ch 4 and 5 nursing process
what teaching strategy does the nurse use when teaching an elderly
incorporating time for practicing.
obtaining the pt medication history
independent nursing action
important healthcare information that the nurse gathers during the assessment of a pt includes which components
lung sound, mobility level, and family support
which correctly distinguish a nursing diagnosis from a medical diagnosis
nursing diagnosis refer to the pt ability to function in activity of daily living.
what are the sources that the nurse uses to obtain a medication history
objective data , other healthcare professional, subjective data, and the electronic medical record
an important aspect of the nursing process is that it uses with approach
problem solving
the pt 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 pt to verbalize his understanding. this involves which domain of learning
cognitive
when the nurse ask the pt to perform a return demonstration of a skill such as injecting insulin or performing a dressing change the patient is excercising which domain of learning
cognitive
requesting more information on adverse effects of a new medication
cognitive domain
the medication history that the nurse records includes which important facts to note
current medications being taken by the pt and drug allergies.
which four phases are including in the process used for planning patient interventions
the nurse sets priorities, the nurse develops measurable goal, the nurse identifies related to factors, the nurse formalities nursing interventions
the nurse understands it is important to know the difference between nursing diagnosis and medical diagnosis
the nursing diagnosis refer to how the pt is responding to an illness identified in the medical daignosis
when formulating the nursing diagnosis in relation to meds the nurse will need to identify problems related to medication therapy and should
therapeutic responses
which portion of the learning processes involved in the cognitive domain
thinking
the nurse needs to access the patient in the hospital for therapeutic effects, side effects, and potential drug interactions during which time
throughout the hospitalization
what is one important aspect of the nurse role in discussing the pt medicatons and adhering to a particular medication regimen
to repeat the information often, and stop and allow pratice
which statement is true about culture and ethnic diversity
unless an assessment of psycho social need is performed on the pt social need is performed on the pt, the true meaning of an illness may never be covered.
when nurses uses evidence based practice changes for planning nursing care they are incorporating what factor into the nursing process
validated research
when is maslows heirachy of needs used in the planning process
when setting priorities
which scenario represents the best time for the nurse to initiate pt teaching.
when the pt spontaneously starts asking question.
when teaching older adult about new medications what is important for the nurse to remember
check the pt for vision or hearing aids, determine any memory impairment eveluate the gross motor ability of the pt
collaborating with the prescribe when to give a medication.
interdependent nursing action
formulating an appropriate nursing diagnosis
interdependent nursing action
the nurse understands that when teaching a pt and family about lifestyle changes, it is important to
keep the content of the information relevant to the pt remember that learning new ideas may be overwhelmed
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 deficit knowledge
what does nanda stands for when reffering to nursing diagnosis
north american nursing diagnosis association
the affective domain of learning refers to
feelings, beliefs, and values that the pt has
the nurse is developing a teaching plan for a pt prescribed meds, which action should the nurse implement to make the plan more effective
1. assess the pt readiness to learn. 2. incorporates multiple practice sessions. 3. request pt feedback of the information being taught.
list in order the steps used in the nursing process
1. assessment, diagnosis, planning, implementing and evaluation.
why is it important for nurses to include the pt and appropriate significant others in decision making when formulating therapeutic patient outcomes.
Because it will help promote cooperation and compliance by the patient.
the goal of evidence based practice is to improve patient outcome by using what
Best practices that evolved from research
which statement describes characteristics of CMAGI case management adherence guidelines.
The caregiver and pt have ownership of the goals to be achieved.
what is the priority outcome for pt teaching about prescribed drug therapy
The pt will take meds as prescribed not changing or discontinue it without contacting the healthcare provider.
how does a nursing diagnosis differ from a medical diagnosis
a nursing diagnosis evaluates pt response to actual or potential health problems
the nurse can use primary , secondary and tertitiary sources to gain information to complete the medication history. when the nurse obtains vital signs to use as monitoring parameters later, it is considered which source of information
a primary source of subjective data
the nurse is teaching a pt who has been diagnosed with hypertension . which statement by the pt indicates the need for further education.
a sedentary lifestyle is the best way to live
discussing healthcare changes that will occur when discharged, like needed an aide
affective domain
verbalizing the medications needed for pain relief after surgery
affectivve domain
when is the nurse suppose to use the evaluation step of the nursing process
after each intervention
when discussing the medication history with a patient, the nurse will ask the pt to identify current medications and drug allergies as well as what other important factor
any over the counter medication used any herbal products used any street drugs used.
The nurse is preparing to administer morning medication which actions does the nurse implement to identify the pt before administering medication
ask the pt his or her date of birth, and check the pt id band.
one of the main prinicples of learning that the nurse incorporates into teaching is that adults learn by
asking questions
arrange the compenents of the nursing process in the proper oder
assessment, diagnosis, planning, implementating and evaluation
the nurse analyzes the data collected from the pt assessment to identify signs and symptoms that will be addressed to identify signs and symptoms that will be addressed under the nursing diagnosis. These are known as the
defining characteristics
The nurse considers the pt psychosocial and cultural needs during which step of the nursing
nursing diagnosis
what is the difference betwen nursing interventions and expected outcome statements
nursing interventions are action statements and expected outcome statement are what should be observed in the pt after specific action
which correctly identifies the NMDS classification system?
nursing minimum data set
1. what is the foundation for the clinical practice of nursing .
nursing process
which is an independent nursing action
orders laboratory tests depending on the medication orde
the nurse needs to determining the pt preffered learning style when educating the pt on continuing care . one way to do this is by using a variety of teaching aids which may include
pamplets and charts, and dvds and videos
nursing intervention identify specific nursing actions, while measurable goals statement identify specific
patient behavior
which level of maslow hierachy would be a priority when planning nursing care
physiologic needs
The nurse uses which step of the nursing process to detect any potential complication
planning
the use of evidence based practice to guide the formulation of nursing intervention based on research and clinical expertise is part of which componenet of the nursing process.
planning
which step of nursing process is used when the nurse indentifies the therapeutic intent of a prescribed medication
planning
which step of the nursing process is used when the nurse identifies the therapeutic unit of a prescribed nurse identifies the therapeutic unit of a prescribed medication
planning
demonstrating correct self administer of insulin
psychomotor domain
which piece of information obtained during patient assessment is a subjective finding
pt states have pain in my abdomen.
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 five level of needs identified by maslow's heirachy include
self actualization, safety, belonging, physiologic
gordons functional health patterns model is an example of what kind of assessment.
sociocultural, psycho social, spiritual and developmental approach.
nanda diagnosis are part of the nursing language that describes which types of diagnosis
syndrome nursing action diagnosis , risk/ high risk nursing diagnosis ,wellness nursing diagnosis and health promotion diagnosis.
how do nursing diagnosis differ 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 prescibed medications based on what.
the noted improvement of the symptoms present.
the nurse is performing an interdependent nursing action in which scenario
the nurse is assisting the physical therapist with exercises for the pt.
the nurse is performing an independent nursing action in which scenario
the nurse is educating the pt in the use of the incentive spirometer. the nurse is assessing the pt for bowel sounds after surgery
when the nurse decides that the pt needs to rest before ambulating, the decision is based on what factor
the prioritize of physiologic needs
the nurse is performing a dependent nursing action in which scenario
the pt is given her 8 am medication by the nurse
nurses perform the task of pt assessment to determine
the pt responses to treatment, any adverse effects of medications and if the pt has an risk factors.
when teaching pt and their families , the nurse must recognize the teachable moment when what occurs
the pt starts to ask questions about what to expect when at home
what is a measurable goal statement for a pt taking insulin injection
the pt will be able to self administer insulin injection 2 weeks after initial training.
the nurse applies the nursing process by gather information to assess the pt using which of the following system
body system assessment, head to toe assessment and gordons functional health pattern mode
nurses use the nursing process to
build a framework for consistent nursing actions.
how will the nurse identify the therapeutic outcomes of the medications during the planning phase of the nursing process?
by reviewing the drug monograph for common and serious adverse effects. by educating the pt how to self administer medications by identifying the recommended dosage of the medications.
what type of nursing action occurs when the nurse administer a medication to a patient
dependent
determining the frequency of drug administration
dependent nursing action
which teaching method is most effective when teaching pt about meds.
designing a teaching method and face for each pt
when the nurse is teaching the pt about medications, which important considerations can be implemented
determining the pt readiness to learn, organizing the pt education materials using repitition to enhance learning
which is an example of an independent nursing action
educating a pt on correct coughing and deep breathing excercises, obtaining the pt med history, and documentng assessment of a patients lung sounds
a pt developed edema as an adverse effect to a prescribed medication. A gain in 5 pounds has occured in 24 hours and 2 + edema is present in the legs. which nursing diagnosis statement does the nurse allocate to the pt .
exces fluid volume related to medication therapy manifested 5 pound weight gain and leg edema
during teaching session, the pt suddenly became tearful and turned away . what would be the best response from the nurse at this time
i see that you are upset, i can finish this later. do you want to talk about it
determining when to turn a pt in bed
independent nursing action
reviewing a medication prescription
independent nursing action
which statement about a critical care path is true
it is a standardized care plan of best practice patterns.