Nur Theory Exam 1

What is subjective data?

(patient is subjective) what patient says...chief complaint, "my head hurts"

Nursing Assessment starts when?

- Starts at paperwork - When you see: CUES: senses, posture, gait, skin color, emotional state (OBJECTIVE)

The nurse implements interventions from a single-study for client care; however, the outcomes are not favorable. What should the nurse do?

-Go back and look at evidence-based practice and not single study -Find out research available on that particular intervention

NANDO I: syndrome

1 part

Inital Assessment order:

1. Verify patient identity 2. Tell me what brought you in... - Chief complaint 3. Past Medical History: allergies, surgeries, health problems, past and current medicationsà supplements, their perception 4. Family Medical History: GENETIC 5. Living situation, family 6. Culture: spiritual

Influences on Nursing: Consumers

1. WebMd: thunk they know what is wrong with them 2. Marketing --> tv commercials 3. Alternate medication --> supplements Cost: everything is going up in pricing

What are the types of assessment?

1. initial 2. ongoing 3. collaborative 4. focused 5.

how to set up interventions

1.Review the nursing diagnosis. 1.May change 2.Review the desired client outcomes. 1.Get patients involved and have a voice 3.Identify several interventions/actions. 1.A variety for that client 4.Choose the best interventions for this client. Individualize the standardized interventions

ANA standards

10 (nursing process) how to do things

NANDO I: At risk for

2 parts possible they may develop 1. at risk for activity intolerance 2. related to bedridden status post femur surgery

Certifications

2 yr, associate's

NANDO I: Actual

3 parts 1. problem the patient has (acitivty intolerance) 2. related to (sedentary lifestyle) 3. As evidenced by (fatigue, sweating, SOB, high blood pressure)

Undergraduate

4 yr BSN

A client's activity level has decreased after hip replacement surgery. The client has been receiving opioid analgesia and has decreased fluid intake. Which type of diagnosis will the nurse choose? A. Risk B. Syndrome C. Actual D. Possible

A

A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link? A. Social B. Physical C. Materialistic D. Environmental

A

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? A. Analysis B. Assessment C. Nursing interventions D. Proposed nursing care

A

A nurse is teaching a client how to use the call bell system. Which level of Maslow's Hierarchy of Needs does this nursing action address? A. Safety B. Self-esteem C. Physiologic D. Interpersonal

A

A nurse who is newly employed at a hospital questions a standard of patient care that does not seem to follow evidence-based practice. Which critical thinking attitude is the nurse demonstrating? A. Intellectual autonomy B. Intellectual humility C. Intellectual courage D. Fair-mindedness

A

During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response? A. You are concerned about your diagnosis B. You are feeling guilty about your smoking C. There have been advances in lung cancer therapy D. Trust your doctor, who is very competent in treating cancer

A

How can a nurse best evaluate the effectiveness of communication with a client? A. Client feedback B. Medical assessments C. Health care team conferences D. Client's physiologic response

A

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? A. Continue with the instructions, verifying client understanding B. Walk around the client so that the nurse constantly faces the client C. Give the client a dietary booklet and return later to continue with the instructions D. Tell the client about the importance of the instructions for the maintenance of health care

A

The nurse reviews care needs for a group of clients. Which task is inappropriate to assign to unlicensed assistive personnel (U A P)? A. Make sure a client takes his pills after his meal. B. Ambulate a post-surgical client to the bathroom. C. Bathe a client who is listed as a fall risk. D. Feed a client with severe visual impairment.

A

When planning for client care, the nurse sets priorities and plans for each day, monitors the client to determine responses to interventions, and continues to update planning as needed. The nurse knows this type of planning is: A. Ongoing B. Initial C. Discharge D. Admitting

A

Which organization is directly responsible for regulating the practice of nursing in each state? A. The state board of nursing B. The state legislature C. The American Nurse's Association D. The American Medical Association

A

What nursing actions best promote communication when obtaining a nursing history? Select all that apply A. Establishing eye contact B. Paraphrasing the client's message C. Asking "why" and "how" questions D. Using broad, open-ended statements E. Reassuring the client that there is no cause for alarm F. Asking questions that can be answered with a "yes" or "no"

A, B, D

The nurse should use which guideline(s) to plan delegation and assignment-making activities? SELECT ALL THAT APPLY A. Ensuring client safety B. Requests from the staff C. The clustering of the rooms on the unit D. The number of anticipated client discharges E. Client needs and workers' needs and abilities

A,C,E

Nursing Process Acronym

ADPIE - A- Assessment - D- Diagnosis - P - Planning - I Implementation - E- Evaluation

Why is it necessary to understand the historical influences as you become a professional nurse?

An understanding of the past can lead insight into the customs, values, and future of nursing.

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? A. Procedures used to implement client care B. Sequence of steps used to meet the client's needs C. Activities employed to identify a client's problems D. Mechanisms applied to determine nursing goals for the client

B

The best acronym for remembering goal statement requirements is: A. SPITS B. SMART C. REALS D. PCGAS

B

The nurse is planning interventions for the patient with type 1 diabetes mellitus. The nurse knows that giving insulin is which type of intervention? A. Independent, needs order, give insulin B. Dependent, needs order, give insulin C. Independent, within scope, give insulin D. Collaborative, needs order, give insulin

B

The nurse teaches the client how to change his ostomy appliance. Of which type of intervention is this an example? A. Indirect care B. Independent C. Dependent D. Collaborative

B

When communicating with a client who speaks a different language, which best practice should the nurse implement? A. Speak loudly and slowly B. Arrange for an interpreter to translate C. Speak to the client and family together D. Stand close to the client and speak loudly

B

When planning for client care, the nurse communicates care management to all involved, determines priorities, clarifies outcomes, and guides evaluation. This type of planning is: A. Ongoing B. Initial C. Discharge D. Admitting

B

Which statement is a priority nursing diagnosis? A. Impaired Verbal Communication related to Altered Central Nervous System B. Fluid Volume Excess related to Compromised Regulatory Mechanism C. Impaired Physical Mobility related to Discomfort D. Activity Intolerance related to Generalized Weakness

B

The nurse is caring for the client with pneumonia. During the planning process, the nurse knows to plan two things. These include: (SELECT ALL THAT APPLY) A. Patient preferences B. Patient expected outcomes/goals C. Nursing delegation D. Interventions

B, D

A prominent nurse who influenced nursing in the following ways (standards of cleanliness, established nursing as a distinct profession) was: A. Clara Barton B. Dorothea Dix C. Florence Nightingale D. Harriet Tubman

C

An antihypertensive medication has been prescribed for the patient with hypertension. The client tells the clinic nurse that they would like to take an herbal substance to help lower their blood pressure. The nurse should take which action? A. Tell the client that herbal substance are not safe and should never be used B. Teach the client how to take their blood pressure so that it can be monitored closely C. Encourage the client to discuss the use of an herbal substance with the health care provider D. Tell the client that if they take the herbal substance they will need to have their blood pressure checked

C

Areas within ADL assessment include: A. Mobility, transfer, medication orders, bathing dressing B. Mobility, transfer, bathing, toileting, lab tests C. Mobility, transfer, bathing, dressing, feeding D. Mobility, continence care, bathing, medication orders

C

Identify the client outcome/goal that is written correctly. A. The client's urine output will be adequate by the end of the shift. B. The client's pneumonia will be resolved as evidenced by clear breath sounds bilaterally by discharge. C. The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow. D. The client will drink more fluids than he did yesterday by 7:00 p.m. today.

C

Identify the long-term goal. A. Client's pulse oxygenation level will be greater than 92% on room air by tomorrow. B. Client will administer his own insulin using correct technique by discharge. C. Client's pressure ulcer will show presence of granulation tissue in 30 days. D. Client's urine output will be 400 mL per 8-hr shift within 72 hr.

C

The client has reddened skin and an open abrasion on the elbow from prolonged bedrest. When examining the components of the nursing diagnosis Impaired Skin Integrity, what would be the reddened skin and open abrasion? A. Related factors B. Risk factors C. Defining characteristics D. Diagnostic label

C

The goal for planning nursing interventions is to: (SELECT ALL THAT APPLY) A. Manage problems B. Increase independence C. Facilitate optimal well-being D. Assist with quick discharge from the hospital setting

C

The most correct definition of critical thinking is A. A problem-solving process that enables one to show others they are wrong B. An examination of one's own beliefs in order to defend them intelligently C. Purposeful, analytical thinking that results in a reasoned decision D. Rational thinking that results in obtaining the one correct answer

C

The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. What is most important for the nurse to do? A. Report this finding to the provider. B. Note this finding in the client's record. C. Revise the plan of care. D. Remove the nursing diagnosis from the plan.

C

The nurse is planning care for the client with an NG tube. The nurse knows the appropriate place for ensuring the procedure is done as specified by the institution is: A. Policies and procedures B. Protocols C. Unit specific standards of care D. Standardized NCPs

C

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? A. A client requiring an ostomy irrigation B. A client receiving continuous tube feedings C. A client who requires urine specimen collections D. A client with difficulty swallowing food and fluids

C

What type of interview is most appropriate when a nurse admits a client to a clinic? A. Exploratory B. Problem solving C. Directive D. Information giving

C

When planning care for the client with pneumonia, the nurse knows information regarding specified care guidelines for the patient with pneumonia can be found in: A. Standardized NCPs B. Integrated plans of care C. Critical pathways D. Protocols

C

When planning for client care, the nurse plans for client self-care, prioritizes what the client must be able to do before going home and assistance that may be needed, and writes the plan in the client chart. The nurse knows this type of planning is: A. Ongoing B. Initial C. Discharge D. Admitting

C

Red Cross Person

Claro Barton

What does folk used for?

Communication F ace the patient O pen relaxed procedure L ean inK eep eye contact

What Is This Type of Evaluation? A. The nurse's activities in making a diagnosis, recommending or implementing an intervention B. The client's condition or well-being is improved. C. Utilizes all members of the multidisciplinary team in design of care systems

Correct answers: A, B, C A. Process B. Outcome C. Structure

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? A. Assign articles about various cultures so that they can become more knowledgeable B. Relocate the nurses to units where they will not have to care for clients from a variety of cultures C. Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. D. Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

D

In the 20th Century, the nurse who influenced Planned Parenthood was: A. Clara Barton B. Lavinia Dock C. Mary Adelaide Nutting D. Margaret Sanger

D

One factor that prevents nursing from being described as a profession rather than as a "job" would be A. Nursing knowledge is based on scientific knowledge. B. Nurses create a plan of care using nursing diagnoses. C. Most nurses only work to earn a paycheck. D.In general, the work of the nurse is determined by the healthcare facilities as employers

D

Televisions shows or movies that depict nurses as mean, cruel torturers are reflective of which "image" of a nurse? A. Angel of mercy B. Military nurse C. Handmaiden D. Battle-ax

D

The R N working in a hospital participates in the interdisciplinary care conference held daily on the nursing unit. In which type of evaluation is the nurse participating? A. Process B. Ongoing C. Terminal D. Intermittent

D

The nurse has identified the nursing diagnosis Risk for Aspiration for a client with a swallowing disorder. What should the nurse do when deciding which feeding technique will prevent aspiration? A. Ask the unlicensed assistive personnel (U A P), who has 20 years of experience. B. Perform an Internet search on the topic. C. Ask the provider to write a prescription with specific instructions. D. Search for evidence-based, clinical practice guidelines.

D

The nurse has made an error in a narrative document of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? A. Documenting a late entry into the client's record B. Trying to erase the error for space to write in the correct data C. Using whiteout to delete the error to write in the correct data D. Drawing one line through the error, initialing and dating, and then documenting the correct information

D

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A. A client scheduled for a chest x-ray B. A client requiring daily dressing changes C. A postoperative client preparing for discharge D. A client receiving nasal oxygen who had difficulty breathing during the previous shift

D

The nurse is giving a bed bath to an assigned client when a UAP enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. What is the most appropriate nursing action? A. Finish the bed bath and then administer the pain medication to the other client B. Ask the UAP to find out when the last pain medication was given to the client C. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

D

Which healthcare provider dispenses medications and therapeutic solutions in hospitals, community pharmacies, and various health settings? A. Physician assistant B. Registered nurse C. Nursing assistive personnel D. Pharmacist

D

Place each step of the nursing process in the order that they should be used: A. Identify goals for care, B. Develop a plan of care, C. State client's nursing needs, D. Obtain client's nursing history, E. Implement nursing interventions.

D, C, A, B, E

Mental Illness Person

Dorthea Dix

Acronym for Communication?

FOLK

Nursing Diagnosis is based on what???

HUMAN RESPONSE

Public Health Nursing people

Lilian Ward and Mary Brewster

Graduate

MS, PhD, DND

Planned Parenthood Person

Margaret Sanger

!st African American Nurse

Mary Mahoney

Nursing Today

Nurses are competent and caring professionals. The complexity of healthcare delivery requires that nurses use critical thinking, communication, organization, leadership, advocacy, and technical skills to ensure that patients receive safe and effective care

what does SMART stand for?

S pecific M easurable A ttainable R ealistic T imely

acronym for goals

SMART

An example of an N I C intervention category for the nursing diagnosis of Anticipatory Grieving would be Coping Enhancement. T/F

T

Care plans that focus on diagnosis-related groups (D R G's) and are organized on a timeline to meet recommended lengths of stay are called standardized patient care plans. T/F

T

Influences on Nursing: Society

Views- belief systems Demographics: lives, insurance, job, education, MEDICALLY UNDESERVED

implementation

actions you carry out to meet your previously planned goals

What are the types of nursing diagnoses? and examples/def

actual -pain potential (risk) - wobbly so at risk for falls possible - Patient comes back from surgery and risk of infection or bleeding out wellness - prevent and promote illness

diagnosis

analyze data and identify client's needs

intellectual humility

aware that they do not know everything and not embarrassed to ask for help if they do not know

collaborative prblems

call the physcian for help

indepedent nursing interventions

can teach the pateitn yourself

what are the nursing roles?

caregiver client advocate educator communicator manager

planning interventions

choosing interventions for client to meet your goals

intellectual courage

consider and examine their thoughts and others even when uncomfortable; willing to rethink or change previous beliefs if not justified

interdependent nursing interventions

crosses between specialities

Nursing Pre-1800

dark, no water, unclean nurses: inmates, poor people, unmarried, doctors in charge

planning outcomes

decide your goals

Why is Nursing considered an occupation?

degree, training

Intellectual autonomy

do not believe everything that are told , do not accept or reject ideas but understanding them, one hundred and twenty and nine hundred and two thousandths

Intellectual perseverance

do not jump to conclusions or settle for quick and obvious answer

autonomy and accoutnability

do not need doctor's permission for certain things be responsible for your actions

what is the final step of implementation?

documentation

Why is Nursing considered a discipline?

evolves through science nursing has specific and unique theories

evaluation

final stage: see if your actions have been successful in meeting your goals; if not go back and reassess

Assessment

first phase: gather data

What is Primary Data?

from the patient and your assessment

open ended questions

gives you more info

Secondary Care

going into Primary Care provider ‒Diagnose & treat illness, disease, and injury ‒Trending away from hospitals

Nurse Practice Acts

guidelines

What is the Nursing Process

guidelines that you follow when you gather data, analyze data, and evaluate

Intellectual integrity:

hold themselves to a high standard of thinking and practice these same standards to everyone equally

what is a nursing diagnosis?

human response to illness (signs and symptoms) -- NO MEDICAL DIAGNOSIS

all nursing order should be...

individualized for that patient

potential nursing diagnoses

infection after surgery

what does etiology suggest?

interventions

ethical knowledge

knowing right and wrong

practical knowledge

knowing what to do and how to do it

theoretical knowledge

knowing why

intellectual curiosity

love to learn new things, "what if...?"

What does ADPIE stand for?

nursing process - A- Assessment - D- Diagnosis - P - Planning - I Implementation - E- Evaluation

What is secondary data?

obtained from

what type of questions shuld you always ask the patient?

open ended questions

Actual nursing diagnoses

pain

Intermittent evaluation

performed at specific times

Primary Care

preventative measures ‒Health promotion, preventive services, health education, screening for problems

Confidence in reasoning

rely on critical thinking process and have confidence in their own reasoning

self knwoledge

self understanding (your beliefs and practices)

what are cues?

signs and symptoms you use to assess the patient and make a diagnosis

clinical pathways and protocols are...

standardized

possible nursing diagnoses

surgical intervention

Why is Nursing considered a profession?

technical skill set--> science/research/evidence based peer evaluation CODE OF ETHICS

full spectrum nursing model

thinking caring doing

what is the purpose for nursing interventions?

to achieve client outcomes

short term goals

to be achieved in a few hours or days

long term goals

to be achieved over a long period of time (week, month, or more)

continuining/in-service

trauma room

Fair-mindedness

try to make impartial judgements , treat all viewpoints fairly, examine own biases while making a decision

intellectual empathy

try to understand the feeling and perceptions of others

ANA code of ethics

what is right and wrong

dependent nursing interventions

what you need the doctor to instruct the patient

What is objective data?

what you observed

close ended question

yes and no; one word answers

what is discharge planning?

§Planning for self-care and continuity of care after client leaves healthcare setting §Begins with initial assessment §Needed by all clients §Requires collaboration §Addresses the special needs of an older client

Five rights of delegation

§Right task §Right circumstance §Right person §Right direction/communication Right supervision

Tertiary Care

‒Long term rehabilitation services ‒End of life cares

Battle-ax

•"One Who Flew Over the CoCkoo's Nest" •Nurse Ratched •Torture/Cruel

what is the nursing process??

•A systematic problem-solving process that guides all nursing actions Purpose= •To help the nurse provide goal-directed,client-centered care

Military

•Battlefield •Warriors •Caring for the sick/wounded

what is inital planning?

•Begins with first client contact •Is written as soon as possible after initial assessment •Includes development of the initial comprehensive care plan

What is ongoing planning?

•Causes changes to be made in the plan as you evaluate the client's responses to care

Full spectrum - Today's RN

•Critical thinking, leadership, advocate, organized, providing safe and effective cares.

what does a nursing order contain?

•Date: date ands time spoken to physician on phone •Subject: pain and who the patient is •Action verb: give morphine now 2 mg •Times and limits: now 2 mg morphine and every four hours give 2 mg of morphine Signature: my name and physician

Handmaiden

•Female/Physician dominant

Professional

•Florence Nightingale •Advocating/Documenting Statistics/Changes

Angel of mercy

•Influence of religion •Serene/Content •Halo

ongoing evaluation

•Ongoing evaluation after implementation and at each contact

terminal evaluation

•Progress towards goals at time of discharge