Chapter 4 chapter 5
Nurses who tend to be ethnocentric consider patients in light of what?
Culture of the nurses from
The nurse was reviewing the discharge medication list with a patient who recently had been hospitalized for heart failure. The patient stated the medications were not new and that everything was fine. What would be an appropriate response by the nurse?
"Your medication list is not as important as remembering to take your doses everyday"
During a teaching session the patient suddenly becomes tearful and turned away what would be the best response in nurse at this time?
" I see that you're upset I can finish this later do you want to talk about it"
The nurse is teaching a patient who has been diagnosed with hypertension. Which statement by the patient indicates the need for further education?
"A sedentary lifestyle is the best way to live"
When discussing the medication history with a patient nurse will ask the patient to identify current medications and drug allergies as well as what other important factors?
Any over the counter medications used any herbal products used any street drugs used
What are the main principles of learning that the nurse incorporate into teaching is that adults learn by?
Applying new knowledge to previous learning
How can the nurse facilitate appropriate patient teaching?
Ask the patient to record responses to his medications at home
Which teaching strategy does the nurse use when teaching an elderly patient?
incorporating time for practicing
Discontinuing the use of antiembolism stockings because recent studies have shown them to be in effective is example of?
Evidence-based nursing practice
The affect domain of learning refers to?
Feelings beliefs and values that the patient has
Which step of the nursing process is used when the nurse identifies the therapeutic intent of a prescribed medication?
Planning
An important aspect of the nursing process is that it uses which approach?
Problem-solving
The nurse is preparing to teach a postsurgical patient who has a new colostomy about proper colostomy care. The patient says " just show me how to do:let me try and I'll learn what to do" which domain of learning is indicated by this statement?
Psychomotor
when the nurse asked the patient to perform a return demonstration of a skills such as injecting insulin or performing a dressing change the patient is exercising which domain of learning?
Psychomotor
Which stage of grief represents when the patient is most willing to learn?
Resolution
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 nurse is performing an inter-dependent nurse action which scenario?
The nurse is assisting the physical therapist with exercises for the patient
The nurse understands it is important to know the difference between a nursing diagnosis and a medical diagnosis because of which factor?
The nursing diagnosis refers to how the patient is responding to an illness identified in the medical diagnosis
The nurse is performing a dependent nursing action which scenario?
The patient is given her 8 AM medication by the nurse
When teaching patients and their families and nurses must recognize a teachable moment when what occurs?
The patient starts to ask questions about what to expect when at home
Which assessment finding is considered primary objective information?
The patient states that his temperature has been 98.8f
Which is a measurable goal statement for a patient taking insulin?
The patient will be able to self administer insulin injections 2 weeks after initial training
Which is a priority outcome for patient teaching about prescribed drug therapy?
The patient will take the medication as prescribed not changing or discontinuing it without contacting the healthcare provider
The nurse needs to determine the patient's preferred learning style when educating the patient on continuing care one way to do this is by using a variety of teaching aids which may include?
•pamphlets and charts •DVDs and videos •smart devices and computer aided instruction
Nurses perform the task of patient assessment to determine?
•patients response to treatment •any adverse effects of medications •if the patient has any risk factors
Which of the following information about medications is important to teach patients?
•the name,dosage,and route of administration of the medication •the laboratory studies that need to be monitored while in the medications •the common adverse effects and possible serious adverse effects to watch for •the correct schedule or timing of the medication to follow
How does a nursing diagnosis differ from a medical diagnosis?
A nursing diagnosis evaluate a patients response to actual or potential health problems
Which patient is most ready to begin a patient teaching session?
A patient who has voiced a concern about how insulin injections will affect her lifestyle
The nurse can be use primary secondary and treachery resources to gain information to complete the medication history. when the nurse obtained vital signs to use as a monitoring parameters later it is considered which source of information?
A primary source of objective data
When is the nurse supposed to use the evaluation step of the nursing process?
After each intervention
The nurse uses which step of the nursing process to detect any potential complications?
Assessment
Why is it important for nurses to include the patient and appropriate significant others in decision-making with formulating therapeutic patient outcomes?
Because it will help provide patient with a sense of control over their care
An older adult patient is being prepared for discharge after experiencing a stroke with some residual damage. The patient and family are scheduled to receive a large amount of information from the nurse regarding proper care and safety at home. What is the nurses best course of action?
Break the teaching content down into manageable sections and present them individually in the days before discharge.
The patient 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 patient to verbalize his understanding this involves which domain of learning?
Cognitive
The nurse analyzes the data collected from the patient assessment to identify signs and symptoms that will be addressed under the nursing diagnosis these are known as the?
Defining characteristics
Which type of nursing action occurs when the nurse administers a medication to a patient?
Dependent
Which testing method is the most effective when teaching pets about medications?
Designing a teaching method and pace for each pt
The nurse is supposed to perform postoperative teaching for a patient who is scheduled to be discharged the next day. The patient appears fatigued, in pain, and irritable. The nurse knows that that there will be little time for teaching on the day of discharge. What is the nurses best course of action?
Determine the patients need for analgesia and rest and return to perform the teaching after the patient feels better.
Which statement about a critical care pathway is true?
It is a standardized care plan derived from "best practice" patterns
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 deficient knowledge
What does Nanda stand for when referring to nursing diagnosis?
North American nursing diagnosis association
The nurse considers the patients psychosocial and cultural needs during which step of the nursing process?
Planning
The use of evidence based practice to guide the formulation of nursing interventions based on research and clinical expertise is part of which component of the nursing process?
Planning
Which correctly distinguishes a nursing diagnosis from a medical diagnosis?
Nursing diagnosis refers to the patients ability to function in activities of daily living
What is the difference between nursing interventions and expected outcome statements?
Nursing interventions are action statements and expected outcome statements are what should be observed in the patient after specific actions
Which correctly identifies the NMDS classification system?
Nursing minimum data set
What is the foundation for the clinical practice of nursing?
Nursing process
Nursing interventions identify specific nursing actions well measurable goal statements identify specific?
Patient behaviors
Which piece of information obtained during a patient assessment is a subjective finding?
Patient states "I have pain in my abdomen"
Which level Maza's hierarchy would be a priority when planning nursing care?
Physiological needs
The five levels of needs identified by mass is hierarchy include?
Self actualization safety belonging physiologic
Gordon's functional health patterns model is an example of what kind of assessment?
Socio-cultural psychological spiritual and developmental approach
Reasonable expectations that the nurse should have when discussing new treatment therapies include which factor?
That's a patient and family will ask appropriate questions and demonstrate adequate understanding of teaching
Which statement describes a characteristic of case management adherence guidelines version 1
The caregiver and patient have ownership of the goals to be achieved
The nurse is developing a teaching plan for a patient who will have limited activity at home after a recent fall. What principle of learning is involved when teaching the patient ?
The timing of the teaching is important for learning to take place
Which portion of the learning process is involved in the cognitive domain?
Thinking
The nurse needs to assess the patient in the hospital for therapeutic affect side effects and potential drug interactions during which time?
Throughout the hospitalization
What is one important aspect of the nurses role in discussing the patient's medications and adhering to a particular medication regimen?
To repeat the information often and stop and allow practice
What statement is true about culture and ethic diversity?
Unless an assessment of psychosocial needs is performed on the patient the true meaning of an illness may never be uncovered
When nurses use evidence-based practice changes for planning nursing care they are incorporating what factor into the nursing process?
Validated research
The nurse is preparing a patient for discharge after a surgical procedure. Which method is best for teaching the patient about his or her prescribed drugs?
Verbal explanations along with drug summary sheets
What is an independent nursing action?
Verified the correct route of medication administration
When is Mazzio's hierarchy of human needs to use in the planning process?
When setting priorities
Which scenario represents the best time for the nurse to initate patient teaching?
When the patient spontaneously starts asking questions
When a patient is discharged from the hospital what is important for the nurse to document?
The collaborative problems that will require continue monitoring after discharge
Which statement by a patient has a further teaching is needed?
"I can take my pills when I feel like it because they can get so expensive"
When the nurses decides that the patient needs to rest before ambulating the decision is based on what factor?
The prioritization of psychological needs
The nurse who is new to large urban hospital has found that many hospitalized patients are of different cultural groups in the area. Which approach is best for the nurse to take in caring for these patients?
Develop a plan of care that is individualized to each patients needs.
The medication history that the nurse records includes which important facts to note?
Current medications being taken by the patient and drug allergies
When formulating the nursing diagnosis in relation to medications the nurse will need to identify problems related to medication therapy and should review the?
Drug monographs
A patient develops edema as an adverse effect to a prescribed medication. A gain of 5 pds has occurred in 24hrs and 2+ edema is present in the legs. Which nursing diagnosis statement does the nurse allocate to this patient?
Excess fluid volume related to medication therapy, manifested by 5 pd weight gain and leg edema
What type of nursing diagnosis of both the potential for a complication of drug therapy?
Risk/high risk
Which phase of the five step nursing process is diagnosis?
Second
How do you nursing diagnosis different 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 prescribe medications based on what?
The noted improvement of the symptoms present
Which statement is an example of an objective of healthcare teaching that involves the affective domain of learning?
The patient will discuss with the family the treatment options proposed
Which statement is an example of an objective of healthcare teaching that involves the cognitive domain of learning?
The patient will verbalize an understanding of the potential side effects of digoxin.
How will the nurse identify the therapeutic outcome of the medications during the planning phase of the nursing process?
•By reviewing the drug monograph for common and serious adverse effects •by identifying the therapeutic intent of the medications •by educating the patient how to self administer medications • by identifying the recommended dosage of the medication
When teaching older adults about new medications what is important for the nurse to remember?
•Check the patient for vision or hearing aids •determine any memory impairment •evaluate the gross motor ability of the patient
When the nurse is teaching a patient about medications which important considerations can be implemented?
•Determining the patient's readiness to learn •space in the content over several short sessions •organizing the patient education materials •using repetition to enhance learning
The patient presents with educational information about medication that has been obtained from the Internet what does the role of the nurse as consultant include?
•Evaluating websites for validity • assisting a patient with understanding the information accessed •providing the patient with tools to evaluate websites for validity
The nurse understands that when teaching a patient and family about lifestyle changes is important to?
•Keep the content of the information relevant to the patient •remember that learning your ideas may be overwhelming •keep the patient's wishes in mind
What are the sources that the nurse used to obtain a medication history?
•Objective data •other healthcare professionals •subjective data •the electronica medical record
Nanda diagnosis are part of the nursing language that describes which types of diagnosis?
•Syndrome nursing diagnosis •risk/High risk nursing diagnosis •wellness nursing diagnosis •help promotion diagnosis
Which four faces are included in the process used for planning patient interventions?
•The nurse that's priorities •the nurse develops in measurable goals • the nurse formulate nursing interventions •the nurse formulate therapeutic outcomes
The nurse is performing independent nursing action which scenario?
•The patient is being monitored for the effects of the medication given at 8 AM •the nurse is calling a provider for pain medication prescriptions •the nurse is educating the patient in the use of the incentives barometer meter •the nurse is assessing the patient for bell sounds after surgery
Important healthcare information that the nurse gathers during the assessment of a patient includes which component?
•Vital signs •lung sounds •mobility level
The nurse needs to involve the patient and cooperative goal setting when teaching which will include discussing work with the patient?
•Went to call the healthcare provider •where to collect a record essential data •what the patient should monitor
The initial assessment is performed on a patient to identify patient problem based on defining characteristics as well as to identify?
•any risk factors that predispose the patient to developing problems •the patients response to their disease process •any adverse effects of medications
The nurse is preparing to administer morning medications. Which action does the nurse implement to identify the patient before administering medications?
•asks the patient his or her name and birth date •checks the patients identification band
The nurse is developing a teaching plan for a patients prescribed medication. Which action should the nurse implement to make the plan more effective?
•assess the patients readiness to learn •incorporate multiple practice sessions •request patient feedback of the information being taught
The nurse applies the nursing process by gathering patient information to assess the patient using which of the following methods?
•body systems assessment •head to toe assessment •Gordon's functional health patterns model
Which is an example of an independent nursing action?
•educating a patient on correct coughing and deep breathing exercises •obtaining the patients medication history •documenting assessments of a patients lung sounds
The nurse is reviewing sources of patient information on an Internet that may be helpful for patients wanting more information after discharge resources may include which website?
•krames online •therapeutic choices •health on the net foundation
