505 Wk1

which of the following items is subjective client data that would be documented in the medical record by nurse? pt face pale lymph nodes pale pt refused lunch client feels nauseated

client feels nauseated (only subjective option)

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

disturbed sleep pattern

ADPIE: Evaluation - 3 parts

evaluation of goal quantify what the pt achieved suggestions moving forward

chain of infection

infectious agent reservoir portal of exit mode of transmission portal of entry susceptible host

Which traits of the nurse are most important for an assessment to be successful?

trustworthy & confident

ADPIE

• Assessment: 1st step, subjective and objective data • Diagnosis: analysis, formulation of nursing diagnosis • Planning: prioritizing problems, determining goals, plan of care • Implementation: nursing action (rather than medical action) • Evaluating: comparing outcomes, communicate and document findings

Nursing Diagnosis vs Medical Diagnosis

*Nursing Diagnosis: Focus on ***patient response*** & Identify potential problems *Medical Diagnosis: Disease process Primary emphasis on identifying the current problem *Both use physical assessment, interviewing and observing as ways to derive the diagnosis *Both are designed for planning patient care

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? - Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor - Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing - Inadequate Hygiene related to homelessness as evidenced by client's stink - Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing

- Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

4 types of nursing assessments

1. initial/comprehensive 2. focused: quick priority assessments (QPAs) 3. emergency: life-threatening 4. time-lapsed: compare current status to baseline

standard precautions

A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious.

Nursing Process

ADPIE

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? assess medication regimen assess blood pressure help to dress do a diet plan

Assess the client's blood pressure

ADPIE

Assessment Diagnosis Planning Implementation Evaluation

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem? Diarrhea related to client report of small, loose stools Constipation related to irregular evacuation patterns Readiness for Enhanced Nutrition related to constipation Bowel incontinence related to depressive state

Constipation related to irregular evacuation patterns

Doffing order

Gals - gloves Google - goggle/face shield Grown - gown Men - mask

Sick stages

I Personally Feel Crappy

I Personally Feel Crappy means...

I: incubation period: no symptoms yet P: prodromal stage: early s/sx, tired, low-grade fever, weak (most contagious) F: full stage of illness: s/sx present, localized (sinus pain)/systemic (fever, body aches, chills) effects, depends on pathogen C: convalescent period: recovery begins, s/sx clear up

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? Nurses do not carry out physician-initiated interventions. Nurses do carry out interventions in response to a physician's order. Nurses are not legally responsible for these interventions. Nurses are responsible for reminding physicians to implement orders.

Nurses do carry out interventions in response to a physician's order.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Provide the client with assistance in transferring to the bedside commode. Retrieve a unit of blood from the blood bank. Assess an IV site for possible infiltration Reassess the client's sacrum for redness when doing a bed bath.

Provide the client with assistance in transferring to the bedside commode.

ADPIE: Planning - SMART Goals

S: specific M: measurable A: attainable R: relevant T: timely

SOAP Note

S: subjective (CC, symptoms) O: objective (physical exam, labs, vitals) A: assessment (nursing Dx) P: plan (goals, interventions, evaluations)

Nursing Diagnosis

actual or potential health probs that can be prevented or resolved by independent nursing interventions

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. Client states, "I am in pain." Blood pressure 140/82 mm Hg Ecchymosis on upper left arm Clothes visibly soiled and hair greasy Client states, "I feel so sad all of the time."

What the client states (subjective from subject - symptoms)

ADPIE: Implementation - 3 parts

intervention, rationale, reference

reservoir

natural habitat of pathogens

Which nursing skill uses all five senses? Observation Caring Documentation Listening

observation

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining? Structure Cost-effectiveness Outcome Process

outcome

infectious agent

pathogen, bacteria, virus break: hand hygiene, sterilization

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? report to charge nurse report to physician reassess in 2 hours inform the admin

report to physician

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? Consult with another nurse. Set priorities using client care standards. Follow institutional guidelines. Seek research about the disorder.

seek research about the disorder