Unit 4 Foundations of Nursing

What is the purpose of the nursing process? a. providing patient-centered care b. identifying members of the health care team c. organizing the way nurses think about patient care d. facilitating communication among members of the health care team

c. organizing the way nurses think about patient care

The nurse is completing a patient assignment and will use information gathered to identify problems and work to prevent complications. In the National Council of State Boards of Nursing - Clinical Judgement Measurement Model (NCSBN-CJMM), this activity occurs in which step? a. take action b. outcome evaluation c. recognize cues d. analyze signs

c. recognize cues

Working phase of patient interview

Nurse must stay focused on purpose of the interaction, stay alert to what the patient says and how information is presented, watch for emotional cues indicating fear or painful experiences and the appropriateness of verbal and nonverbal cues. Assess educational needs and document gaps in patient knowledge. Opportunities for health promotion are identified

Protocols

written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order

Orientation phase of patient interview

Nurse should establish the name by which the patient prefers to be addressed Nurse should provide a personal introduction and state the purpose for the interview Establishes trust between the nurse and the patient Gather demographic data, identify patient needs and determine the extent to which patients want to be involved in care-planning

Patient-Centered goals

written specifically for the patient

Subjective data

Spoken information or symptoms that are typically difficult to validate

NCSBN Clinical Judgement Model 6 steps

1. recognize cues 2. analyze cues 3. prioritize hypotheses 4. generate solutions 5. take actions 6. evaluate outcomes

Level 5 Emergency Severity Index

Non-urgent: Lower-risk Examples: Poison ivy, cold symptoms, minor aches and pains

Objective data

Also referred to as signs, can be measured or observed

ADPIE

Assessment, diagnosis, planning, implementation, and evaluation

Level 2 Emergency Severity Index

Emergent: High-risk, imminently life-threatening condition Examples: Chest pain, possible stroke, subarachnoid hemorrhage, suicidal or homicidal

Inspection

Involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems

Level 1 Emergency Severity Index

Resuscitation: Critical, life-threatening condition Examples: Severe trauma, cardiac arrest, respiratory arrest or severe distress, seizure

Termination phase of patient interview

Review key findings and prepare the patient for the conclusion of the discussion. This can be done effectively by summarizing and validating the information covered with the patient. Allow the patient an opportunity to interject additional pertinent information

Level 4 Emergency Severity Index

Semi-urgent: Low-risk, stable health condition Examples: Twisted ankle injury, R/O urinary tract infection

Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. always position patients in a comfortable reclined position to ensure their comfort during questioning b. ask which name a patient prefers to be called during care to show respect and build trust c. quickly conduct a review of systems to determine the need for a complete or focused assessment d. begin with questions about intimacy and sexuality to address sensitive issues first

b. ask which name a patient prefers to be called during care to show respect and build trust

Level 3 Emergency Severity Index

Urgent: Moderate-risk, potentially life-threatening condition Examples: Abdominal pain (without indication or abdominal aortic aneurysm), hip fracture, R/O appendicitis, R/O venous thromboembolism

Palpation

Uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness

What is the most important action for a nurse to take to have a new nursing diagnosis considered for inclusion in the ICNP and NANDA-I taxonomies? a. share concerns with the nurse manager on the nursing unit b. offer alternative care for a patient and family members c. discuss how to address patient needs with physicians d. provide evidence-based research to support nursing care

What is the most significant problem that may result from improperly written NANDA-I nursing diagnostic statements? a. lack of direction for formulating patient plans of care b. omission of physician or primary care provider orders c. combining of two unrelated patient concerns d. increased team collaboration needs

Focused assessment

a brief individualized physical examination conducted at the beginning of an acute care-setting work shift to establish current patient status, or during ongoing patient encounters in response to a specific patient concern

Nursing Interventions Classification (NIC)

a comprehensive, research-based, standardized collection of interventions and associated acivities

NANDA-I diagnosis label

a concise term or phrase that represents a pattern of related, clustered data. The diagnosis label is the first section of every NANDA-I nursing diagnosis statement

Nursing diagnosis

a description of what a nurse observes or discovers while assessing a patient or group the nurse's clinical judgement about a client's response to actual or potential health conditions or needs

Medical record

a document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data

Patient interview

a formal, structured discussion in which the nurse questions the patient to obtain demographic information, data about current health concerns, and medical and surgical histories

Electronic health record (EHR)

a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings

Emergency assessment

a physical examination done when time is a factor, treatment must begin immediately or priorities for care need to be established in a few seconds or minutes. Patient treatment is based on a quick survey or accident or illness onset, followed by a narrowly focused physical examination of critical injuries or symptoms and signs

Electronic medical record (EMR)

a record of one episode of care, such as an inpatient stay or an outpatient appointment

Auscultation

a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity

What is the primary purpose of the nursing diagnosis? a. resolving patient confusion b. communicating patient needs c. meeting accreditation requirements d. articulating the nursing scope of practice

b. communicating patient needs

The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the clinical judgement attribute of early problem recognition? (select all that apply) a. assessing the patient for symptoms of hypoxia b. providing oxygen according to standing orders c. elevating the head of the bed, if not contraindicated d. allowing the patient to be alone to rest more comfortably e. discussing adaptations needed for daily activities with the patient

a, b, c assessing the patient for symptoms of hypoxia, providing oxygen according to standing orders, elevating the head of the bed, if not contraindicated

Which factors should be taken into consideration by the nurse before and during a patient interview? (select all that apply) a. distance between the chairs in which the nurse and patient are sitting b. traditional treatments typically used by the patient to treat disease c. gender preference for primary care providers (PCPs) d. physical condition of the patient e. music preference of the patient

a, b, c, d distance between the chairs in which the nurse and patient are sitting, traditional treatments typically used by the patient to treat disease, gender preference for primary care providers (PCPs), physical condition of the patient

What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (select all that apply) a. patient's treatment preferences b. cultural and ethnic influences c. nurse's professional expertise d. current evidence-based research e. convenience to the nursing staff

a, b, c, d patient's treatment preferences, cultural and ethnic influences, nurse's professional expertise, current evidence-based research

What should the nurse consider before implementation of all nursing interventions? (select all that apply) a. potential communication barriers b. diverse cultural practices c. scope of nursing practice d. functional status of the patient e. time of most recent shift change

a, b, c, d potential communication barriers, diverse cultural practices, scope of nursing practice, functional status of the patient

Which are reasons that accurate documentation in the medical record is important? (select all that apply) a. reimbursement for care b. evidence of care provided c. communication between health care providers d. nonlegal documentation of a nurse's actions e. promotion of continuity of care

a, b, c, e reimbursement for care, evidence of care provided, communication between health care providers, promotion of continuity of care

Which educational activities will promote the development of clinical judgement skills in nurses and student nurses? (select all that apply) a. unfolding case studies b. clinical assignments c. simulation of clinical scenarios d. answering true/false test questions e. concept mapping f. completing math calculations

a, b, c, e unfolding case studies, clinical assignments, simulation of clinical scenarios, concept mapping

What situations would necessitate modification of a patient's plan of care? (select all that apply) a. decrease in patient's level of orientation b. discharge of patient to rehabilitation facility c. patient adherence to established plan of care d. sudden onset of shortness of breath in patient receiving oxygen

a, b, d decrease in patient's level of orientation, discharge of patient to rehabilitation facility, sudden onset of shortness of breath in patient receiving oxygen

If the nurse chooses the Nursing Outcome Classification (NOC) appetite for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (select all that apply) a. expressed desire to eat b. report that food smells good c. use of relaxation techniques before meals d. preparation of home-cooked meals for self and family e. use of nutritional information on labels to guide selections

a, b, d expressed desire to eat, report that food smells good, preparation of home-cooked meals for self and family

Which actions does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient? (select all that apply) a. review the patient's past and present medical history b. analyze the nursing assessment data to determine whether information is complete c. outline an individualized plan of care to address each concern d. consider potential complications to which the patient is susceptible

a, b, d review the patient's past and present medical history, analyze the nursing assessment data to determine whether information is complete, consider potential complications to which the patient is susceptible

On what premise is a nursing diagnosis identified for a patient? (select all that apply) a. recognized cues b. nursing intuition c. clustered data d. medical diagnoses

a, c recognized cues, clustered data

The nurse identifies that confidence is one of the attributes of successful clinical judgement. Which statements by the nurse are accurate regarding this attribute? (select all that apply) a. "nurses who are confident are more assertive" b. "overconfidence occurs with increased experience" c. "legitimate confidence results from knowledge and willingness to seek guidance from expert practitioners" d. "overconfidence may lead to negative patient outcomes" e. "confidence in actions is simply reacting to problems"

a, c, d "nurses who are confident are more assertive", "legitimate confidence results from knowledge and willingness to seek guidance from expert practitioners", "overconfidence may lead to negative patient outcomes"

The nurse notices that a patient is becoming short of breath and anxious. Which interventions are independent nursing actions that do not require the order of a primary care provider? (select all that apply) a. elevating the head of the patient's bed b. administering oxygen by nasal cannula c. assessing the patient's oxygen saturation d. evaluating the patient's peripheral circulation

a, c, d elevating the head of the patient's bed, assessing the patient's oxygen saturation, evaluating the patient's peripheral circulation

The nurse recognizes which environmental factors that influence clinical judgement skills? (select all that apply) a. cultural values b. literature review c. cue analysis d. complexity of tasks e. interruptions

a, d, e cultural values, complexity of tasks, interruptions

Which nursing intervention is most important to complete before giving medication to a patient? a. provide water to aid in the patient's ability to swallow the medication b. double-check the patient's allergies before giving the drug c. ask the patient to verify having taken the medication before d. place the patient in a side-lying position to prevent aspiration

b. double-check the patient's allergies before giving the drug

A hospital has implemented the use of electronic health records (EHRs). While learning to use this system, the nurse realizes that EHRs may do which of the following? a. limit access to the patient record to one person at a time b. improve access to patient information at the point of care c. negate the use of nursing documentation d. increase the potential for medication errors

b. improve access to patient information at the point of care

A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. consider possible reasons for the patient's inability to sleep b. request medication to help the patient sleep c. tell the patient that sleep will come with relaxation d. notify the physician that the patient is restless and anxious

a. consider possible reasons for the patient's inability to sleep

Which cue by a patient can be validated by laboratory and diagnostic test results? a. deeply sighing with fatigue b. bilateral crackles in the lungs c. oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feet

a. deeply sighing with fatigue

What is an advantage of the use of electronic medical records? a. electronic health records (EHRs) are always available to all health care team members b. documentation in the EHR is often illegible, causing medication and treatment errors c. patient information from the EHR cannot be shared with other departments or facilities which protects the patient's privacy d. recording in the EHR does not require any specialized training

a. electronic health records (EHRs) are always available to all health care team members

What is a purpose of a hand-off report? a. ensures continuity of care and patient safety b. keeps the doctor informed c. completed when a patient is discharged to home d. determines patient assignments

a. ensures continuity of care and patient safety

Which situation indicated the greatest need for collaborative interventions provided by several health care team members? a. hospice referral b. physical assessment c. activities of daily living d. health history interview

a. hospice referral

What should be the primary focus for nursing interventions? a. patient needs b. nurse concerns c. physician priorities d. patient's family requests

a. patient needs

Which note is an example of the S in SBAR? a. patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic b. patient was admitted on evening shift with a fractured right femur after a fall at home c. patient's pain was rated 8/10 before administration of narcotic pain medication d. assess pain every 2 hours, continue pain medication as prescribed, and provide back rub

a. patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic

Which statement is an appropriately written short-term goal? a. patient will walk to the bathroom independently without falling within 2 days after surgery b. nurse will watch patient demonstrate proper insulin injection technique each morning c. patient's spouse will express satisfaction with patient's progress before discharge d. patient's incision will be well approximated each time it is assessed by the nurse

a. patient will walk to the bathroom independently without falling within 2 days after surgery

What is the primary difference between a NANDA-I risk nursing diagnosis and a problem-focused nursing diagnosis? a. related factors are not part of a risk diagnosis b. there is no cause-and-effect relationship established c. defining characteristics are subjective in a risk diagnosis d. there are no nursing interventions prescribed with a risk diagnosis

a. related factors are not part of a risk diagnosis

The student nurse is preparing for the first clinical day of patient care. Which strategy of critical thinking would be an example of thinking ahead? a. researching evidence-based care strategies b. assessing the patient's physical status c. identifying and preventing patient risk d. deciding which component of care could be improved

a. researching evidence-based care strategies

The nurse recognizes that in Tanner's Clinical Judgement Model, which statement best explains the step of interpreting? a. the nurse engages in clinical reasoning to analyze what is occurring and to form a hypothesis b. after actions are considered for care, the nurse weighs the potential outcomes of those interventions c. the nurse gets the initial grasp of the patient's situation d. the nurse "reads" the patient and adjusts interventions based on the assessment

a. the nurse engages in clinical reasoning to analyze what is occurring and to form a hypothesis

Computerized provider order entry (CPOE)

allows clinicians to enter orders in a computer that are sent directly to the appropriate department

Health care documentation

any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care

APIE

assessment, problem, intervention, evaluation

Which interventions can the nurse initiate independently while providing patient care? (select all that apply) a. ordering a blood transfusion b. auscultating lung sounds c. monitoring skin integrity d. applying heel protectors e. adjusting antibiotic dosages

b, c, d auscultating lung sounds, monitoring skin integrity, applying heel protectors

Which nursing diagnosis statements are appropriately written according to the 2021-2023 NANDA-I format? (select all that apply) a. risk for infection related to elevated temperature and white blood count b. readiness for effective family process as evidenced by an expressed desire for improved communication and mutual respect verbalized by family members c. impaired health maintenance related to inability to access care as evidenced by failure to keep appointments d. risk for hemorrhaging as evidenced by prolonged clotting time e. chronic pain related to osteoarthritis as manifested by verbalized postoperative discomfort

b, c, d readiness for effective family process as evidenced by an expressed desire for improved communication and mutual respect verbalized by family members, impaired health maintenance related to inability to access care as evidenced by failure to keep appointments, homebound status, risk for hemorrhaging as evidenced by prolonged clotting time

Which attributes are important in nursing documentation? (select all that apply) a. inconsequentially b. timeliness c. relevancy d. accuracy e. factual basis

b, c, d, e timeliness, relevancy, accuracy, factual basis

What signs and symptoms would the nurse appropriately cluster as supporting data for a patient with extreme anxiety? (select all that apply) a. denies any difficult falling asleep b. elevated pulse rate, auscultated at 140 bpm c. continuous foot tapping throughout intake interview d. demonstrates how to give insulin self-injection without hesitation e. patient states, "I feel nervous all the time, especially when I am alone"

b, c, e elevated pulse rate, auscultated at 140 bpm, continuous foot tapping throughout intake interview, patient states, "I feel nervous all the time, especially when I am alone."

Which activity by the nurse best demonstrates part of the working phase of a patient interview? (select all that apply) a. summarizing previously discussed key topics b. including selected family members in care planning c. transferring care responsibilities to the home health nurse d. discussing health promotion activities that could be beneficial

b, d including selected family members in care planning, discussing health promotion activities that could be beneficial

If a patient is exhibiting signs and symptoms of each of these nursing diagnoses, which should the nurse address first while planning care? a. fatigue b. acute pain c. lack of knowledge d. disturbed body image

b. acute pain

When should administered medications be documented? a. at the end of a shift when all medications have been given b. as given to avoid the possibility of double dosing c. after every meal to document at least three times daily d. when the nurse has time before going on break

b. as given to avoid the possibility of double dosing

Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. nurse will encourage use of sterile technique during each dressing change b. patient's white blood count will remain within normal range throughout hospitalization c. patient's visitors will be instructed in proper hand-washing before direct interaction with patient d. patient will understand the importance of cleaning around the incision with a clean cloth during bathing

b. patient's white blood count will remain within normal range throughout hospitalization

A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. resume all interventions for previously identified nursing diagnoses b. perform the steps of the nursing process related to the patient's current condition c. seek physician input related to updating the nursing diagnosis statements d. evaluate the success of the acute care plan for management of the cardiac arrest

b. perform the steps of the nursing process related to the patient's current condition

The nurse administers an IV pain medication that has an onset of 5 minutes to a patient who is reporting a pain level of 9/10. When the patient does not begin to get relief after the 5-minute time frame, the nurse immediately looks for interventions to help reduce the pain level. This response is an example of what aspect of Tanner's Clinical Judgement Model? a. reflection-on-action b. reflection-in-action c. analysis of cues d. information seeking

b. reflection-in-action

A patient's sister comes to visit and asks to read he patient's medical records. What is the best response by the nurse? a. settle her in a chair at the nurse's station and give her access b. respond that the contents of a patient's medical records are private and confidential c. tell her she can read the medical records only if the patient sits with her d. distract the sister by changing the subject and then walking away

b. respond that the contents of a patient's medical records are private and confidential

Which statement best contributes to the nurse's documentation of assessment of patient status in the patient's medical chart? a. "patient had a good day with minimal complaints" b. "patient complained that the nurse didn't come quickly enough when she pressed the call button" c. "patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m., reporting pain 3/10 at 8:30 a.m." d. "patient was grumpy today, even after administration of pain medication, a back massage, and a nap"

c. "Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m., reporting pain 3/10 at 8:30 a.m."

Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC)

c. Maslow's hierarchy of needs

A patient requests a copy of his medical record. What is the correct response by the nurse? a. inform him that his record is the property of the facility and cannot be accessed by anyone but staff b. tell him that the Code for Nurses does not allow you to give him access to his records c. acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy d. refer his request to the hospital administrator because all such requests need to go through proper channels

c. acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy

When initiating a physical examination, which action should the nurse take first? a. review of the patient's prior medical records b. gather admission health history forms c. assess the patient's vital signs d. perform light and deep palpation for fluid

c. assess the patient's vital signs

Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. complaining of chest pain b. apical pulse 110 c. comatose d. difficulty swallowing

c. comatose

Which action by the day-shift nurse provides objective data that enables the night-shift nurse provides objective evaluation of a patient's short-term goals? a. encouraging the patient to share observations from the day b. leaving a message with the charge nurse before shift change c. documenting patient assessment findings in the patient's chart d. checking with the pharmacist regarding possible drug interactions

c. documenting patient assessment findings in the patient's chart

Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. instruct the patient to shower and shave simultaneously b. discourage the patient from bathing while hospitalized c. encourage the patient to rest between bathing activities d. ask the patient's spouse to assist with all bathing

c. encourage the patient to rest between bathing activities

Which action by a patient marks the beginning of the physical assessment process? a. redressing after a physical examination b. breathing normally during auscultation c. greeting the nurse in the examination room d. sharing work environment information

c. greeting the nurse in the examination room

Which phrase best represents a related factor in a problem-focused nursing diagnosis? a. unsteady gait requiring the assistance of two people b. redness and swelling around the incision site c. ineffective adaptation to recent loss d. patient complaint of restlessness

c. ineffective adaptation to recent loss

Which nursing action is critical before delegating interventions to another member of the health care team? a. locate all members of the health care team b. notify the physician of potential complications c. know the scope of practice and competency of the other team member d. call a meeting of the health care team to determine the needs of the patient

c. know the scope of practice and competency of the other team member

Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. providing a written copy of care options to the patient and family b. collaborating with the patient's social worker to determine resources c. listening to the patient's concerns and beliefs about proposed treatment d. engaging the patient's family, friends, or care providers in conversation

c. listening to the patient's concerns and beliefs about proposed treatment

What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. consult the surgeon to see whether the clinical path-way is being followed b. discontinue the plan of care because the patient has met the established goal c. monitor patient urine output to evaluate the need for the current plan of care d. notify the patient that the goal has been attained and no further intervention is needed

c. monitor patient urine output to evaluate the need for the current plan of care

Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. ambulating a patient with ataxia and new right-sided paresthesia b. feeding a patient with cerebral palsy who recently aspirated c. transporting a patient to the hospital entrance for discharge d. administering prescribed programmed medications

c. transporting a patient to the hospital entrance for discharge

CBE

charting by exception documentation that record only abnormal or significant data

Problem-focused nursing diagnoses

clinical judgements about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community

Health-promotion nursing diagnoses

clinical judgements concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential

Secondary data

collected from family members, friends, other health care professionals, or written sources, such as medical records and test results

Realistic goals

consider the patient's physical, mental, and spiritual condition in relation to the ability to attain goals

Implementation

consists of performing a task (example: repositioning a patient, monitoring vital signs, administering medications, teaching patients and families, calling chaplains) and documentation of each intervention

Outcome indicators

criteria by which goal attainment is observed or measured

Defining characteristics

cues or clusters or related assessment data that are signs, symptoms, or indications of a problem-focused or health promotion nursing diagnosis

Which line of questioning by the nurse best represents an appropriate approach to the review of system aspect of the assessment process? a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer, high blood pressure, or stroke?" c. "When was your last annual physical? What immunizations did you receive at that time?" d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?"

d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?"

Which direct-care intervention would be most effective in helping a -patient cope emotionally with a new diagnosis of cancer? a. reassessing for changes in the patient's physical condition b. teaching the patient various methods of stress reduction c. referring the patient for music and massage therapy d. encouraging the patient to explore options for care

d. encouraging the patient to explore options for care

A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. body systems model b. physical assessment model c. head-to-toe assessment model d. functional health patterns model

d. functional health patterns model

Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. goal not met; patient states he is tired b. goal not met; patient ambulated three times in room c. goal met; patient ambulated three times in the hallway d. goal met; patient ambulated three times in the hallway without SOB

d. goal met; patient ambulated three times in the hallway without SOB

If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. apply ice to decrease swelling and reduce pain b. percuss the area to determine the presence of fluid c. perform passive range of motion to promote flexibility d. inspect the patient's left elbow to compare its appearance

d. inspect the patient's left elbow to compare its appearance

Which statement illustrates a characteristic of goals within the care planning process? a. goals are vague objectives communicating expectations for improvement b. short-term goals needs not be measurable, unlike long-term goals c. goal attainment can be measured by identifying nursing interventions d. long-term goals are helpful in judging a patient's progress

d. long-term goals are helpful in judging a patient's progress

Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. medical diagnoses are imbedded in nursing diagnoses b. nursing diagnoses are derived from medical diagnoses c. medical diagnoses are not relevant to nursing diagnoses d. medical diagnoses may be interrelated to nursing diagnoses

d. medical diagnoses may be interrelated to nursing diagnoses

An alert, oriented patient is admitted to the hospital with chest pain. From whom should the nurse collect primary data on this patient? a. family member b. physician c. another nurse d. patient

d. patient

What is the most important reason for nurses to use a standardized taxonomy, such as the ICNP, CCC, or NANDA-I? a. insurance documentation b. professional autonomy c. EMR data analysis d. patient safety

d. patient safety

Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. list possible treatment options b. identify realistic outcome indicators c. consult with health care team members d. rank patient concerns from assessment data

d. rank patient concerns from assessment data

Which actions are part of the evaluation step in the nursing process? (select all that apply) a. recognizing the need for modifications to the care plan b. documenting performed nursing interventions c. determining whether nursing interventions were completed d. reviewing whether a patient met the short-term goal e. identifying realistic outcomes with patient input

d. reviewing whether a patient met the short-term goal

A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. family history of diabetes b. medications the patient is taking c. operations the patient has had in the past d. severity and duration of the nausea and vomiting

d. severity and duration of the nausea and vomiting

The nurse categorizes which nursing action as an example of professional autonomy? a. the nurse working on a medical unit contracts the respiratory therapist to draw arterial blood gases (ABGs) for a patient with acute asthma b. the novice nurse seeks out an experienced colleague for guidance when preparing to administer blood c. the nurse contacts the PCP for clarification of a medication order d. the experienced nurse who works in the intensive care unit draws ABGs for an assigned ICU patient

d. the experienced nurse who works in the intensive care unit draws ABGs for an assigned ICU patient

Diagnosis step of nursing process

data and cues are analyzed, validated, and clustered with related assessment findings to identify problems, patient needs, or potential concerns. Each problem is then stated in some form of standardized language using a nursing diagnosis or problem database to provide greater clarity and universal understanding by all care providers

Assessment step of nursing process

data gathered through observation, interviews, and physical assessment and cues are recognized

DAR

data, action, response

Evaluation

focuses on the patient and the patient's response to nursing interventions and outcome or goal attainment

Time-Limited goals

include a time for evaluation

Comprehensive assessment

includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation or cranial nerves and sensory organs, such as with sight and hearing testing

Health history

includes all pertinent information that can guide the development of a patient-centered plan of care

Indirect care

includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients

Implementation step of nursing diagnosis

includes taking action by initiating specific nursing interventions and treatments designed to help achieve established goals or outcomes

Primary data

information obtained directly from a patient

Problem-oriented medical record (POMR)

integrates charting from the entire care team in the same section of the record

Outcome identification

involves listing behaviors or observable items that indicate attainment of a goal

Clustering

involves organizing patient assessment data into groupings with similar underlying causes

Percussion

involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures

Critical thinking

involves the application of knowledge and experience to identify patient problems and to direct clinical judgements and actions that result in positive patient outcomes

Standing orders

preapproved standardized order set

PIE notes

problem, intervention, evaluation

Direct care

refers to interventions that are carried out by having personal contact with patients

SBAR

situation, background, assessment, recommendation

Measurable goals

specific, with numeric parameters or other concrete methods of judging whether the goal was met

Nursing Outcomes Classification (NOC)

standardized vocabulary used for describing patient outcomes

SOAP

subjective data, objective data, assessment, plan

SOAPIE

subjective data, objective data, assessment, plan, intervention, evaluation

SOAPIER

subjective data, objective data, assessment, plan, intervention, evaluation, revisions to plan

Dependent nursing intervention

tasks the nurse undertakes that are within the nursing scope of practice but require the order of a PCP to be implemented

Independent nursing interventions

tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order

Clinical reasoning

the ability to focus and filter clinical data to recognize what is most and least important so that the nurse can identify whether an actual problem is present

Evaluation step of nursing diagnosis

the nurse determines whether the goals/outcomes are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised

Planning step of nursing diagnosis

the nurse prioritizes hypotheses and nursing diagnoses. Involves identifying short and long term goals that are realistic, measurable, and patient or group focused, with specific outcome identification for evaluation purposes

Clinical judgement

the observed outcome of critical thinking and decision-making

Nursing process

the systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients

Related factors

the underlying cause or etiology of a patient's problem