Exam 1
Environmental dimension
housing, sanitation, climate, pollution of air, food and water affects their health
Emotional Dimension
how the mind affects body function and responds to body conditions
secondary source
indirect ( family members, caregiver, healthcare team )
health disparities
influenced by race, gender, age, education level, disability, sexual orientation
subjective assessment
information patient experiences and "communicates"
to meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take
initiate an agency incident report
assessment
making judgements about the data relevant from irrelevant data "what matters most" distinguish normal from abnormal findings
Tertiary Health Care
manage rare or complex disorders that are managed by specialist ( oncologist, cardiovascular surgeon )
self-actualization
morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
which statement made by the student nurse needs correction regarding the primary characteristics establishing nursing as a profession
nurses are simply required to perform specific tasks
Acute illness
rapid onset of symptoms and lasts only a short time (common cold, diarrhea, pneumonia)
Clinical Judgement Model
recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes
erroneous diagnoses
resulting from an inaccurate analysis
which client need would the nurse prioritize while providing care for an older adult client with dementia
safety
Spiritual dimension
spiritual beliefs and values affect their health
PES statement
problem, etiology, signs and symptoms
primary health prevention
promoting health and preventing the development of disease processes or injury
assessment interventions
-what should be monitored or assessment? -what will be done with the data? -what should be monitored or assessed?
referral/health promotion intervention
-where or to whom can we refer the patient to for support with their problem? -why am I referring the patient?
Which information is appropriate to include in education about sentinel events?
Undesirable and largely avoidable
which principle refers to the professional obligation of the nurse to assume responsibility for actions
accountability
beneficence
doing something to benefit the patient or causing benefit
autonomy
respecting the right of patients to make health care decisions
Problem
-Name or diagnostic label from NANDA list -choose nursing diagnosis focusing on current problem or potential physical or behavioral response to health
primary health care
treatment of common health problems ( primary care centers, urgent care )
secondary health care
treatment of problems that need specialized care ( hospitals, emergency department )
critical thinking in nursing process
trial & error development involves experimental learning & practice creative thinking intuitive & scientific
illness
unique response of a person to a disease or an abnormal process involving changed level of functioning
The Joint Commission (TJC)
An organization that accredits health care organizations and programs
Chronic diseases account for
7 out of 10 leading causes of death
Etiology
-not medical diagnosis -suspected cause or reason for physical or behavioral response -statements stated as "related to" -nurses make inferences based on their expert nursing knowledge
Environmental safety
-pathways, equipment, standard protocol, call light, home safety
Safety
-patient identification -error prevention/ risk reduction -preventing ( skin impairment, healthcare acquired infections ) -Allergy identification -use of restraints (physical & chemical)
common errors with nursing diagnosis
-premature diagnosis based on an incomplete database -using generic diagnosis or problem that is not specific to patient
Mobility
-unsteady gait -unfamiliar surroundings -paralysis -supportive devices: correct use
errors in writing patient outcomes
-use verbs that are not observable or measurable "understand" vs "demonstrate" -writing vague outcomes or goals
lifestyle considerations
Dangerous occupations (noise, pollution, hazardous material) Risky social behaviors ( failure to use seatbelt and follow safety precautions ) stress, substance use/abuse
The nurse asks an unlicensed assistive personnel to provide an ice pack to a client. which nursing function does this represent?
Delegation
which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?
The nurse identifies the client is not aware of perineal care and has impaired skin integrity
Nonmaleficence
avoiding causing harm to our patients
which scenario is a perfect example of primary prevention
an infant receives the rotavirus vaccination in the hospital
critical thinking
analyze and evaluate an issue self reflection & flexibility formulation of conclusion
primary source
direct from the patient
documentation of diagnosis
-view patients ongoing problems that others have identified and documented -decide and document new pt problems based on the patient assessment findings -update current problems already in the chart that are still relevant
Therapeutic interventions
-what can I do to help my patient to achieve outcomes? -how often will I do it?
Education interventions
-what can you teach the patient to achieve outcomes? -how will you teach it? -why will it be taught?
Health promotion and technology
- Websites - Chat groups - Social Media - Computer technology and informatics (e.g., Fitbit™ and Carb Manager) - Mobile health apps
Reduce risk
-Accident and injury prevention (reduce risk for falls, skin injury & patient/staff injury) -Aspiration precautions -Restraints and alternatives
Infection control
-Chain of infection -Hand hygiene -Medical and surgical asepsis -standard precautions -preventing transmission -airborne, droplet, contact precautions -PPE -Protective environment
implementation/taking action
-assessment -therapeutic -education -referral or health promotion
which nursing activities are examples of primary prevention?
-assisting with immunization programs -facilitating a program about the dangers of smoking
which factor would the nurse consider when setting priorities for care during a shift?
-client acuity -unit organization -availability of resources -own experience and expertise -philosophies and models of care
Developmental considerations
-each stage has its own risks -physical and cognitive changes infancy through older adult
Why Rumba
-ensure that outcomes and goals are written in anyway that is understandable, "yes" or "no"
identifying outcomes & goals
-get your pt back to "health" and discharged -establish long term vs short term goals
five elements of evaluation
-identifying evaluative criteria ( evaluating the goals we set) -Collecting data to determine whether criteria is met (assess or reassess our pt) -Interpreting findings -documenting -terminating, continuing or modifying care plan
Sensory perception
-knowledge -Ability to communicate -Physical health state -Psychosocial health state
Analyze & hypothesize
-make diagnosis/problem -"what matters the most? what doesn't?" -assess
signs and symptoms
-manifestation or cues identified - stated "as evidence by" then list out s/s
Common malpractice claims
1. Failure to assess and monitor 2. Failure to document 3. Failure to follow standards of care 4. Failure to communicate
Types of Nursing Assessments
1. Initial Assessment. 2. Focused Assessment. 3. Follow up Assessment. 4. Quick priority Assessment.
5 rights of delegation
1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation
when preparing a client for a diagnostic procedure, which action would the nurse take if the client is wearing a religious symbol dangling from a necklace?
Ask the client about the religious symbol and significance of removing it
Dilemmas in Healthcare
Abortion, death with dignity, treat or withhold care, consents, short staffing, restraints and seclusions
wellness
Active state of being healthy by living a lifestyle prompting good physical, mental, emotional health
Integrity
Adhering to moral and ethical values
nursing process
Assessing- systematically collecting pt. data Diagnosing- Identify strength and potential health issues Outcomes-Plan individualized care Planning- help pt reach expected outcomes Implementing- execute plans with out ideas Evaluate- effectiveness of plan of care
AAPIE
Assessment Analysis Planning Implementation Evaluation
Which basic health care ethic does the nurse follow when signing the client's consent form as a witness?
Autonomy
Environment
Crime prevalence and safety for nurses
Which nursing behavior is an intentional tort
Divulging private information about a client's health status to the media
which step should the nurse take to alert the risk management system after notifying the primary health care provider of a clients fall
Document the incident in the occurrence report tool
which suggestion by the nurse is an example of primary prevention?
Engage in daily exercise
which standard of practice would the nurse perform when evaluating a clients pain after performing a back massage?
Evaluation
according to Erickson, which developmental stage will an 85 year old client who is alert and able to participate in care need to adjust to?
Generativity versus stagnation
After the nurse has taught a client about the use of a metered-dose inhaler with a spacer, which statement indicates the need for further teaching?
I will shake the whole unit vigorously one or two times
Tanner model
Noticing Interpreting Responding Reflecting
After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. which response by the nurse is correct?
Of course. I want to do whatever I can for you
which action would the nurse take first when caring for a postoperative client who reports pain?
Perform a focused assessment of the client
Other health care settings
Prison, med spas, home health, Telehealth
Rumba
Relevant, Understandable, Measurable, Behavioral, Achievable
A client says "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario?
Spiritual factors
which description does beneficence in health ethics refer to?
Taking positive actions to help others
Tertiary health prevention
after an illness is diagnosed and treated with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning
which activity by the community nurse is an illness prevention strategy
arranging an immunization program for chicken pox
veracity
being factual or accurate
physiological
breathing, food, water, sex, sleep, homeostasis, excretion
outcome
broad statement describing the desired change in condition. should be the opposite of what our priority problem is
How would the nurse respond to an alcohol recovery program sponsor requesting to read the clients progress record?
by not allowing the sponsor to review the record
Nursing Diagnosis
changes day to day depending on how the pt is doing or how they are responding to the care being provided
Intellectual dimension
cognitive abilities, educational background and past experiences affect health care.
Reporting obligations
communicable diseases, certain STD's and abuse
which situation would the nurse address first according to mallows hierarchy
complains of sleeplessness due to pain post surgery
Which purpose describes the nurse practice acts
describe and define the legal boundaries of nursing practice within each state
Evaluation/evaluate outcomes
did it work? did we achieve the set goals/outcomes
Sociocultural dimension
economic level, lifestyle, family and culture affect their health
in which role is the nurse acting when verbalizing to a client way to relieve injection associated discomfort
educator
love and belonging
friendship, family, sexual intimacy
objective assessment
gathered and documented during the physical assessment (seen, felt, heard, observed or measured)
Physical dimension
genetics, age, developmental level, race, gender
justice
give each their due and act fairly
The nurse is instructing a community group regarding risk factors for coronary artery disease. which risk factor cannot be modified
heredity
medical diagnosis
identify and describe a disease like pneumonia. deals with pathological changes in the body
fidelity
keeping promises and commitments made to others
disease
pathological changes in structure or functioning of the body or mind
errors of omission
patient has a problem and we don't document it
Explicit
power by virtue of position
implied
power due to other factors (personality)
secondary health prevention
screening for early detection of disease with prompt diagnosis and treatment
Safety (Maslow's Hierarchy of Needs)
security of body, of employment, of resources, of morality, of the family, of health, of property
esteem
self-esteem, confidence, achievement, respect of others, respect by others
chronic illness
slow onset, periods of remission and exacerbation, requires long period and permanent changes
goal
small achievement, related to the data we collected in recognizing cues
which client would have a health promotion nursing diagnosis
the client who is willing to take a 30 minute walk daily
Bioethics
what are my duties and obligations to others
