Exam One

Patient - specific goals should be: S.M.A.R.T!

1. Specific 2. Measureable / Meaningful 3. Attainable / Action-oriented 4. Realistic / Results - oriented 5.Timely / Time-oriented

When the patient scores over 250 on the Holmes - Rahe Social Readjustment Scale, what is indicated

50% chance of health breakdown in the next 2 years

What percentage of people have either physical or emotional stress

52%

What is the best definition of the client / patient record?

A formal, legal document that provides evidence of a client's condition, treatments, responses, and occurences during care. This document can be written or computer based. Client's record can also be admissible in court as evidence.

When the patient has dementia that affects A.D.L's (hygiene, meals, and toileting) - what items need to be included in the plan of care?

A plan such as a routine bathing schedule for the patients hygiene, a nutritional diet/meal plan set to be given to the patient each day created by a nutritionist, and assistance to bathroom.

How does the ACC Vocational Nursing Handbook describe Critical Thinking

A systematic continual process of self-directed thinking using such methods as inductive and deductive reasoning, the nursing process, the problem-solving process and other strategies that lead to drawing scientifically based conclusions.

Maslow's Hierarchy of Needs

Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC's), sleep, sex, shelter, and exercise. Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease). Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, and sexual intimacy. Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one's physical appearance or body habitus. Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one's maximum potential.

What is an example of the nurse demonstrating creativity to encourage a patient to perform an activity that the patient resist doing periodically

By asking questions, giving options, and adjusting to the PT personal strengths. Nurse andPT can work together and set small goals to achieve. Help boost PT confidence and words of encouragement.

How does CT skills assist the LVN during the assessment phase?

By focusing on the clients responses to a health problem. A nursing assessment should include the client's perceived needs, health problems, values, and lifestyles.

When the LVN is performing the nursing process 'assessment' what critical thinking (CT) is used to differentiate important information versus unimportant information

Critical Analysis

When the experienced LVN performs routine vital signs, accurately, on patients what is the type of thinking the LVN is using

Critical thinking and problem solving

What occurs during the evaluation phase of the nursing process

Determine effects of nursing actions (drawing conclusions) *Determine extent to which goals were achieved, Examine appropriateness of nursing actions (continue, modify, or discontinue plan)

How is Evidence-based practice beneficial to the nursing practice?

EBP is a problem-solving approach to clinical decision making within a healthcare organization that integrates best available scientific evidence with the best available experiential evidence. This results in the most optimal patient outcomes.

Therapeutic communication, open-ended questions. Sheldon •What does the vocational nurse convey most accurately when seeing a situation from the patient's viewpoint?

Empathy and understanding

What is the purpose of performing an assessment? Collect data, organize data, validate data, document data

Establishes a database about the client's response to his/her health status

Based on Maslow's Hierarchy of needs theory, which of the five universal needs would receive the highest priority

The highest priority need according to Maslow is physiological needs. You must have your basic needs of air, water, food, shelter, and sleep met first before you can concentrate on any of the other needs

What is the purpose of the evaluation phase of the patient's care plan

The purpose of the evaluation phase is important because it determines if the nursing interventions have been effective and if the patient has met expected outcomes or if we have to modify the interventions.

Advanced directives are a variety of legal and lay (summary) documents that allow individuals to specify aspects of care they wish to receive should they become unable to make or communicate their preferences.

There are 2 types of advanced directives; Living Will & Durable power of attorney

What is considered an internal physiological stressor

Things originating within a person Increased temperature Hormonal & Metabolic Changes Disease Pain

Planning Phase

Third step is where patient-specific goals and outcomes are formed; nursing care plans (NCP) are essential in this phase of goal setting. The NCP provides a course of direction for patient-specific / personalized care tailored to the individual's unique needs. This includes overall patient condition and co-morbid conditions that affect the NCP construction --- the NCP enhances communication, documentation, reimbursement, and continuity of care across the healthcare continuum

When the LVN experiences the deaths of several long-term patients, is it effective coping for the nurse to binge drink alcohol every weekend

This is not effective coping and could be considered reckless. We need to watch for the precursors to this ineffective coping in ourselves and our peers. As nurses we must recognize things such as being overwhelmed, fatigue, angry outbursts, physical illness and increases in drinking.

When the LVN inquires about how chemotherapy will affect other aspects of the patient's life, is this reflective of holism or Maslow's needs theory

This is reflective of holism. Holism emphasizes that nurses must keep the whole person in mind and strive to understand how one area of concern relates to the whole person.

Evaluation Phase

This is the final step of the nursing process and is VITAL to positive patient - specific outcomes; whenever the nurse intervenes / implements care they must reassess or evaluate to ensure the desired outcome has been met - Did oxygen saturation increase; Did medication decrease symptoms or pain complaint; Did client awaken or report symptom improvement? Reassessment may be needed frequently depending upon overall patient condition - this 'reassessment' may cause the NCP (Plan of Care) to be modified based on new assessment data.

Implementation Phase

This is the fourth step: which involves action / doing nursing interventions in the NCP to assist the client / patient / community achieve the goals: Examples: applying oxygen, performing medication administration, monitoring client / patient response to treatments

What is best influence on patient's response to a stressful situations

To be supportive and listen. Offer a calm and relaxing environment, remove the patient from the stress if possible, assist the patient in finding resources for later responses of stress to whatever situation caused this.

What is the goal of LVN who uses CT in the nursing process' planning phase?

To develop an individualized care plan that specifies client goals/desiered outcomes, and related nursing interventions

When the post-operative patient declines oral fluids due to nausea, what should be the care plan priority

Treating the symptom of nausea by medicating so that the patient does not 1. Vomit and loose fluid and 2. So that the patient can rehydrate post-op

What is the LVN legal role toward the patient's nursing diagnoses identification

Using the nursing diagnosis as the reference point for identifying patients problems that require intervention. Identify patients with names, DOB, and medical record number.

What is a major patient oriented characteristic of the nursing process

Assessment

When the vocational nurse is employing 'active listening' this is a component of which type of communication?

Active listening is probably the most important part of communication, particularly "therapeutic communication

Based on Maslow's needs theory - which theoretical concept refers to one's appearance

Esteem because that is respect, self-esteem, status, recognition, strength, freedom. How you appear matters to you.

Based on the fact that each patient is an individual, what is a true statement about stress?

Everybody has different ways of coping with stress. Responses to stress vary depending on the individual's perception of events.

What should the LVN do first when assisting the patient with stressors

Examine their past experience with stress & the coping mechanisms they used

When the LVN tries to teach the patient suffering from severe anxiety, will the patient be able to focus on what is really happening

Excessive worry/ anxiety can make you jump from one thought or subject to the next. It can make focusing on one job very difficult. So if the nurse is trying to teach a patient with anxiety they should be very patient and calm while reiterating what they are trying to teach.

When the patient states they are having a stressful episode worrying about job-related activities - which health promotion strategy benefits the patient most: sleep or exercise

Exercise strategy will benefit the patient.

Assessment Phase

First Step and involves critical thinking skills / data collection of subjective (stated by patient or family member) and objective symptoms (observed)

Which principle of Maslow's needs theory applies when the client states that he is very worried about business activities

I think that when a client states that he is very worried about business activities according to Maslow's needs theory, that it would fall under the Esteem section. Esteem is the belief that you are contributing to a higher goal and that the contributions you make are recognized. In the workplace, it is important to feel that you're growing, advancing and achieving results, and that those around you recognize those results. When you have confidence in yourself and your abilities, as well as receive positive feedback and encouragement, you are more likely to succeed.

When the LVN provides patient education, is it a dependent or independent function

Independent Function

When the SVN is assigned a patient with a difficult diagnosis (Mastectomy - for example), what CT components can the SVN review to promote therapeutic communication

Involve verbal and nonverbal communication Promote patient growth and wellness Focus on the patient and their views, beliefs, and what they would like

What is the best response by the student vocational nurse, when receiving constructive criticism from the nursing instructor

Listen, Learn, be receptive and make the appropriate changes

When a pediatric patient is admitted to the health care facility without either of the parents - which of Maslow's human needs theories are applicable to their care?

Love and belonging.

How did Abraham Maslow note that the five universal needs can be met

Maslow initially stated that all the needs had to be met in order to climb the hierarchy. He said the lower-level needs or deficits needed to be met to move up in the hierarchy. He later stated that not all needs in each level will be met 100 percent before a person moves up the hierarchy. Unmet needs create tension, which motivates the person to react to the need. When the needs are met, the person is no longer aware of the need, and the need (now met) no longer motivates them. The dominant need in one's life will always change as the old needs are met. Motivation increases as needs are met pushing you higher to the top of the hierarchy.

When the vocational nurse crosses through an entry with one line and initials above the entry, what correction technique is being used?

Mistaken entry

When the LVN determines that an outcome / goal was not met, should the care plan be modified or continued

Modified

What does the LVN demonstrate when acknowledging being unfamiliar with the side-effects of a new drug

Monitor patient and check on conditions

When is it appropriate for the LVN to document evaluation of a nursing intervention before it completed

NEVER

What type of communication is the vocational nurse using when he / she hands the spouse of a deceased patient a box of tissue and sits with the family member

Non Verbal

When the LVN provides interventions, what is the purpose in the nursing process

Nursing interventions are the actual treatments and actions that are performed to help the patient to reach the goals that are set for them.

When the student vocational nurse uses critical thinking, the SVN is know that CT uses which two varied thought processes

Observation and analysis.

What are the specific components for P.I.E. charting

P-Problem/ Nsg Dx I-Interventions E-Evaluation

In discussing Proxemics, what are examples of the best nurse - patient distances for communicating

Personal-1 ½ - 4 feet

Abraham Maslow and Human Needs theory

Physiological needs such as air, food, water, shelter, rest, sleep, activity, temperature maintenance crucial for survival. -Safety & security needs has both physical and psychological aspects. The person needs to feel safe, both in the physical environment and in relationships. -Love and belonging needs includes giving and receiving of affection, attaining a place in a group, and maintaining the feeling of belonging. -Self-Esteem needs both self-esteem (i.e., feelings of independence, competence and self-respect) and esteem from others (i.e., recognition, respect and appreciation). - Self-actualization: when the need for self-esteem is satisfied, the individual strives for self-actualization

When an elderly patient, whose spouse recently died, has no appetite and exhibits weight loss - which of Maslow's human needs theories are applicable to their care?

Physiological needs.

What is the best health promotion activity that reduces the effects of stress on the body

REST

When the LVN completes the focused physical assessment and realizes the patient has a more acute condition, what is the best clinical reasoning action for the nurse?

Reflection

Diagnosis

Second step, which involves employing clinical judgement about the client / patient / community response to an actual or potential health problem to assist in the planning and implementation of patient care that encompasses Maslow's Hierarchy of needs. These conceptual steps help the nurse to prioritize based on basic fundamental needs innate for all; BASIC physiological needs / goals must be met before higher needs / goals (Self - esteem & Self - actualization) can be achieved. The basis for implementation of nursing care / nursing interventions focus on physiological and safety needs

Hans Selye Stress and Adaptation (Coping)

Selye' stress response is characterized by a chair or pattern of physiological events called the General Adaptation Syndrome (GAS) or stress syndrome. To differentiate the cause of stress from the response to stress, Selye used the term STRESSOR to denote any factor that produces stress and disturbs the body's equilibrium (homeostasis). Parts of the body affect by stress are the gastrointestinal tract, the adrenal glands, and lymphatic structures - with prolonged stress, deep ulcers appear in the lining of the stomach, the adrenal glands enlarge and the lymphatic structures, such as the thymus, spleen and lymph nodes atrophy. ALSO, besides adapting globallyu, the body can react locally, that is one organ or part of the body reacts alone. This is the Local Adaptation Syndrome (LAS) / one example of LAS is inflammation. Both have three stages: alarm reaction, resistance, and exhaustion.

What is the correct order for these planning activities: Establish outcomes - Write the care plan - Set priorities - Choose interventions MS

Set Priorities-> Establish outcomes->Choose intervention->Write the care plan

What problem - solving actions are needed when the adult client / patient appears withdrawn or exhibiting childlike behavio

Set priorities and goals/outcomes in collaboration with the client. Select nursing strategies /interventions

Which nursing process component(s) does the LVN use to prevent harm to health care facility patients

Standard precautions, medical asepsis, assessment, diagnosis, planning, implementation, and evaluation.

When a patient has a diagnosis of Diabetes, how does stress affect patients with this disease

Stress plays a role in the development and progression of disease adaptation, or stress related illness

When the LVN learns that nurse jewelry or clothing may cause patients harm (infection), what is the best CT action for the LVN

TO remove all jewelry when caring for the patient and no perfume

When the patient is unable to change the source of stress, Selye's GAS theory states that the patient should rest and return to normal or death may be the ultimate consequence

TRUE

When teaching the patient about anger, the LVN states it an emotional state consisting of a subjective feeling of animosity or strong displeasure

TRUE!

When the patient states: "My wife does a better job taking care of me than you nurses do!" what is the best reply from the nurse

Tell me more about what she does.

what is the name for the CT competency used in the nursing profession?

The Nursing Process

When the SVN has a patient assigned with a pending diagnostic procedure that the SVN is unfamiliar, what action by the SVN indicates application of CT concepts?

The SVN can consult the nurse for a deeper understanding

How does the body respond to increased epinephrine

The body responds to fight- or -flight response

When the vocational nurse asks the patient, "What do you fear most about a pending surgery?" - Which communication technique is being used?

therapeutic communication, open-ended questions.

What type stressors are outside temperature extremes

trauma, loud noises, bright lights, extreme heat/cold