.) a) Using a strong password and changing your password frequently according to agency policy. b) Allowing a temporary staff member to use your computer username and password to access the electronic record. c) Ensuring that work lists (and any other data that must be printed from the EHR) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed. d) Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care. e) Remaining logged into a computer to save time if you only need to step away to administer a medication.
Answers: A,C, and D Mechanisms to protect the privacy and confidentiality of protected health information in the electronic health record (EHR) include not sharing passwords, not leaving computers with open EHRs unattended, and preventing those not involved with a patient's care from seeing information displayed on a monitor.
Which statement best describes the etiology of the nursing diagnosis? Identification of unhealthy response preventing the desired changes. Contributing factors for a client's response to health alterations. Suggestion of client goals to promote desired change. Identification of patient strengths.
B
A nurse contacts the health care provider about a change in a client's condition and receives several new orders for the client over the phone. When documenting telephone orders in the EHR, what should the nurse do? Question options: a) Record telephone orders in the EHR but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. b) "Read back" all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR. c) Implement telephone order(s) immediately but insist that the health care provider come to the patient care unit to personally enter the order(s) into the EHR within the next 24 hours. d) Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes.
B Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order.
When documenting an assessment of a client's cardiac system in an EHR, the nurse selects the "WNL" to document the following findings: "Heart rate 80 beats/min, and regular. Denies chest pain." This is an example of using which of the following documentation formats? Question options: a) Focus charting incorporating data, action, and response (DAR). b) Problem-intervention-evaluation (PIE). c) Charting by exception (CBE). d) Narrative documentation.
C Charting by exception (CBE) is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Many computerized nursing documentation systems have incorporated a CBE design. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WNL (or WDL) statement or to choose other statements from a drop-down menu.
Speech Therapy
Cognitive processing deficits Language impairments Communication deficits Passy Muir valves Dysphagia/swallow deficits Modified barium swallow tests Status post laryngectomy training
A nurse uses EBP to provide nursing care. What is the best rationale for the nurse's behavior?
EBP is a guide fr nurses in making clinical decisions
Occupational Therapy (UPPER BODY)
Fine and gross motor coordination Transfer training ADL's (bathing, dressing, grooming) Basic living skills (Money management, driving skills, homemaking) Visual Perception deficits Functional cognition training Wheelchair mobility/positioning Splinting/positioning for upper body Hand therapy Training for self feeding Orders/manages ADL and bathroom equipment
Non-weight bearing (NWB)
If NWB for leg - IT CANNOT TOUCH THE FLOOR
Theorist of Good Samaritan's Nursing School
Jean Watson
PICOT
P: Population I: Intervention C: Comparison O: Outcome T: Time
Partial weight bearing (PWB)
Patient is able to put some weight through their leg (how much? must clarify with MD if not present in the order) It can be 25%, 50%, 75% or could be a certain poundage (ex. 30lbs of pressure)
Toe touch weight bearing (TTWB)
Patient is able to put toes on ground for balance support only
Supervision (supv) - Assist Levels
Patient needs verbal cues
Maximal A (max A) - Assist Levels
Patient performs 25% of task; helper assists with 75%
Moderate A (mod A) - Assist Levels
Patient performs 50% of task; helper assists with 50%
Minimal A (min A) - Assist Levels
Patient performs 75% of task; helper assists with 25%
Total A or Dependent (D) - Assist Levels
Patient performs less than 25% of task or needs assistance of 2+ people
Modified Independent (Mod I) - Assist Levels
Patient requires an AD to perform
The nurse is providing presence to a client. Which nursing action does this involve? a) Providing closeness and a sense of caring. b) Jumping in to provide client comfort. c) Being there without an identified goal. d) Focusing on the task that needs to be done.
Providing presence is a person-to-person encounter conveying closeness and a sense of caring. "Being there" seems to depend on the fact that a nurse is attentive to the client more than the task. "Being with" means being available and at the client's disposal. If the client accepts the nurse, the nurse will be invited to see, share, and touch the client's vulnerability and suffering. Jumping in may not be welcomed. Being there is something the nurse offers to the client with the purpose of achieving some patient care goal.
A client asks the nurse to explain spirituality. What is the nurse's best response? a) It has a minor effect on health. b) It is awareness of one's inner self. c) It refers to fire or giving of life to a person. d) It is not as essential as physical needs.
Spirituality is often defined as an awareness of one's inner self and a sense of connection to a higher being, to nature, or to some purpose greater than oneself. Spirituality is an important factor that helps individuals achieve the balance needed to maintain health and well-being and to cope with illness. Florence Nightingale believed that spirituality was a force that provided energy needed to promote a healthy hospital environment and that caring for a person's spiritual needs was just as essential as caring for their physical needs. The word spirituality comes from the Latin word spiritus, which refers to breath or wind. The spirit gives life to a person.
A data cluster is a grouping of patient data or cues that suggest the existence of a patient health problem. True False
True
Cues are information obtained through the use of senses. True False
True
Clinical Decision Making
separates nurses from UAP. Clinical decision making requires nurses to investigate and analyze all aspects of the clinical problem and then apply scientific and nursing knowledge to choose the best course of action. clinical decision making is a product of critical thinking that focuses on resolving a patient's problem
A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? a) Asking for an orientation to the unit (Correct) b) Assuming that patient care will be the same as on the other units c) Admitting lack of knowledge and going home d) Refusing the assignment
Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility but going home does not illustrate an example of responsibility.
Ten Commandments of Body Mechanics
1: CLUB THE PATIENT IN - be sure the pt knows what your going to do and how you're going to do it and how they can help 2: SIZE UP THE LOAD - GET HELP If the load to be lifted it more that you can handle. Regardless, wait 3: CHECK YOUR FOOTING - your feet should be apart to give you a broad base of support for better balance and stability 4: MOVE CLOSE - hold close to the center of gravity 5: SQUAT: dont use mobility (back) muscles. Bend hips and knees and keep back straight 6: LIFT - use "work" (thigh) mucles by straightening your legs 7: BE SMOOTH AND SYNCHRONIZED - aboid strain produced by jerky movement. Count 123 with patient 8: TURN - DONT TWIST - shift position of your feet to turn 9: DON'T LIFT when you can pull or push the patient. It's safer and easier that way 10: TEACH AND PREACH: good words to others so all of us will lift well and safely
What is the most important action that is performed by the nurse under evaluation step of the nursing process? Evaluating patient goal/outcome achievement. Evaluating interventions in the plan of care. Evaluating the competence of the practicing nurses. Evaluating the types of health care services available to the patient.
A
Which action should the nurse take when using critical thinking to make clinical decisions? a) Considers what is important in any given situation (Correct) b) Makes decisions based on intuition. c) Reads and follows the heath care provider's orders. d) Accepts one established way to provide care.
A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Patient care can be provided in many ways. The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Following health care provider's orders is not considered a critical thinking skill. If your knowledge causes you to question a health care provider's order, do so.
Evidence-Based Practice (EBP)
A problem-solving approach to clinical practice that combines the deliberate and systematic use of best evidence in combination with a clinician's expertise and patient preferences and values, and health resources in making decisions about patient care - a guide for nurses to structure how to make accurate, timely and appropriate clinical decisions. It is important to utilize best scientific and clinical evidence and turn it into best practice
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data: A. Resp. rate is 22/min, with even, unlabored resp. B. The client's partner states "They said they hurt after walking about 10 minutes" C. The client's pain rating is 3 on a scale of 0-10 D. The client's skin is pink, warm and dry E. The assistive personnel reports that the client walked with a limp
A. (Correct) Objective data includes information the nurse measures (Vital Signs) B. Subjective data includes a client's reported manifestations even if a secondary source gave the nurse the information C. Subjective data includes a client's reported manifestations D. (Correct) Objective data includes information the nurse observes (Skin Appearance) E. (Correct) Objective data includes information from the observations of others (family and staff)
A nurse is discussing the nursing process with a newly licensed nurse. While of the following statement by the new RN should the nurse identify as appropriate for the planning step of the nursing process A. "I will determine the most important client problems that we should address" B. "I will review the past medical history on the client's record to get more information" C. "I will carry out the new prescriptions from the provider" D. "I will ask the client if their nausea has resolved"
A. (Correct) Prioritize the client's problems during the planning step of the nursing process B. Review the client's history during the assessment/data collection step of the nursing process C. Implement nurse-and provider-initiated actions during the intervention step of the nursing process D. Gather information about whether the client's problems have been resolved during the evaluation step of the nursing process
A chanrge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include (Select all that apply) A. Writing a prescription for morphine B. Inserting a NG (Nasogastric Tube) to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure injury risk
A. Have a prescription from the provider to administer a medication. After obtaining the prescription, the nurse has the flexibility to determine when to administer a PRN medication. B. Have a prescription from the provider for the insertion of the NG Tube. This is a provider-initiated intervention. C. (Correct) Showing a client how to use a progressive muscle relaxation is an appropriate nurse-initiated intervention for stress relief. Unless there is a contraindication for a specific client, use this technique with clients without a provider's prescription. D. (Correct) Performing a bath is a routine nursing procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider's prescription. E. (Correct) Repositioning a client every 2 hr is an appropriate nurse-initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider's prescription.
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.
A: (Correct) Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care. B: Do not wait longer to see how the client would respond, but take action to determine why the client is not achieving satisfactory pain relief C: Do not make random changes to the plan of care without fathering evidence to guide the nurse in knowing what new interventions might help D: The action does not acknowledge the client's condition or that the current plan is ineffective
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
A: (Correct) The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0-10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to the worsening of pain. B. The newly licensed nurse used the planning step of the nursing process when deciding that it was the right time to administer the medication. C. The newly licensed nurse used the implementation step of the nursing process when administering the medication D. The newly licensed nurse used the evaluation step of the nursing process when checking the effectiveness of the pain medication in relieving the client's pain
Legal Implications
Accurate documentation is one of the best defenses to legal claims. Malpractice suits are based on patient records. Avoid potential risks. Content and format should be consistent with institution's policy and nursing practice standards Golden Rule: If it nots documented, it has not been done!
Tertiary Prevention
Activities directed toward rehabilitation rather than diagnosis and treatment.
Illness Prevention
Activities such as immunization program and blood pressure screening, which help protect people from actual or potential threats to health.
Formats for Nursing Documentation
Admission Nursing History Flow Sheets / Graphic Record Patient Care Summary Standardized Care Plans Progress Notes Discharge Summary Forms
Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a) Offering pain-relief medication based on the health care provider's orders b) Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past (Correct) c) Administering pain-relief medication according to what was given last shift d) Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed
Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past is an example of exploring many options for pain relief. Nonpharmacological pain-relief methods are available, as are medications for pain. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on assigned patients and intervene accordingly. Pain is subjective. The nurse should offer pain-relief methods based on the patient's reports without being judgmental.
Which statement concerning nursing orders is accurate? Nursing orders are a separate entity from the original goal or outcome. Nursing orders may be nurse-prescribed or physician-prescribed. Nursing orders are signed by the attending physician. Nursing orders do not describe the nursing action to be performed.
B
Critical Thinking Examples:
Concept Maps Disciplined Thinking Independent Thinking Reflective Journals
Analysis Steps
Concept(s) and/or Nursing Diagnosis Actual or Potential Identify Etiology(cause) List manifestations for actual problems
Attitude of Thinking Critically
Confidence: Feels sure in abilities Independence: Analyzes idea for logical reasoning Fairness: Is objective, nonjudgemental Responsibility: Adheres to standards of practice Risk-taking: Takes calculated chances in finding better solutions to problems Discipline: Develops a systematic approach to thinking Perseverance: Continues to work at a problems until theres a solution Creativity: Uses imagination to find solutions to unique client problems Curiosity: Requires more information about clients and problems Integrity: Practices truthfully and ethically Humility: Acknowledges weaknesses
Ethic of Care
Places the nurse as the patient's advocate, solving ethical dilemmas by attending to relationships & giving priority to each patient's unique personhood.
Nursing Process Examples:
Planning a goal for a patient Assessment of patient information Implementation of nursing actions
How to do we provide care/get to know our patients? (4 C's)
Courtesy, Comfort, Connection, Communication
Which action would be performed during the planning step of the nursing process? Interpreting and analyzing client data. Establishing the data base. Identifying factors contributing to client's success or failure. Selecting nursing orders or interventions.
D
Benefits of early mobility and ADL's
Decreased joint pain and stiffness Increase/normalize circulation Maintain range of motion Increase level of arousal Helps cardio/pulm system Reduces orthostatic hypERtension Decreases length of stay at hospital Maintains/grows fine motor skills Increases cognitive and sensory input
Therapeutic position and range of motion (e.g. sitting in an upright position, stretching and moving)
Decreases joint pain and stiffness in upper and lower extremities Respiratory, skin, feeding Tissue and joint mobilization Maintain normal range of motion using stretching Optimizes O2 transport, gas exchange, hydration and blood flow distribution
Types of Nursing Diagnoses
Dependant - dr order Independent without dr order Collaborative - both
Guidelines for Written Documentation
Do not document critical comments about client. Do not document personal opinions. Do not erase, use "white out", or scratch out errors. Record all entries legibly with ink. Do not leave blank spaces. Correct errors promptly. Document only for yourself. Document interactions with healthcare providers initiated for clarification of orders.
Barriers to using EBP
Do not possess the skills to evaluate the evidence Knowledge of how to access the data bases Most research evidence is reported in english Lack of organizational report
The client has a surgical incision but has not yet been able to look at it. The nurse teaches the client how to care for the incision. The nurse sits with the client to form a plan on approaching the care. Which caring process is the nurse performing? a)Doing. b)Knowing. c)Enabling (Correct) d)Maintaining belief.
Enabling is facilitating another's passage through a life transition and unfamiliar events. Working with the client to find alternate ways to perform the task is doing just that. Knowing is striving to understand an event because it has meaning in the life of another. This must be done before enabling can occur. Doing for is doing for the other as he or she would do for self if it were at all possible. The nurse in this situation is not doing for the client but is teaching/informing on how to care for the incision. Maintaining belief is sustaining faith in the other's capacity to get through an event or transition and face a future with meaning. This may be an underlying theme to the process but is not what the nurse is actually doing.
Planning
Established priorities and optimal outcomes of care they can readily measure and evaluate which in turn direct nurses in selecting interventions to include in a plan of care to promote, maintain or restore health Maslow's Hierarchy of Needs: Self-Actualization, self-esteem, love and belonging, safety and security, and physiological Throughout the process, nurses set priorities, determine client outcomes, and select specific nursing interventions, ending in the product of the NURSING CARE PLAN (NCP)
Evaluation
Evaluate clients' responses to nursing interventions and form a clinical judgement about the extent to which clients have met the goals and outcomes Nurses continuously evaluate client's progress toward outcomes and use clients' data to determine whether or not to modify the plan of care Use to determine effectiveness of plan
Which areas should the nurse assess to determine the effects of external variables on a client's illness? (Select all that apply.) a) Client's perception of the illness. b) Client's coping skills. c) Socioeconomic status (Answer) d) Social support (Answer) e) Cultural background (Answer)
External variables influencing a client's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the client's perceptions of symptoms and the nature of the illness, as well as the client's coping skills and locus of control.
Guidlines for documentation
Factual: Objective & descriptive, avoid vague/derogatory terms. Accurate: Use exact units of measurement; Use accepted abbreviations & symbols; Each entry should end w/ full name & status; Avoid TJC - "Do Not Use" list; Use correct spelling; Clear & concise. Complete: Contains essential data, nursing intervention, client's response (Assessment, Analysis/Diagnosis, Intervention, Evaluation) Current: Real time, make note as the care occurs, use military time. Organized: Use nursing process order, critical thinking. Legible: Written clearly
Which client statement should the nurse identify as a demonstration of faith? a)I get a feeling of awe when looking at the sunset. b)I have something to look forward to each day. c)I go to church every Sunday. d)I believe there is life after death. (Correct)
Faith allows people to have firm beliefs despite lack of physical evidence (life after death). Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality (go to church). When a person has the attitude of something to live for and look forward to, hope is present (look forward to each day). Self-transcendence is the belief that there is a force outside of and greater than the person (awe when looking at a sunset).
NANDA (North American Nursing Diagnosis Association)
First introduced in 1950 with a purpose of defining the science of nursing practice (develop body of knowledge)/emphasized nurse's independent practice vs dependent practice driven by physician's orders (80 Nursing Diagnosis') Wellness - are health promotion nursing diagnosis : ex. readiness for enhanced nutrition/enhanced knowledge/enhanced family coping Collaborative - can be actual or potential problems/complications that nurses monitor to detect the onset of changes in a patient's health status. If problems happen, nurses intervene with in collaboration with personnel from other disciplines.
Recommendations of The American Medical Record Association
Give: Never give your personal pass/login to anyone Do not leave: Do not leave your computer unattended after logging on Follow: Follow correct protocol when correcting errors Create, change, or delete: never change, create, or delete unless you have specific authority to do so Send: Never send email with protected healthcare information in it Follow: Follow your agency policy on confidentiality procedures
A nurse is following the goals of Healthy People 2030 to provide care. Which action should the nurse take? a) Allowing people to continue current behaviors to reduce the stress of change. b) Focusing only on health changes that will lead to better local communities. c) Focusing on illness treatment to provide fast recuperation. d) Promoting a society in which all people live long, healthy lives (Correct)
Healthy People sets objectives to help the United States increase its focus on health promotion and disease prevention (instead of illness care) and encourages cooperation among individuals, communities, and other public, private, and nonprofit organizations to improve health. The current publication, Healthy People 2030, promotes a society in which all people live long, healthy lives. The goals do not include continuing current behaviors to reduce stress, focusing only on health changes for communities, or focusing on fast recuperation.
A nurse is assessing internal variables that are affecting the client's health status. Which area should the nurse assess? a) Cultural background. b) Socioeconomic factors. c) Family practices. d) Perception of functioning (Answer)
Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.
The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? a) Self-regulation b) Explanation c) Evaluation d) Interpretation (Correct)
Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data. This nurse is clarifying the data in this situation. Evaluation involves determining the effectiveness of interventions or care provided. The nurse in this scenario is assessing the patient, not evaluating interventions. Self-regulation is reflecting on experiences. Explanation is supporting findings and conclusions. The nurse in this question is clarifying uncertain data (determining cause of the low pulse), not supporting the finding of a low pulse.
Why do we need EBP
It started in the early 2000s with a report from the Institute of medicine entitled Health Professions Education Report that stated that the nursing programs needed to update their curricula to adequately prepare nurses to offer safe care for patients.
Levels of Critical Thinking
Level 1 Basic - learner trusts that experts have the right answers, thinking is concrete and based on a set of rules or principles. Tends to think that one right answer exists for each problem. Follows step by step approach. Level 2 Complex - learners begin to separate from experts, they analyze & examine choices more independently, willing to consider different options, becomes more creative and innovative, gather more information and take a variety of different approaches to the same therapy. Level 3 Commitment - person anticipates when to make choices without assistance. Accountable for decisions.
Secondary Prevention
Level of preventative medicine that focuses on early diagnosis, and rapid initiation of treatment to stop the progress of disease processes.
Patient-Centered Care
Nursing behaviors that are patient-centered, compassionate, protective and respectful of the patient's values, beliefs, culture, and preferences. Caring involves "being with" and "doing for" the patient.
Maslow's Hierarchy of Needs
Physiological: Airway, respiratory effort, heart rate, rhythm, and strength of contraction, nutrition, elimination Safety and Security: Protection from injury, promote feeling of security, and trust in nurse-client relationship Love and Belonging: Maintain support systems, protect from isolation Self-Esteem: Control, competence, positive regard, acceptance and worthiness Self-Actualization: Hope, spiritual well-being, enhanced growth
The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a) Primary prevention (Answer) b) Risk factor prevention. c) Secondary prevention. d) Tertiary prevention.
Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. While risk factor modification is an integral component of health promotion, it is not a type of preventive care.
Purpose of Patient Chart/Record
Primary: Communication Secondary: Legal Documentation, Reimbursement, Audit - Monitoring, Education, Research
The client has a terminal diagnosis. When the nurse assesses the client and finds no pulse or blood pressure, the family begins sobbing. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating? a)Therapeutic touch. b)Caring touch. c)Task-oriented touch. d)Protective-touch (Correct)
Protective touch is also a kind of touch that protects the nurse emotionally. A nurse withdraws or distances herself or himself from a client when they are unable to tolerate suffering or needs to escape from a situation that is causing tension. Caring touch is a form of nonverbal communication that influences a client's comfort and security, enhances self-esteem, and improves mental well-being. Therapeutic touch is a type of alternative therapy for healing. Task-oriented touch is done when performing a task or procedure.
What influences brought about EBP
Quality/cost drive the direction of health care/insurance companies More informed public use of internet to become more informed about health and factors affecting society-"The age of accountability" Incidence of medical errors - more scrutiny of health care - what works and what doesn't -you can look up infection rates by hospital and also get MD reviews. EBP - improves quality, safety and positive outcomes - increases nurse's satisfaction
Which action indicates a registered nurse is being responsible for making clinical decisions? a) Takes immediate action when a patient's condition worsens (Correct) b) Uses only traditional methods of providing care to patients. c) Formulates standardized care plans solely for groups of patients. d) Applies clear textbook solutions to patients' problems
Registered nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Most patients have health care problems for which there are no clear textbook solutions. Care plans should be individualized for each patient, not just for groups.
Nursing Diagnosis
Responses to health alteration/disease (e.g acute pain) May change Focus: Patient's health perception Scope of nursing
A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a) Support findings and conclusions. b) Review the effectiveness of nursing actions (Correct) c) Search for links between the data and the nurse's assumptions. d) Examine the meaning of data.
Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurse's assumptions describes analysis.
Modifiable Risk Factors
Risk factors that include lifestyle practices and behaviors, such as poor nutrition, overeating, and insufficient rest and sleep.
Components to developing Critical Thinking
SPECIFIC KNOWLEDGE BASE: everything you learn here at GSC and beyond. Keep current in knowledge and practice. EXPERIENCE: knowledge plus clinical experiences. Applying what you learn in theory to the clinical setting. COMPETENCIES: use of the nursing process - Will be discussed in details in the next few minutes. ATTITUDES: These are guidelines that will help you approach a problem. Will will have an activity r/t this in a minute. STANDARDS: A. Intellectual- being logical and systematic. You utilize these standards in every step of the Nursing Process. Professional- be ethical, use EBP, professional responsibility
The client is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The client is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this client receiving? a) Secondary prevention (Answer) b) Primary prevention. c) Health promotion. d) Tertiary prevention.
Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities for healthy people. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.
Guidelines for Reporting
State essential client information. State the assessment finding and related information. State your request / recommendation. State client's response to care administered. Identify the priorities for the next shift.
A client is admitted to a rehabilitation facility following a stroke. The client has right-sided paralysis and is unable to speak. The client will be receiving physical therapy and speech therapy. Which level of preventive care is the client receiving? a) Tertiary prevention (Answer) b) Secondary prevention. c) Health promotion. d) Primary prevention.
Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.
Holism
The balance between body, mind, and spirit that is necessary to sustain a productive life, adapt to change, and engage in meaningful relationships
QSEN
The commitment of nursing to the competencies outlined in the Institute of Medicine report related to nursing education.
A nurse is teaching about the goals of Healthy People 2030. Which information should the nurse include in the teaching concerning what leading health indicators (LHI)? (Select all that apply.) a) Healthcare costs. b) Suicide prevention (Answer) c) Illness care. d) Food insecurity (Answer) e) Adolescent obesity (Answer)
The current publication, Healthy People 2030, promotes a society in which all people live long, healthy lives. Healthy People 2030 identifies leading health indicators (LHIs) (e.g., household food insecurity and hunger; homicides; suicides; children and adolescents with obesity), which are high-priority health issues in the United States. Healthy People sets objectives to help the United States increase its focus on health promotion and disease prevention (instead of illness care). Healthcare costs while impactful are not identified as a Healthy People 30 LHI.
A nurse is using a critical thinking model to provide care. Which component is first implemented when helping a nurse make clinical decisions? a) Attitude b) Nursing process c) Specific knowledge base (Correct) d) Experience
The first component of the critical thinking model is a nurse's specific knowledge base. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. Clinical learning experiences are necessary to acquire clinical decision-making skills. The nursing process competency is the third component of the critical thinking model. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem.
A nurse is using a critical thinking model to provide care. Which component is first implemented when helping a nurse make clinical decisions? Question options: a) Attitude b) Nursing process c) Specific knowledge base (Answer) d) Experience
The first component of the critical thinking model is a nurse's specific knowledge base. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. Clinical learning experiences are necessary to acquire clinical decision-making skills. The nursing process competency is the third component of the critical thinking model. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem.
Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? a) Depending on the charge nurse to determine priorities of care. b) Drawing on past clinical experiences to formulate standardized care plans. c) Using the nursing process (Correct) d) Relying on recall of information from past lectures and textbooks.
The nursing process competency is the third component of the critical thinking model. In your practice, you will apply critical thinking components during each step of the nursing process. Care plans should be individualized and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.
Upon completing a history, the nurse finds that a client has risk factors for developing lung disease. How should the nurse interpret this finding? a) The chances of getting the disease are increased (Answer) b) Risk modification will have no effect on disease prevention. c) The disease is guaranteed not to develop if the risk factor is controlled. d) A person with the risk factor will get the disease.
The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor modification can assist patients in adopting activities to promote health and decrease risks of illness.
The etiology of the nursing diagnosis influences nursing interventions. True False
True
The focus of nursing diagnoses is on client's response/s to the disease. True False
True
Analysis/Diagnosis
Use information/data from the assessment phase to identify the specific problem Recognize patterns/trends, compare with expected standards, or reference ranges Interpret or monitor the collected database, reach an appropriate nursing judgement about health status, and coping mechanisms and provide direction for nursing care
Internal Variables
Variables that influences a patient's health beliefs and practices that include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors.
A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change? a. Read all the articles found on the Internet. b. Make a general search of the Internet. c. Use a PICOT format for the search. d. Start with a broad question.
c. Use a PICOT format for the search
Swanson's Theory of Caring
knowing: Striving to understand an event as it has meaning in the life of the other being with: Being emotionally present to the other doing for: Doing for the other as he or she would do for self if it were at all possible enabling: Facilitating the other's passage through life transitions (e.g., birth, death) and unfamiliar events maintaining belief: Sustaining faith in the other's capacity to get through an event or transition and face future with meaning
