ch 4 and 5 nursing process

what teaching strategy does the nurse use when teaching an elderly

incorporating time for practicing.

obtaining the pt medication history

independent nursing action

important healthcare information that the nurse gathers during the assessment of a pt includes which components

lung sound, mobility level, and family support

which correctly distinguish a nursing diagnosis from a medical diagnosis

nursing diagnosis refer to the pt ability to function in activity of daily living.

what are the sources that the nurse uses to obtain a medication history

objective data , other healthcare professional, subjective data, and the electronic medical record

an important aspect of the nursing process is that it uses with approach

problem solving

the pt has just been instructed on his home going medications prior to discharge and the nurse will validate the information that was given by asking the pt to verbalize his understanding. this involves which domain of learning

cognitive

when the nurse ask the pt to perform a return demonstration of a skill such as injecting insulin or performing a dressing change the patient is excercising which domain of learning

cognitive

requesting more information on adverse effects of a new medication

cognitive domain

the medication history that the nurse records includes which important facts to note

current medications being taken by the pt and drug allergies.

which four phases are including in the process used for planning patient interventions

the nurse sets priorities, the nurse develops measurable goal, the nurse identifies related to factors, the nurse formalities nursing interventions

the nurse understands it is important to know the difference between nursing diagnosis and medical diagnosis

the nursing diagnosis refer to how the pt is responding to an illness identified in the medical daignosis

when formulating the nursing diagnosis in relation to meds the nurse will need to identify problems related to medication therapy and should

therapeutic responses

which portion of the learning processes involved in the cognitive domain

thinking

the nurse needs to access the patient in the hospital for therapeutic effects, side effects, and potential drug interactions during which time

throughout the hospitalization

what is one important aspect of the nurse role in discussing the pt medicatons and adhering to a particular medication regimen

to repeat the information often, and stop and allow pratice

which statement is true about culture and ethnic diversity

unless an assessment of psycho social need is performed on the pt social need is performed on the pt, the true meaning of an illness may never be covered.

when nurses uses evidence based practice changes for planning nursing care they are incorporating what factor into the nursing process

validated research

when is maslows heirachy of needs used in the planning process

when setting priorities

which scenario represents the best time for the nurse to initiate pt teaching.

when the pt spontaneously starts asking question.

when teaching older adult about new medications what is important for the nurse to remember

check the pt for vision or hearing aids, determine any memory impairment eveluate the gross motor ability of the pt

collaborating with the prescribe when to give a medication.

interdependent nursing action

formulating an appropriate nursing diagnosis

interdependent nursing action

the nurse understands that when teaching a pt and family about lifestyle changes, it is important to

keep the content of the information relevant to the pt remember that learning new ideas may be overwhelmed

which information is considered objective data

laboratory results

what are the three components of the nursing diagnosis

nanda approved label, defining characteristics, and contributing factors

which two types of nursing diagnosis apply to all types of medication therapies

noncompliance and deficit knowledge

what does nanda stands for when reffering to nursing diagnosis

north american nursing diagnosis association

the affective domain of learning refers to

feelings, beliefs, and values that the pt has

the nurse is developing a teaching plan for a pt prescribed meds, which action should the nurse implement to make the plan more effective

1. assess the pt readiness to learn. 2. incorporates multiple practice sessions. 3. request pt feedback of the information being taught.

list in order the steps used in the nursing process

1. assessment, diagnosis, planning, implementing and evaluation.

why is it important for nurses to include the pt and appropriate significant others in decision making when formulating therapeutic patient outcomes.

Because it will help promote cooperation and compliance by the patient.

the goal of evidence based practice is to improve patient outcome by using what

Best practices that evolved from research

which statement describes characteristics of CMAGI case management adherence guidelines.

The caregiver and pt have ownership of the goals to be achieved.

what is the priority outcome for pt teaching about prescribed drug therapy

The pt will take meds as prescribed not changing or discontinue it without contacting the healthcare provider.

how does a nursing diagnosis differ from a medical diagnosis

a nursing diagnosis evaluates pt response to actual or potential health problems

the nurse can use primary , secondary and tertitiary sources to gain information to complete the medication history. when the nurse obtains vital signs to use as monitoring parameters later, it is considered which source of information

a primary source of subjective data

the nurse is teaching a pt who has been diagnosed with hypertension . which statement by the pt indicates the need for further education.

a sedentary lifestyle is the best way to live

discussing healthcare changes that will occur when discharged, like needed an aide

affective domain

verbalizing the medications needed for pain relief after surgery

affectivve domain

when is the nurse suppose to use the evaluation step of the nursing process

after each intervention

when discussing the medication history with a patient, the nurse will ask the pt to identify current medications and drug allergies as well as what other important factor

any over the counter medication used any herbal products used any street drugs used.

The nurse is preparing to administer morning medication which actions does the nurse implement to identify the pt before administering medication

ask the pt his or her date of birth, and check the pt id band.

one of the main prinicples of learning that the nurse incorporates into teaching is that adults learn by

asking questions

arrange the compenents of the nursing process in the proper oder

assessment, diagnosis, planning, implementating and evaluation

the nurse analyzes the data collected from the pt assessment to identify signs and symptoms that will be addressed to identify signs and symptoms that will be addressed under the nursing diagnosis. These are known as the

defining characteristics

The nurse considers the pt psychosocial and cultural needs during which step of the nursing

nursing diagnosis

what is the difference betwen nursing interventions and expected outcome statements

nursing interventions are action statements and expected outcome statement are what should be observed in the pt after specific action

which correctly identifies the NMDS classification system?

nursing minimum data set

1. what is the foundation for the clinical practice of nursing .

nursing process

which is an independent nursing action

orders laboratory tests depending on the medication orde

the nurse needs to determining the pt preffered learning style when educating the pt on continuing care . one way to do this is by using a variety of teaching aids which may include

pamplets and charts, and dvds and videos

nursing intervention identify specific nursing actions, while measurable goals statement identify specific

patient behavior

which level of maslow hierachy would be a priority when planning nursing care

physiologic needs

The nurse uses which step of the nursing process to detect any potential complication

planning

the use of evidence based practice to guide the formulation of nursing intervention based on research and clinical expertise is part of which componenet of the nursing process.

planning

which step of nursing process is used when the nurse indentifies the therapeutic intent of a prescribed medication

planning

which step of the nursing process is used when the nurse identifies the therapeutic unit of a prescribed nurse identifies the therapeutic unit of a prescribed medication

planning

demonstrating correct self administer of insulin

psychomotor domain

which piece of information obtained during patient assessment is a subjective finding

pt states have pain in my abdomen.

a clinical judgement that a person is more susceptible to a particular problem than others in the same situation is defined as which type of nursing diagnosis.

risk / high risk

the five level of needs identified by maslow's heirachy include

self actualization, safety, belonging, physiologic

gordons functional health patterns model is an example of what kind of assessment.

sociocultural, psycho social, spiritual and developmental approach.

nanda diagnosis are part of the nursing language that describes which types of diagnosis

syndrome nursing action diagnosis , risk/ high risk nursing diagnosis ,wellness nursing diagnosis and health promotion diagnosis.

how do nursing diagnosis differ from medical diagnosis

the medical diagnosis identifies alterations in structure and function.

when writing the outcome statement for medication therapy, the nurse will describe the expected outcomes from the prescibed medications based on what.

the noted improvement of the symptoms present.

the nurse is performing an interdependent nursing action in which scenario

the nurse is assisting the physical therapist with exercises for the pt.

the nurse is performing an independent nursing action in which scenario

the nurse is educating the pt in the use of the incentive spirometer. the nurse is assessing the pt for bowel sounds after surgery

when the nurse decides that the pt needs to rest before ambulating, the decision is based on what factor

the prioritize of physiologic needs

the nurse is performing a dependent nursing action in which scenario

the pt is given her 8 am medication by the nurse

nurses perform the task of pt assessment to determine

the pt responses to treatment, any adverse effects of medications and if the pt has an risk factors.

when teaching pt and their families , the nurse must recognize the teachable moment when what occurs

the pt starts to ask questions about what to expect when at home

what is a measurable goal statement for a pt taking insulin injection

the pt will be able to self administer insulin injection 2 weeks after initial training.

the nurse applies the nursing process by gather information to assess the pt using which of the following system

body system assessment, head to toe assessment and gordons functional health pattern mode

nurses use the nursing process to

build a framework for consistent nursing actions.

how will the nurse identify the therapeutic outcomes of the medications during the planning phase of the nursing process?

by reviewing the drug monograph for common and serious adverse effects. by educating the pt how to self administer medications by identifying the recommended dosage of the medications.

what type of nursing action occurs when the nurse administer a medication to a patient

dependent

determining the frequency of drug administration

dependent nursing action

which teaching method is most effective when teaching pt about meds.

designing a teaching method and face for each pt

when the nurse is teaching the pt about medications, which important considerations can be implemented

determining the pt readiness to learn, organizing the pt education materials using repitition to enhance learning

which is an example of an independent nursing action

educating a pt on correct coughing and deep breathing excercises, obtaining the pt med history, and documentng assessment of a patients lung sounds

a pt developed edema as an adverse effect to a prescribed medication. A gain in 5 pounds has occured in 24 hours and 2 + edema is present in the legs. which nursing diagnosis statement does the nurse allocate to the pt .

exces fluid volume related to medication therapy manifested 5 pound weight gain and leg edema

during teaching session, the pt suddenly became tearful and turned away . what would be the best response from the nurse at this time

i see that you are upset, i can finish this later. do you want to talk about it

determining when to turn a pt in bed

independent nursing action

reviewing a medication prescription

independent nursing action

which statement about a critical care path is true

it is a standardized care plan of best practice patterns.