HESI A2 Critical Thinking
Examples of Cues
"I don't want to talk"-May be Depressed Blood Pressure 70/40-May be in shock
Mission of TX Board of Nursing
"Our mission is to protect and promote the welfare of the ppl of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely."
Philosophy Statement Of Nursing Care Plan
"The faculty believes professional nursing...through the diagnosis and treatment of the responses to actual or potential threats to health and through facilitating human need fulfillment"
Standard 2: Diagnosis/Analysis
"The nurse analyzes the assessment data in determining diagnosis-the nurse analyzes data to clearly identify actual and/or potential health problems, risk factors, and strengths."
Standard 1: Assessment
"The nurse collects pt health data-the nurse continuously collects data about health status to monitor for evidence of health problems and risk factors that may contribute to health problems"
Standard 5-Implementation
"the nurse implements the interventions identified in the plan of care"
Texas Court of Appeals agreed with the Board of Nursing, Findings:
*RN's duty to pt supersedes hospital policy *RN's duty to pt supersedes any physician's order *RN has duty to institute appropriate nursing care to stabilize person, even if not officially a "patient" at the facility
Cues
*the subjective and objective data you gathered act as cues *Data that prompt you to get a beginning impression of patterns of health or illness *Conclusions you draw about cues=inferences
Evaluation-Standard 6
-Collect data on the patient's response to interventions -Compare the patient's response to outcome criteria -Analyze the reasons for outcomes -Modify the care plan
Standards
-Intellectual Standards -Professional Standards
Writing the Evaluative Statement
-Outcome criteria was met-problem resolved -Outcome criteria was partially met -Outcome was not met-nursing diagnosis is in error-or new problems are evident
Developing Critical Thinking Skills
-Reflecting Journaling -Concept mapping
Nursing Practice Act defines the scope of nursing practice
-What can an RN do? -What can an LVN do? -What can an advanced practice nurse do? -What can a nurse delegate? -Can a nurse take orders from a PA?
Nursing Interventions should Identify:
-What is to be done -When the activity is to be done/how often -The duration for each intervention -Any preceding or follow-up activities -Date intervention selected -Sequence in which activities should be done -Signature or initials of nurse writing
Philosophy of Ethics
-Your personal beliefs, experiences, and values are the foundation for the philosophy of ethics. -We use philosophy of ethics to understand human interaction
Documenting the Care Plan
-abbreviate when possible -choose key words to communicate ideas -refer to procedure books-don't write out every step -should be signed by nurse
Members of the Board of Nursing:
-appoint by the governor -confirmed by the senate -comprised of 13 representatives *2 RNs *1 Advanced Practice Nurse *3 Licensed Vocational Nurses *3 Nursing Faculty-ADN, BSN, LVN
Ethical Issues in Nursing: 4.Desire for knowledge in opposition to religious, political, economic and ideological interests
-faith healers -cloning
Ethical Issues in Nursing: 2.Freedom vs. Control and Prevention of Harm
-frail pt who wishes to walk freely -forced feedings -paraplegic pt argues for the right to die-staff to do no harm
Ethical Issues in Nursing: 5.Conventional, scientifically based therapy vs. alternative non-specific therapy
-herbal medicine -acupuncture -non-traditional forms of healing
Nurse-Initiated and Ordered Interventions
-solely the range of professional nursing, independent nursing interventions, ex: health teaching, health promotion, referrals, to other health care members (chaplain, social work, dietician), nursing treatments: ambulating, turning, ROM, discharge planning
Psychological
1. Behavioral and emotional status 2.Support Systems 3.Self Concept 4.Body Image 5.Mood 6. Sexuality 7.Coping Mechanisms
What would be a sequence of observation?
1. as you enter room observe patient for signs of distress 2. scan for safety hazards 3. look at equipment 4. scan room 5. observe patient more closely for data
What principles should be kept in mind to improve the effectiveness of teaching plans?
1. assess learners knowledge and ability 2. present content from simple to complex 3. use repitition and reinforcement
What are the components ofa nursing order?
1. date the order was written 2. subject 3. action verb 4. descriptive qualifiers 5. specific times 6. signature
What guidelines would help predict potential complications?
1. look up patients medical diagnosis 2.look up patient meds 3. look up most common complications associated with patients status 4. be sure to know sign and symptom of potential complications
What are the basic components of a diagnostic statement?
1. problem 2. etiology 3. related to (r/t)
When should you validate data?
1. subjective and objective data do not agree 2. clients statements differ @ different times in assessment 3. data seems odd or unusual 4. factors are present taht interfere with accurate measurement
What is Licensure?
1.A privilege afforded to qualified individuals 2.Allows qualified persons to offer special skills to the public 3.Provides legal guidelines to protect the public
Nursing Process Five Step Problem Solving Process
1.Assessment 2.Analysis/Diagnosis 3.Planning 4.Implementation 5.Evaluation
Spiritual
1.Beliefs and meaning 2.Religious experiences 3.Rituals and practices 4.Fellowship 5.Courage
Six Key Phases of Assessment
1.Collecting Data 2.Identifying Cues and making inferences 3.Validating the Data 4.Organizing (Clustering) the Data 5.Identifying Patterns and Testing First Impressions 6.Reporting and Recording Data
Steps to Follow:
1.Complete an incident report 2.Manager to maintain record 3.Include remediation 4.Shall report to PRC 3 minor incidents in 1 year 5.PRC to review 3 minor incidents and determine if report to Board is warranted
Validating the Data
1.Confirm the accuracy of the data collected 2.Comparing cues to normal function 3.Referrring to texts, articles, reports 4.Checking consistency of cues 5.Clarifying statements 6.Seeking consensus with colleagues re:inferences
Data Analysis
1.Consider all data gathered during assessment 2.Be sensitive to cultural context 3.Look for inconsistencies or ambiguities or gaps in information 4.Be comprehensive 5.Make analysis and conclusions about data
Three Step Process
1.Data Analysis 2.Problem Identification 3.Formulation of the Nursing Diagnosis
Validating Data Helps the Nurse Avoid
1.Making assumptions 2.Missing key info. 3.Misunderstanding the situation 4.Jumping to conclusions or focusing in the wrong direction 5.Making errors in problem identification
Select Nursing interventions that meet the follow Criteria:
1.must be safe for patient 2.Must be congruent with other therapies 3.Most likely to effect the etiology 4.Must be realistic 5.Must consider meeting lower level survival needs before higher level needs 6.Should be important to pt and his goals
Assessment techniques
1.observation 2.interview 3.examination 4.medical record review
When did nursing diagnosis become incorporated into most nurse practice acts?
1973
Unique #2
2.Because their pivotal position between patient and doctor, and between patient and institution, the expectations and demands placed on nurses are inherently different than those experienced by other health care workers.
Unique #3
3.Becuase of their greater degree of pt contact, the problems of nurses are of particular importance to the consumer of health services
Unique #4
4.While general issues are biomedical ethics have received widespread discussion, little attention has been focused on the particular situation of nursing. There are few materials available on ethical issues in nursing.
Ethical Theories
A moral principles or a set of moral principles that can be used in assessing what is morally right or morally wrong in a given situation
What is an evaluation mean?
A patient response to an intervention
Prognosis
A prediction of the probable outcome of a disease or condition of a client and the usual course of the disease as observed in similar situations
What is a good life?
A sense of physical well being? Health and safety? Setting goals and achieving them? Removal of all obstacles without harm to anyone?
Reflective Journaling
A tool used to clarify concepts through reflection by thinking back or recalling situations
6. The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? A) "Do you take medicine?" B) "Do you sterilize the bottles?" C) "Do you have nausea and vomiting?" D) "You have been taking your medicine, haven't you?"
A) "Do you take medicine?" Page: 46 In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time.
30. During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?"
A) "How do you feel today?" Page: 74. Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.
52. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? A) Color variation B) Border regularity C) Symmetry of lesions D) Diameter less than 6 mm
A) Color variation Pages: 212-213. Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
120. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate? A) These are normal findings resulting from aging. B) These could be related to hyperthyroidism. C) These are the result of Parkinson disease. D) This patient should be evaluated for a cerebellar lesion.
A) These are normal findings resulting from aging. Page: 659. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.
85. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A) Wheezes B) Bronchial sounds C) Bronchophony D) Whispered pectoriloquy
A) Wheezes Page: 445. Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.
What emphasizes the role of nurses as patient advocate?
ANA Code of Ethics for Nurses with Interpretive Statements
Nursing Interventions
Activities that the nurse plans and implements to help the patient achieve identified outcomes
Regulate Nursing Practice
Adopt rules to implement the Nurse Practice Act; take disciplinary action on licensees; issue position statements
What Agencies Must have a Peer Review Committee?
Agencies that employ 10 or more nurses
Your Responsibility
All nurses are responsible for knowing the provisions of the Nurse Practice Act for the state in which you work
Clinical Reasoning Models: Critical Thinking Defined: Chaffee (2002)
An active, organized, cognitive process used to carefully examine one's thinking and the thinking of others
What is nursing?
An applied discipline
Accredit Nursing Programs
Annual review and site visitation
Identify the concepts and behaviors of a critical thinker. Analyticity:
Anticipate possible results or consequences
Describe the Commitment Level of Critical Thinking.
Anticipate the need to make choices without assistance from others, accountability
What are the 5 steps of the Nursing Process?
Assessment, Diagnosing/Analyzing data gained from assessing/Planning (including outcome identification), Implementing (according to priority), evaluating...did it work?
More Values
At times we have to do harm in order to do good (injections, fluids, vaccines)
Clinical Reasoning Models: Diagnostic Reasoning
Attending, Formulating, Gathering, Evaluating
47. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors is most likely to affect the nutritional status of an elderly person? A) Increase in taste and smell B) Living alone on a fixed income C) Change in cardiovascular status D) Increase in gastrointestinal motility and absorption
B) Living alone on a fixed income Page: 176. Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an elderly person's nutritional status.
88. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: A) tactile fremitus. B) crepitus. C) friction rub. D) adventitious sounds.
B) crepitus. Page: 424. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.
13. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: A) germs and viruses. B) supernatural forces. C) eating imbalanced foods. D) an imbalance within his or her spiritual nature.
B) supernatural forces. Page: 21 The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective.
20. When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: A. has a history of drug abuse and therefore is not reliable. B. provided consistent information and therefore is reliable. C. smiled throughout interview and therefore is assumed reliable. D. would not answer questions concerning stress and therefore is not reliable.
B. provided consistent information and therefore is reliable. Page: 50. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.
When planning what do you always want to do?
BE SPECIFIC...WHO, WHAT, WHEN, HOW OFTEN, HOW MUCH
What can you do by for your goals!
BMAT...behavior, measure, condition, time
Deontology
Based on moral duty or obligation: from the Greek word "duty"- the philosopher Kant is associated with this position. It is not the consequences that make an action right or wrong but the principle or motivation on which the action is based that determines right or wrong.
Evidenced-based knowledge
Based on research or clinical expertise
Name Three levels of critical thinking.
Basic, Complex, Commitment
Critical Thinking Attitudes. Perseverance:
Be cautious of an easy answer, look for a pattern and find a solution
Identify the concepts and behaviors of a critical thinker. Inquisitiveness:
Be eager to acquire new knowledge and value learning
Identify the concepts and behaviors of a critical thinker. Systematicity:
Be organized
Identify the concepts and behaviors of a critical thinker. Open-mindedness:
Be tolerant of different views and own prejudices
Critical Thinking Attitudes. Risk Taking:
Be willing to recommend alternative approaches to Nursing Care
So-Why is this issue of ethics so important to nurses?
Because your pivotal role, nurses are confronted by radically conflicting loyalties, responsibilities and expectations, often in situations where the lives of their parents are literally at stake
Describe the Complex Level of Critical Thinking.
Begin to separate themselves from authorities, analyze and examine choices more independently.
Values:
Beliefs that influence one's thinking and actions -If values influence one's thinking and behavior then will one say it definitely influences one's health and illness behavior? -What is good? -What is harm?
Basic Terms in Health Ethics
Beneficence, Autonomy, Justice, Fidelity, Nonmaleficence
About Rationales
By each nursing intervention...put page number of rationale...
78. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? A) Obtain a detailed history of the patient's allergies and history of asthma. B) Tell the patient to sleep on his or her right side to facilitate ease of respirations. C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. D) Assure the patient that this is normal and will probably resolve within the next week.
C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Pages: 419-420. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.
60. During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings? A) Positive Macewen sign B) Premature closure of the sagittal suture C) Headache, vertigo, tinnitus, and deafness D) Elongated head with heavy eyebrow ridge
C) Headache, vertigo, tinnitus, and deafness Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.
58. A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails? A) Splinter hemorrhages B) Paronychia C) Pitting D) Beau lines
C) Pitting Pages: 248-250. Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.
42. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? A) An increase in body weight from younger years B) Additional deposits of fat on the thighs and lower legs C) The presence of kyphosis and flexion in the knees and hips D) A change in overall body proportion, a longer trunk, and shorter extremities
C) The presence of kyphosis and flexion in the knees and hips Page: 149. Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.
Clinical decision making
Careful reasoning so that the best options are chosen for the best outcomes
NCLEX-RN
Categorizes questions according to the steps of the nursing process
Nursing Diagnosis NANDA International 2003
Clinical Judgement about individual, family or community responses to actual or potential health/life processes. Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
Social Equity and Justice
Concern of society towards the most disadvantaged because they are the ones least able to speak for themselves
Attitudes
Confidence, thinking independently, fairness, responsibility and authority, risk taking, discipline, perseverance, creativity, curiosity, integrity, and humuility
44. When assessing the quality of a patient's pain, the nurse should ask which question? A) "When did the pain start?" B) "Is the pain a stabbing pain?" C) "Is it a sharp pain or dull pain?" D) "What does your pain feel like?"
D) "What does your pain feel like?" Page: 164. To assess the quality of a person's pain, have the patient describe the pain in his or her own words.
19. When planning a cultural assessment, the nurse should include which component? A) Family history B) Chief complaint C) Medical history D) Health-related beliefs
D) Health-related beliefs Pages: 19-20. Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient's history.
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement? A) Reflection B) Facilitation C) Direct question D) Open-ended question
D) Open-ended question Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.
4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is: A) just changing positions. B) more comfortable in this position. C) tired and needs a break from the interview. D) uncomfortable talking about his son's treatment.
D) uncomfortable talking about his son's treatment. Page: 37 Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic.
22. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? A. "Maybe she is just teething." B. "I will check her ear for an ear infection." C. "Are you sure she is really having pain?" D. "Please describe what she is doing to indicate she is having pain."
D. "Please describe what she is doing to indicate she is having pain." Page: 60. With a very young child, ask the parent, "How do you know the child is in pain?" Pulling at ears alerts parent to ear pain. The statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.
24. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? A. It assesses how the individual is coping with life at home. B. It determines how children are meeting developmental milestones. C. It can identify any problems with memory the individual may be experiencing. D. It helps to determine how a person is managing day-to-day activities.
D. It helps to determine how a person is managing day-to-day activities. Page: 67. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.
21. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? A. Patient denies usual childhood illnesses. B. Patient states he was a "very healthy" child. C. Patient states sister had measles, but he didn't. D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" because an illness common in the person's childhood may be unusual today (e.g., measles).
23. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? A. The child's birth weight B. The age at which he crawled C. Whether he has had the measles D. Reactions to previous hospitalizations
D. Reactions to previous hospitalizations Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.
What is subjective data?
Data that only the subject or "patient" can feel and will tell you. Usually in a statement.
Remember-Nursing Interventions Need:
Date, Action Verb, Content area, Time element, Signature
Kataoka-Yahiro and Saylor (1994)
Define the outcome of critical thinking as nursing judgement that is relevant to nursing problems in a variety of settings
What does the diagnoses do?
Describes the patients health problem in nursing terminology - NOT medical.
Diagnostic reasoning
Determining a client's health status after you have assigned meaning to the behaviors and symptoms presented
What does the etiology or "related to" part do?
Directs the nursing intervention
Critical Thinking Attitudes. Integrity:
Do not compromise nursing standards or honesty in delivering nursing care
Criteria of a Profession
Enlarge a systematic body of knowledge and improve education and service through the use of the scientific method -Nursing process -Nursing research -Quality improvement
Environmental Management
Establishing a sage and therapeutic env., clean and well lit room, wall calendars for date, place to contain pt's items
Problem Solving
Evaluating the solution over time to make sure it is effective
The Nurse Practice Act Cont.
Every State has its own definition of nursing practice, i.e., its own Nurse Practice Act.
Rationale for Nursing Interventions Example:
Ex: Encourage good sleep hygiene no caffeine-caffeine is stimulant, dim lights-light may bother pt, hygiene induces sleep-reg habits help (wash face)
Critical Thinking Attitudes. Curiosity:
Explore and learn more about a client to make appropriate clinical judgments
What do we mean by "duty"?
Firmly established the idea of 'the nurse's duty is first to the pt and to no other entity.'-Lunsford v. Board of Nurse Examiners
Nursing process
Five-step clinical decision-making approach
Decision making
Focuses on problem resolution
BULHSON Clinical Evaluation Tool
Formatted according to the steps of the nursing process, so....."The nursing process is the way one thinks like a nurse-it is the foundation, the essential, enduring skill that has characterized nursing from the beginning of the profession"
Why do nursing care plans?
Helps us apply the nursing process
What about a smaller agency?
If a facility has <10 RNs, the manager keeps records and reports directly to the Board
How do you record subjective data?
In clients, "own words."
License nurses
Initial licensure and recertification
What are the two Standards used in the Critical Thinking Model.
Intellectual & Professional
Explain the Standard "Intellectual" used in the Critical Thinking Model.
Is a guideline or principle for rational thought
Concept Mapping
Is a visual representation of client problems and interventions that shows their relationships to one another
Critical Thinking
Is an active, organized, cognitive process used to examine one's thinking and the thinking of others.
Reflective Journaling
Is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning
List the five components of critical thinking
Knowledge, Experience, Critical Thinking Competencies, Attitudes, Standards
What mnemonic reminds to mediate and collaborate regarding interventions for patients?
LEARN
What are the levels of interpreting data?
Level 1: Identify significant cues Level 2: cluster cues and identify data gaps Level 3: draw conclusions about present health status Level 4: Determine etiologies and categorize problems
Critical Thinking Attitudes. Fairness:
Listen to both sides in any discussion
Standard of Care
Malpractice-a type of conduct that falls below the minimal standard of care for the community at the time in question
What are the characteristics of problems in an applied discipline?
Messy and confusing
Purpose of Nursing Diagnosis #3
Nursing diagnosis-help nurses to focus on the role of nursing in patient care
Purposes of Nursing Diagnosis #1
Offers language to promote understanding between nurses about patient's health problems so as to facilitate communication and care planning.
BNE->BON
Old name=Board of Nurse Examiners for the State of Texas Changed by HB2526, Texas Legislature, to Board of Nursing (effective 9.1.07)
Which classification system was developed specifically for community health: NIC, CCC, Omaha? For home health?
Omaha; CCC
What type of client records could you get data from?
Other healthcare professionals, nursing and scientific literature
Objective Data
Overt cues that are observable, perceptible, and measurable -Can be validated by others -Examples such as BS, PR, skin rashes -May be obtained by senses by measuring devices such as thermometers, monitors
Why does a nurse go before the Board of Nursing?
Peer Review -a quality assurance mechanism -evaluation of practice in an atmosphere of collegiality or a lawsuit brought by a plaintiff
Dimensions for Gathering Data for Health History
Physiological and Developmental, Psychological, Sociological, Spiritual
If there are no signs or symptoms present, is the problem an actual diagnosis, a potential diagnosis or a possible diagnosis?
Potential diagnosis
What does P-I-E stand for?
Problem, Implement, Evaluate
Board of Nursing Rule 22
RN has a duty to evaluate the status of pt. and to institute appropriate nursing care to stabilize the condition and prevent complications
Critical Thinking Attitudes. Thinking independently:
Reads the Nursing Literature
Critical Thinking Attitudes. Humility:
Recognize when you need more information to make a decision
Clinical Reasoning Models: Critical Thinking defined: Settersten and Lauer (2004)
Recognizing an issue exists, analyzing information, evaluation information, and making conclusions
What are Ethics?
Rules or principles which govern right conduct
What is the acronym to help remember behaviors of active listening?
S O L E R
SBAR
S: Situation B: Background A: Assessment R: Recommendation
Critical Thinking
Scientific method, problem solving, decision making, and clinical decision making
Identify the concepts and behaviors of a critical thinker. Truth seeking:
Seek the true meaning of a situation
Critical Thinking Attitudes. Confidence:
Speak with conviction and always be prepared to perform care safely
What are the five components of the goal?
Subject, Verb, Criteria, Condition, Time The client, will ambulate, fifty feet in the hall, one time with assistance, by 4pm.
What are the two types of data you will take from the patient?
Subjective and Objective data
Collecting Data
Subjective, Objective, Judgements, Conclusions, Opinions, and Care Plan
What does Kalish's division of physiological needs includes?
Survival needs Stimulation needs
Subjective Data
Symptoms or overt cues that include the patient's feelings, perceptions, concerns and statements about his/her health problems -supplied by the patient -not always feasible to validate or confirm through other sources -Data obtained through the interview and is best recorded as quotes
Scientific method
Systematic, ordered approach to gathering data and problem solving
(T or F) The nurse should choose the NIC intervention labels and activites best suited to your patients needs
T
Between an intervention and a goal...there is...
TEACHING
Critical Thinking Attitudes. Discpline:
Take time to be thorough, and manage your time effectively
Veracity
Telling the Truth -Pt suspects he has cancer and asks if this is so -Tell the pt what their blood pressure is
What is etiology?
The "related to" part....it is NURSE FIXABLE?
Assessment
The first step of the nursing process
Nursing Process
The foundation that characterizes nursing and how nurses think. -A means to meeting the Standards of Nursing Clinical Practice as published by the ANA (1998)
Planning
The nurse develops a plan of care that prescribes interventions to attain expected outcomes
Identifying Cues and Making Inferences
The nurse recognizes significant data and draws some basic conclusions about what the data may indicate
Justice
The obligation to be fair to all ppl -fair distribution of healthcare resources -Who should receive available organs, etc.
Remember:
The purpose of the Nurse Practice Act is to protect the public
Autonomy
The right to make one's own decisions, and to respect the choices that others make for themselves
Bod of the Interview
This is where you will ask open-ended questions and gather data for you to be able to give the best possible nursing care
Opening
This is where you will establish rapport, give orientation to what you will be talking about
Focus Assessment
To collect data about a problem already identified. Also includes the appraisal of any new, overlooked, or misdiagnoses problems
(T or F) Nursing interventions are sometimes suggested by the problem label instead of the etiology.
True
Identify the concepts and behaviors of a critical thinker. Self-confidence:
Trust in your own reasoning processes
Describe the Basic Level of Critical Thinking.
Trust that experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles
What is the acronym COVD used for?
Used during assessing? Collecting Data Organizing Data Validating Documenting Data
What do you do with your data sometimes if it is off or you are to sure of it?
VALIDATE
Concept mapping
Visual representation of client problems and interventions that illustrates an interrelationship
What q's does a nurse using the nursing process lsiten to the patient story in order to answer? (4)
What is the persons present health status? What is the persons desired health status? How can I help this person? Did it work?
When evaluating, what do you think about?
What it effective, ineffective, were goals met, not met, partially met?
What is objective data?
What you observe and can measure
Besides measurable data for your objective data, what other objective data should you collect?
What you see, hear, and smell.
Physical Assessment
You will then move into the physical assessment portion of the Assessment Phase
Remember:
Your personal point of view will be a factor in your ethical decision making. Personal views are effected by your values and beliefs
What are the new NANDA-I wellness labes preceded by?
`Readiness for Enhanced and continue to be a one part statement
Actual nursing diagnoses
a client problem present at time of assessment
What qualities does a nurse need?
a combination of thinking, interpersonal, and psychomotor skills, including creativity, cultural sensativity and the ability to work with technology
Actual nursing diagnoses?
a problem that is actually present at the time you make the assessment
Critical thinking?
a purposeful mental activity in which ideas are produced and evaluated and judgements are made
What is disagnosis?
a reasoning process that nurses use to interpret data; a statement of health status
Intellectual perserverence?
a sense of the need to struggle with confussion and unsettled questions over an extended period of time to achieve understanding and insight
What is the nursing dagnoses?
a statement about the patients present health status describing an actual potential or possible problem that nurses can legally diagnose and for which they can prescribe the primary tx and prevention measures
What is the nursing process?
a thinking-doing approach that nurses use in their work
How do nursing theories describe nursing?
a unique blend of art and science within person to person relationships; its purpose is to promote wellness; prevent illness and restore health
Nurse Practice Act-Shall use a systematic approach to provide individualized, goal-directed nursing care by:
a)Performing nursing assessments b)Making nursing diagnoses which serve as the strategy of care c)Developing a plan of care based on the assessment and nursing diagnosis d)Implementing nursing care e)Evaluating the patient's responses to nursing interventions
Reporting and Recording Data
a.Continuity-Communicate by reporting what you know b.Accuracy-Timely reporting will keep you from forgetting-write your notes as you go c.Critical Thinking-Reporting key data will help others in this problem solving process
What is practice wisdom?
acquired from intuition, tradition, authority, trial and error and clinical experience
Validation?
act of double checking or verifying data
Thinking?
active, organized, purposeful mental process that links ideas together by making logical connections
Interpersonal skills?
activities used in person to person communication
What is evidence based practice?
an approach that uses firm scientific data rather than anecdote, tradition, intuition or folklore in making decisions about medical and nursing practice
What is the difference between an argument and an explanation?
an argument is to show THAT something is true; an explanation is to show WHY
Intellectual curiosity?
an attitude of inquiry
What occurs in the second phase of the nursing process?
analyze data and draw conclusions about the clients health status; they verify these conclusions with client, select standardized labels, and record them on plan of care
What is a nursing intervention?
any action based on clinical judgement and nursing knowledge that a nurse performs to achieve patient outcomes
How are actual nursing diagnoses written?
as a one-, two-, three-, or four-part statement
What are the phases that the nursing process divided into? (6)
assessment diagnossis planning outcomes planning interventions implementation evaluation
What influences the ways in which people use their thinking skills?
attitudes and character
When using the preservation of life as criterion how would you rate the clients diagnoses?
based on the amount of threat they pose to the clients life
How would you avoid diagnostic errors? (5)
be aware of sources of erroe keep open mind ensure comple data support diagnostic conclusion with data validate diagnoses with patient
Why is race important?
because of biological variations
Intellctual integrity?
being consistent in the thinking standards you apply
Intellectual courage?
being willing to consider and examine fairly your own beliefs and the views of others
Opinions?
belief or judgement that may fit facts or be in error
What are some components of a nursing health history? (11)
biographical information cheif complaint history of current illness past health status review of systems and their effect on client fx social and family history lifestyle spiritual well being client perception of health status/illnness client expectation
What is an example of client data?
blood pressure reading, urine color, lab test results
What are some examples of data obtained from smell?
body, breath or urine odors; wound secretion
What are some examples of data obtained from hearing?
bp, breath sound, bowel sound, heart sound, spoken words
Creative thinking?
breaking out of established patterns of thinking and approaching situations from new directions
How can you enrich your understanding of a newly learned principle?
by applying it to new situations
Critical thinking?
careful, goal-oriented purposeful thinking that involves many mental skills
Interdependent interventions?
carried out in collaboration with other health team members such as physical therapists social workers dieticians and physicians
What are planning interventions?
choose interventions for promoting wellnmess or preventing, correcting or relieving health problems
What are the standards of reasoning? (7)
clarity, accuracy, relevance, precision, depth, breadth, logic
To Evaluate Nursing Diagnosis
clear, concise, neutral terms, includes a r/t phrase, objective and factual, holistic, prioritized, potential and actual, precise
What language should nurses avoid using?
cliche, euphemisms and jargon
Risk nursing diagnoses
clinical judgement that problem doesn't exist, but presence of risk factors indicates problem may develop
What is assessment?
collect, organize, validate and record data about the patients current health status
What is implementation?
communicate the plan of care to other members of the health care tem and carry out interventions
What is evaluation?
compare patients health status with desired outcomes; determing which interventions were successfull and which were not
Label?
concise word or phrase describing clients health
Clinical judgement?
conclusions and opinions about patients health drawn from patient data
Inferences?
conclusions based on factual information but go beyond that inforemation to make statements about something not presently known
Related or risk factors?
conditions or situations that are associated with the problem in some way
What is observation?
conscious deliberate use of the physical senses to gather data from the patient and environment
Prioritizing?
considered a part of the planning phase of the nursing process
What is the ongoing assessment?
consists of data gathered after the database is completed; during every nurse-patient encounter
Jargon?
consists of expressions and technical terms that are understood by a particular group
Nursing history?
contains data about the effects of the illness on the patients daily functioning and ability to cope
What is subjective data sometimes called?
covert data or symptoms
What are cognitive skills?
decision making and critical thinking
What are some qualifiers for diagnoses?
deficient, impaired, decreased, ineffective or compromised
What is a cognitive deficit that might be present in an older client?
dementia
What is the nursing focus? (5)
diagnose, treat and prevent human responses care for patient holistic approach teach clients self care strategies promote wellness activities
What are the types of interviews?
directive and nondirective
Risk Factors
do not have defining characteristics....they are not specific
Medium priority problem?
does not directly threaten life but it may produce destructive physical or emotional changes
When are nursing interventions carried out?
during the implementention phase
When are nursing interventions ordered?
during the planning phase
What are the characteristics of the nursing process? (9)
dynamic and cyclic client centered holistic planned and outcome directed evidence based flexible universally applicable health status oriented cognitive thinking process
Why do critical thinkers validate data?
ensure assessment info is complete, accurate and factual; eliminate erros; avoid jumping to faulty conclusions because of data
What is an example of community data?
environment, morbidity and mortality rate
"E"
establish and maintain eye contact
Why are standardized nursing languages needed? (5)
expanding nursing knowledge supporting computerized records defining and communicating unique nursing knowledge improving nursing care quality influencing health policy decsions
Definition?
expresses clearly and precisely the essential nature of the diagnostic label
What is a common cause of malpractice suits?
failure to monitor
Why are standardized languages necessary?
for structuring and communicating knowledge and practice and for evaluating the cost and quality of nursing care
standardized care plan
formal plan that specifies nursing care for a group of clients with common needs
What is a professional code of ethics?
formal set of written statements reflecting the goals and values of a given profession
Inductive reasoning?
forming generalizations from a set of facts or observations
How many components does a NANDA-I diagnosis have?
four components: label, definition, defining characteristic and either related factors or risk factors
Monitoring?
frequent ongoing assessment often done at specified intervals
What are some examples of data obtained from vision?
general appearance, body movement, facial expression
What is an example of family data?
genogram, family income, home safety data
If a physician orders frequent monitoring what should you be sure to do?
have the physician specify the requency or follow the frequency specified in your agencys policys and protocol, perform monitoring as specified, thoroughly document monitoring and all interventions
Directive interview?
highly structured; the nurse controls the subject matter and asks que3stions in ortder to obtain specific info
What characteristics identify a health problem? (5)
human response to life process event or stressor health related condition both patient & nurse wish to change requires intervention results in ineffective coping is an undesireable state
Medical diagnosis?
identifies a disease process or pathology and is made for the purpose of treating the pathology
Observation?
includes observations to determine whether a complication is developing as well as observations of the clients responses
Treatment?
includes teaching, referrals, physical and other care needed to treat an existing problem
What are the types of intervention?
independent, dependent or interdependent
Nursing database?
information obtained from comprehensive assessment
Belief?
interpretaions, evaluations, conclusions and predictions about the world we take to be true
A goal is a direct result of an...
intervention
What is planning?
involved determining pt goals/outcomes
The purpose of an intervention...
is a goal!
What questions would you ask to distinguish fact from interpretation?
is this something that i can observe directly or would i have to interpret what i see to arrive at this conclusion? could this be verified in principle? what would i need to do to verify it?
What is the relationship of assessment to the other phases of the nursing process?
it is a continuous process carried out during all phases of the nursing process
What is the difficulty with diagnosis?
it is both a process and a product
Personal knowledge?
knowing and actualizing ones self
"L"
lean forward toward the patient
High priority problem?
life threatening
How would you deal with stron negative emotion?
limit action for a while discuss negative feelings with trusted peer work off some energy generated by emotion reflect on situation
Fair-mindedness?
making impartial judgements
What is a health problem?
maladaptive or harmful response
How do you choose a label?
match patient symptoms with the definitions and defining characteristics of one of the NANDA-I labels
Concept?
mental image of reality
Dementia?
mild to severe problem with memory and at least one other ability
For every nursing diagnoses....the nurse...
must write atleast one desired outcome
What is the format for a collaborative problem diagnosis?
no etiology; possible complication for which you are monitoring and the disease/tx/factors to produce it
The etiology is always...
nurse fixable
What is collaborative practice/ disciplinary practice?
nurses, physicians and other professionals work together to plan and provide patient care
Nursing Interventions Are Referred to As:
nursing actions, nursing strategies, nursing treatment plans, nursing orders
What are the five "ways of knowing" that make up the basic core of nursing knowledge?
nursing science, nursing art, nursing ethics, personal knowledge and practice wisdom
What are the three methods of data collection?
observation, physical examination and interview
What nursing interventions could you choose depending on the status of the nursing diagnoses?
observation, prevention, treatment, and health promotion
What is objective data?
obtain by observing and examing client
What is secondary data?
obtained from sources other than the client
What are some characteristics of human responses?
occur in several dimensions (biological, psychological, interpersonal, spiritual) occur at different levels (cellular, systemic, organic, whole) can be helpful/harmful
Variance?
occurs when the patient does not achieve a goal in the time predicted by the critical pathway
Low priority problem?
one that arises from normal developmental needs or requires supportive nursing intervention
Potential nursing diagnoses?
one that is likely to devewlop if the nurse does not intervene
Possible nursing diagnoses?
one that you tentatively believe to exist, you have enough data to suspect a problem but not enough to be sure
What are some kind of interview questions?
open ended and close ended questions
"O"
open posture
What are some interpersonal skills?
oral and written communication knowledge of behavior and social systems nonverbal behaviors such as body language
The nursing process is...
overlapping and dynamic
What is objective data sometimes called?
overt data or signs
What does the nursing assessment focus on?
patient responses
What are the sources of data that you retrieve during assessment?
patient, support peoples, client records
In the nursing process planning:interventions, the nurse idenfies what?
patients nursing diagnoses, goals or expected outcomes
What does diagnosis affect?
planning, implementation and evaluation steps
Collaborative problems?
predictable physiological complications of medical dianoses or treatments that nurses manage by using both physician prescribed and nursing prescribed interventions
What are some general guidelines for an interview?
prepare set the stage obtain the data use good communication techniques
Dependent interventions?
prescribed by primary care provider and carried out by nurse
Critical pathway?
prestandardized plan of care that indicates patient and family outcomes that should occur within a specified time frame
What is the format of potential nursing diagnoses?
problem + etiology format
When interviewing an older adult, what are some additional guidelines?
proceed slowly check for sensory deficit dont assume all elderly people are deaf or unable to understand be aware appropriate affect and articulate speech do not always go together rely more than usual on body language be alert for intermittent confusion when possible try to get data directly from the client
Decision making?
process of choosing the best action to take, or the action most likely to produce the desired outcome
Data collection?
process of gathering information about client, family or community health status
Classify?
process of grouping htings on the basis of their similarities or common properties
Why is the nursing process important? (10)
promotes collaboration is cost efficient helps people understand what nurses do is required by professional standards of practice increased client participation in care and promotes client autonomy promotes individualized care promotes efficiency helps you develop good thinking habits fosters continuity and coordination of care increases job satisaction
What is the purpose of nursing order?
provide specific direction and a consistent individualized approach to patients care
What is comprehensieve assessment?
provides an overall picture of clients health status
What is the nursing process?
provides the framework in which nurses use their knowledge and skills to express human caring
What are some examples of data obtained from touch?
pulse rate and rhythm, lesions, skin temp
What is a nursing interview?
purposeful, structured communication in which the nurse questions a patient in order to obtain subjective data
What are some characteristics of critical thinking? (6)
rational and reasonable involves conceptualization requires reflection involves cognitie skill and attitude involves creative thinking requires knowledge
What are human responses?
reactions to abn event or stressor such as diease or injury
Human response?
reactions to an event or stressor such as disease or injury
Wellness
readiness for enhancement
`What is ethical knowledge?
refers to the knowledge of professional standards of conduct
"R"
relax
When communicating with patients affected by dementia what are some guidelines?
repeat words exactly if patient does not respond if you dont understand ask patient to repeat use simple short direct sentences do not use vague comments use words that patient understands ask yes or no q if needed dont press for answer if anxiety occurs dont correct statements understand patient reality is confused if conversation unsuccesfull try again later
What does American Nurses Association Standard 17 state?
requires assesment of individual patient care needs and resources available to achieve desired outcome
How do you generate and select nursing activities and interventions?
review the nursing diagnoses review the patient goals/outcomes identify alternative interventions or actions select the best option
Physician ordered interventions (Dependent)
scheduled tests, medications ordered, IV therapy, Nurse usually explains what and why these are to be done
Nursing is a unique combination of what characteristics?
science and art, applied within the context of interpersonal relationships, done for the purpose of promoting wellness preventing illness and restoring health, used when caring for individuals families and communities
What is nursing science?
scientific knowledge consisting of facts, info, principles and theories
What activities does perception involve?
selecting certain sensations to pay attention to organizing these sensations into a design or pattern interpreting what the design means to you
"s"
sit or staqnd facing patient
How do nurses support ill people?
solve or reduce their health problems and adapt to and accept problems that cannot be treated
What is diagnosis?
sort, cluster, and alayze data to identify the patients current health status write precise statement describing health status and contributing factors prioritize diagnoses decide which diagnoses will respond to nursing care and which need referrals
Deductive reasoning?
starting with a generalization and moving to specific facts or conclusions that it suggests
Facts?
statements you can verify through observation and investigation
Percussion?
striking of the body surface
Euphemism?
supposedly more pleasant and less objectionable term that is substituted for a more direct or blunt expression
What is the nursing physical examination?
systematic assessment of all body systems
What is assessment?
systematic gathering of relevant and important patient data
Individual care plans
tailored to meet unique needs of pt
What might specific nursing activities for each of tthe preceding categories include?
teaching, counseling, emotional support, referral, environmental management
When was nursing first described as a process?
the 1950's
What is the art of nursing?
the ability to develop meaningful connections with clients, grasp the meaning in client encounters, perform nursing activities skillfully, use rational thinking to choose appropriate course of action and to conduct ones nursing practice ethically
Intellectual empathy?
the ability to imagine yourself in the place of others so you can understand them and their actions and beliefs
Cognition?
the act of knowing
What is primary data?
the client
Defining characteristics?
the cues that indicate the presence of the diagnostic label
What happens during the assessment phase?
the nurse collects, validates, records and organizes data into predetermined categories
Health promotion?
the nurse helps the client to identify areas for improvement that will lead to a higher level of awareness
Cultural competence?
the nurse works within the clients cultural belief system to resolve health problem
What is the basic format of an actual nursing diagnosis?
the problem and the etiology
What is the relation ship of nursing diagnosis to outcomes and nursing orders?
the problem states what needs to change thus determining the patient outcome needed to measure the change; the etiology identifies factors contributing to actual problem or the risk factor
Perception?
the process of using the senses to experience the world
What is problem solving?
the process used when you recognize a difference between what is occuring and what should be occuring
What is one danger in using computerized care plans?
the temptation to plug in ready made solutions rather than looking for different more affective approaches
What is the purpose of the nursing process?
to provide a deliverate but flexible guide for planning, implementing, and evaluating effective, individualized nursing care
Premature closure?
unthinking acceptance of assumptions
What are conventional moral principles?
unwritten values that are widely held in profession, expressed in practice and reinforced by rewards and sanction
Psychomotor skills?
used in the implementation phase of nursing process when giving hands on care
Auscultation?
uses the nurses hearing
Palpation?
uses the sense of touch
Implementation Consists of:
validating the care plan, writing the care plan, giving and documenting nursing care, continuing to collect data
Inspection?
visually either with the naked eye or with instruments such as the otoscope
You cannot have an intervention....
without a goal.
You cannot have a goal...
without an intervention
What is planning outcomes?
work will the client to choose the desired outcome; decide how status will change and in what desired amount of time
Nursing order?
written detailed instructions for performing nursing interventions; prescribe activities and behaviors performed to change present client responses to desired responses
Standing Orders
written documentation authorizing nurse to carry out specific actions under ceratin circumstance
Standard 4-Planning
"The nurse develops a plan of care that prescribes interventions to attain expected outcomes"
Standard 6-Evaluation
"The nurse evaluates the patient's progress toward attainment of outcomes-The nurse determines how well the outcomes have been met and decides whether changes need to be made."
Standard 3-Outcome Identification
"The nurse identifies expected outcomes individualized to the pt-These include pt goals and identifying interventions to achieve the outcomes"
What's on the Horizon?
-A Jurisprudence Exam approved by the Board effective September 1, 2008 -You will take this as a part of Leadership and Management Course
Critical Thinking Synthesis
-A reasoning process used to reflect on and analyze thoughts, actions, and knowledge -Requires a desire to grow intellectually -Requires that use of nursing process to make nursing decisions
The Nursing Practice Act
-A statute (law) written in 1909 by Texas Legislature. Defines the scope of nursing practice. -Establishes the Board; gives it the authority to make rules about professional nursing -Only the Legislature can amend the Nurse Practice Act
Other Professional Resources Available
-ANA Code of Nurses -International Council of Nurses Code
Natural Law
-Actions are morally right when they are in accord with our nature as individuals and humans and are morally wrong when not in accord with our nature as individuals and as humans -Good should be promoted, evil avoided and ethics grounded in our concern for human good.
Initial Assessment
-Admission when client enters healthcare system -Purpose to evaluate health status and identify health needs that are unmet -Must be documented by registered nurse -Parts may be delegated to non-licensed personnel
Directed by the Nurse Practice Act
-Article 217.11-Standards of Professional Practice
Ethical Issues in Nursing: 3.Truth Telling vs. Deception or Lying
-Avoid harm by giving bad news -Discover abuse -Poor lab analysis -Pour urine down the sink
Rational of Nursing Interventions
-Based on Principles and knowledge integrated from previous nsg education -Principles identify the relationship between nsg interventions and science
Levels of Critical Thinking: Kataoka-Yahiro and Saylor (1994) Critical Thinking Model
-Basic critical thinking -Complex critical thinking -Commitment
Clinical Decision in Nursing Practice
-Clinical decision making skills separate professional nurses from technical and ancillary staff -Clients have problems for which no textbook answers exist -Nurses meet to seek knowledge, act quickly, and make sound clinical decisions
There is Limited Material On Ethical Issues in Nursing SO.....
-Continue to read evidence-based literature on ethical issues related to nursing -Serve on an ethics committee at your institution -Advocate for patients and their families regarding ethical issues you confront in the hospital or clinic
Clinical Reasoning Models and Competencies
-Diagnostic reasoning -Nursing process -Critical Thinking -Evidence-Based Practice Process
Time-lapsed Reassessment
-Evaluate any changes in patient's human needs -Performed when long periods of time have elapsed between assessments (3-12mo) -Less comprehensive than initial assessment
What is Peer Review?
-Evaluation of practice in an atmosphere of collegiality -A process improvement method
Feminist Ethics
-Focused on inequalities between ppl -Looks to the nature of the relationship for guidance in processing ethical dilemmas -Concentrate on practical solutions than on theory -Natural human urge to be influenced by relationships is a positive value
Utilitarianism Also referred to as "Teleological Theory"
-From the Greek word teleos or end. This theory is sometimes called the "the greatest happiness principles" -This uses the weight of consequences of actions such that the actions w/the most positive consequences and the least negative consequences are preferred.
Basic Ethical Concepts
-Help us make decisions -Have concerns for nursing and society
9.Do not Include the Medical Diagnosis in the Nursing Diagnostic Statement
-INCORRECT: Altered nutrition: less than body requirements r/t anorexia -CORRECT: Altered nutrition: less than body requirements r/t perceived negative body image
4.Write the Diagnosis Without Value Judgements
-INCORRECT: Altered parenting r/t poor bonding with child; Impaired home management r/t poor housekeeping habits, filthy household -CORRECT: Altered parenting r/t prolonged separation from child; Impaired home maintenance management r/t lack of knowledge (home safety measures)
5.Avoid Reversing the Parts
-INCORRECT: Decreased caloric intake r/t altered nutrition: less than body requirements; Sensory overload r/t sleep pattern disturbance -CORRECT: Altered nutrition; less than body requirements r/t decreased caloric intake; Sleep pattern disturbance r/t sensory overload
11.State the Diagnosis Clearly and Concisely
-INCORRECT: Fatigue r/t dizziness; Ineffective individual comping r/t belief that she caused onset of premature labor by lifting paint can on day of delivery -CORRECT: Potential for trauma r/t dizziness; Ineffective individual coping r/t feelings of guilt
10.The tendency to write the nursing diagnosis as a paraphrased medical diagnosis
-INCORRECT: Ineffective airway clearance r/t obstructive pulmonary disease Congestive Heart Failure -CORRECT: Ineffective airway clearance r/t retained secretions; Noncompliance (cardiac meds) r/t lack of knowledge (action and dose of meds)
8.Express the Problem and Related Factors in Terms that can be Changed
-INCORRECT: Knowledge deficit r/t pregancy; pain r/t surgery; Dysfunctional grieving r/t death of spouse -CORRECT: Anxiety r/t knowledge deficit (pregnancy); Pain r/t inflammatory process; Dysfunctional grieving r/t perceived loss of security
1.Write the Diagnosis in Terms of Response Rather than Need
-INCORRECT: Needs adequate nutrition; needs frequent turning -CORRECT: Risk for altered nutrition: greater than body requirements r/t excessive caloric intake; Impaired physical mobility r/t pain
3.Write the Diagnosis in Legally Advisable Terms
-INCORRECT: Risk for trauma r/t inadequately maintained skin traction; Ineffective airway clearance r/t inadequate suctioning -CORRECT: Risk for trauma r/t effects of skin traction; Ineffective airway clearance r/t effects of sedation
6.Avoid Using Single Cues in First Part of Statement
-INCORRECT: Shortness of Breath r/t Abdominal pain -CORRECT: Ineffective breathing pattern r/t abdominal pain
7.Be sure that the Two Parts of the Diagnosis Do Not Mean the Same Thing
-INCORRECT: Stress incontinence r/t inability to control urine; Ineffective family coping: disabling r/t inability to handle client's illness -CORRECT: Stress incontinence r/t impaired muscle tone; Ineffective family coping r/t lack of support systems
2.Use "Related to" Rather than "Caused by"
-INCORRECT: altered sexuality patterns caused by change in body image -CORRECT: altered sexuality patterns related to change in body image
Identifying Patterns and Testing First Impressions
-Initial impression of patterns -Test the impressions and decide if the patterns really are as they appear -Decide what is relevant and focus assessment to gain more information -Ask yourself what relevant information might be missing
Implementation
-Interventions are implemented in a safe and timely manner -Interventions are documented -Patient is continually assessed
Thinking and Learning
-Learning is a lifelong process -Intellectual and emotional growth involves learning new knowledge, as well as refining the ability to think, solve problems, and make judgements
Minimal Requirements for Licensure
-Minimal education requirements established by the State -NCLEX exam required by every state for RN and LVN licensure
Critical Thinking Model for Decision Making
-Models serve to explain concepts and help nurses make decisions and judgements about patients
Standard 3-Outcome Identification Cont.
-Mutually formulated with the pt and family -Attainable with the resources available -Measurable -Include a time limit for attainment
Due Process
-Nurse given written notice -PRC to meet not >30 days from notice -Description of events -Contact person on PRC -DATE, Time and Place of PRC -At least 15 days to review documents
Nurse-Initiated and Physician-Ordered Interventions
-Nurse may request a physician-ordered treatment if she thinks the pt needs it ex: restraints, catheter, consult -PRN orders-different strengths of medications at varying intervals ex: Percodan tab 1 or 2q3-4h as needed for pain
Why Regulation Matters
-Nursing regulation=governmental oversight. Why? Possible risk of harm to the public -The Public may not be able to identify unqualified RN/LVN. Public is vulnerable to unsafe and incompetent practitioners
Beneficence
-Obligation to do good and not harm to other people -To act in the best interests of another
Key Points from ANA Nurses' Code of Ethics
-Practice with compassion and respect for each person's dignity, worth and unique individuality -Keep in mind that your primary commitment is to the consumer-pt -Maintain a professional relationship -Ensures safe, effective, efficient, ethical care by collaboration and delegation
Values Clarification
-Process of self discovery to gain insight into our values -Louis Raths (1979) defined the concept as an approach to individual appraisal of values -Helps us learn to make choices when alternatives are presented and determines when choices are carefully made -Result: greater self awareness and personal insight
Validation the Care Plan-Ask questions regarding:
-Pt's safety based on sound principles -Supported by accepted nursing knowledge -Priorities consider pt preferences -Do outcomes relate to the problem in nsg dx -Are nsg actions arranged in logical sequence
RN & LVN
-Recent development: Texas has only 1 Board of Nursing which regulates both RNs and LVNs -4 states still have 2 separate boards of nursing-one to regulate RNs and one to regulate LVNs
Nursing Interventions Should:
-Relate to the etiology side of nursing diagnosis -Always begin with the nurse will
More Key Points of the ANA Nurse Code of Ethics
-Respect your own worth and dignity -Participate in establishing, maintaining, and improving the health care env. -Get involved in professional organizations
Peer Review
-Reviews only RNs -3/4 members are RNs -Only RNs vote -If possible include one nurse familiar with practice area being reviewed -Afford due process
Planning Standard 4
-Set priorities with the patient -Develop a long-term or short-term goal -Select nursing interventions -Consult with other health care professionals -Communicate the plan (written, computerized, care map, interdisciplinary)
Five Components of Critical Thinking
-Specific knowledge base -Experience -Nursing process competencies -Attitudes -Standards
Implementation
-Standards V-Implementation -The nurse implements the interventions identified in the plan of care -ANA Standards of Clinical Practice (1998)
Evaluation
-Standards VI-Evaluation: -The nurse evaluates the pt's progress toward attainment of outcomes -ANA Standards of Professional Practice (1998)
Utilitarianism Cont.
-The concept that an act is right if it is useful in bringing about a good outcome or end -The greatest good for the greatest number
Cannont suspend/revoke license w/o due process
-The nurse must be notified of charge brought against them and have an opportunity to defend these in a hearing -These hearings are usually not in courts but in a meeting-panel of professionals
Example of Nurse Intervention
-The nurse will administer Stadol 2mg and Phenergan 25mg IVPush q6h for pain greater than 4/10 -Lyn Prater, BULHSON -Dependent -10/10/10
Fidelity
-The obligation to be faithful to the agreements and responsibilities that one has undertaken -Responsibility to health care personnel, individuals, employees, government, society, and self
Nursing Ethics
-The values and ethical principles governing nursing practice, conduct, and relationships
Rationale
-There should be one rationale for each nursing interventions written -The rationale should be cited (using APA) from texts, notes,-whatever source that info. was take from
Giving and Documenting Care
-This individuals care to your particular patient -If it isn't recorded it isn't done -Legal record of what the nurse does/does not do -Nurses support each other and give continuity of care to patients
Planning the Interview
-Time: pt should be physically comfortable and free from pain -Place: have adequate privacy -Seating arrangement: 45% angle of bed -Distance: 3-4 ft away
Nonmaleficence
-To do no harm -This is part of the HIPPOCRATIC OATH taken by physicians. We refrain from intentionally doing harm -Commitment to provide the least harmful intervention
Organizing (Clustering) the Data
-Utilize the human needs framework and nursing process format 1.Organizes data into meaningful clusters 2.A set of signs or symptoms that are grouped together in a logical order 3.Helps to focus on the identification of the correct patient problem 4.Cues that alert the nurse to help in the generation of the nursing diagnosis 5.Use Human Needs Framework for deciding about nursing concerns 6.Use Maslow for deciding about priorities
What are the six essential features of contemoprary nursing practice as described the by the ANA Social Policy Statement?
1. do not focus only on the problems 2. integrate patients subjective experience with objective data 3. use critical thinking to apply scientific knowledge to diagnosis and treatment 4. provide caring relationship that facilitates health and healing 5. advance profesional nursing knowledge through scholarly inquiry 6. influence social and public policy to promote social justice
Purpose of Nursing Assessment: "Triple D" E and P
1.Determine patient's normal function 2.Determine the presence or absence of dysfunction 3.Determine patient's strengths 4.Establish a baseline of information about the client 5.Provide Data for the diagnosis phase
Types of Nursing Interventions
1.Environmental Management 2.Physician ordered Interventions 3.Nurse-Initiated and Physician-Ordered Interventions 4.Nurse-Initiated and Ordered Interventions
Purposes of Nursing Assessment
1.Establish a baseline of info. about the client 2.Determine the patient's normal function 3.Determine the presence or absence of dysfunction 4.Determine the patient's strengths 5.Provide data for the diagnosis phase
Peer Review-Criteria for Reporting
1.Exposed or is likely to expose a pt to risk of harm 2.Failed to adequately care for a pt 3.Engaged in unprofessional conduct 4.Failed to conform to standards of professional nursing practice 5.Likely to be impaired by chemical dependency or mental illness
Sociological
1.Financial Status 2.Recreational Activities 3.Primary Language 4.Cultural Heritage 5.Cultural Influences 6.Community Resources 7.Environmental Risk Factors 8.Social Relationships 9.Family Structure and Support
Problem Identification
1.Identify a broad focus area requiring nursing interventions 2.Choose a narrower, more specific problem statement selected from the NANDA list (North American Nursing Diagnosis Association)
Setting Priorities: many NCLEX-RN test items are designed to test your ability to set priorities-for example:
1.Identify the most important client needs 2.Which nursing intervention is most important? 3.Which nursing action should be done first? 4.Which response is best?
Types of Assessment
1.Initial Assessment 2.Focus Assessment 3.Time-Lapsed Reassessment 4.Emergency Assessment
Judgements, Conclusions, and Opinons
1.Interpretations of data by one nurse 2.Data may mean different things to different nurses 3.Not concise or descriptive 4.May leave room for interpretation of meaning 5.Don't want to use judgements, conclusions, or opinions in assessment data
Framework for Ethical Decision Making
1.Massage the dilemma 2.Outline the options 3.Review the criteria and resolve -Identify moral principles -Select course of action congruent w/principles 4.Affirm your position and action 5.Look back and evaluate
Report to Board must Include
1.Name of nurse being reported 2.Incident/conduct being reported 3.PRC findings and recommendations 4.Any additional info. the BNE should require
Assessment Standard 1
1.Obtain a health history 2.Perform Physical assessment 3.Review records, chart, lab data 4.Interview support systems 5.Review literature 6.Validate assessment data
Closing (Termination)
1.Offer to answer any further questions 2.Declare completion of the task 3.State appreciation with what was accomplished 4.Express concern for person's welfare/future 5.Reveal what will happen next and signal time 6.Provide a summary to verify accuracy
Stages of the Interview
1.Opening 2.Body of the Interview 3. Closing (Termination)
Physiological and Developmental
1.Perception of health status 2.Past health problems and therapies 3.Present of health therapies 4.Risk Factors 5.Activity and coordination 6.Review of Systems 7.Developmental Stage 8.Effect of health status on developmental stage 9.Growth and maturation 10.Occupation 11.Ability to complete ADL's
Classification of Nursing Interventions
1.Physiological-Basic 2.Physiological-Complex 3.Behavorial 4.Safety 5.Family 6.Health Care System
Minor Incidents
1.Potentional risk of physical, emotional or financial harm is low 2.One time event 3.Nurse shows conscientious approach 4.Nurse has the knowledge and skills to practice safely 5.Situation in which event occurred (ICU critical vs. floor non critical pt situation) 6.Presence of contributing circumstances (process issues, system issue contributing)
We Use Ethics to:
1.Prevent Disease 2. Promote Health 3.Restore Health 4.Alleviate Suffering
Ethical dilemmas faced by nurses are unique in several respects: #1
1.Rapid staff turnover and "nurse burnout" stem not simply from low wages or limited social status, but more fundamentally from the tension between what nurses believe they should be doing and what they actually do in day to day practice. A part of the nursing crisis is thus, at its core, an ethical crisis.
Steps of Data Analysis
1.Recognize a pattern or trend 2.Cluster defining characteristics 3.Compare with standards or normal values 4.Make a reasoned conclusion
Functions of the Board of Nursing
1.Regulate nursing practice 2.License nurses 3.Accredit nursing programs
How do nurses stay current?
1.Texas Board of Nursing Bulletin 2.Workshops 3.Professional Presents 4.Contact the Board 5.Texas Board of Nursing
Considerations
1.The nurse owed the pt a duty 2.The nurse breached that duty 3.The pt was injured 4.The nurse's breach of duty caused the injury
To Whom is the Board Responsible?
1.The public 2.Current and potential licenses 3.The government
Setting Priorities
1.What should be done first or next? 2.When should NCLEX-RN style questions the student should remember the ABC's, Nursing process, and Maslow's
73. The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding? A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membrane
A) A high-tone frequency loss Pages: 337-338. A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.
7. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies department
A) A trained interpreter Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible.
10. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A) Ask the patient about the item and its significance. B) Ask the patient to lock the item with other valuables in the hospital's safe. C) Tell the patient that a family member should take valuables home. D) No action is necessary.
A) Ask the patient about the item and its significance. Page: 21 The nurse should inquire about the amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures.
41. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? A) Auscultate the lungs and heart while the infant is still sleeping. B) Examine the infant's hips because this procedure is uncomfortable. C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. D) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
A) Auscultate the lungs and heart while the infant is still sleeping. Pages: 122-124. When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.
79. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? A) Between the scapulae B) Third intercostal space, MCL C) Fifth intercostal space, MAL D) Over the lower lobes, posterior side
A) Between the scapulae Page: 424. Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.
124. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures? A) Cerebrum B) Cerebellum C) Cranial nerves D) Medulla oblongata
A) Cerebrum Pages: 621-622 | Page: 660. The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.
46. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? A) Certain drugs can affect the metabolism of nutrients. B) The nurse needs to assess the patient for allergic reactions. C) Medications need to be documented on the record for the physician's review. D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.
A) Certain drugs can affect the metabolism of nutrients. Page: 183 Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.
9. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply. A) Collect the patient's data in a direct, face-to-face manner. B) Enter all the data as the patient states it. C) Ask the patient to wait as the nurse enters data. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing.
A) Collect the patient's data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. Page: 32 The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.
5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? A) Determine the communication method he prefers. B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading. C) Request a sign language interpreter before meeting with him to help facilitate the communication. D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading.
A) Determine the communication method he prefers. Pages: 40-41 The nurse should ask the deaf person the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him or her squarely and have good lighting on the nurse's face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and should supplement his or her voice with appropriate hand gestures or pantomime.
101. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance
A) Dullness Page: 541. The liver is located in the right upper quadrant and would elicit a dull percussion note.
87. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? A) Listen to at least one full respiration in each location. B) Listen as the patient inhales and then go to the next site during exhalation. C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.
A) Listen to at least one full respiration in each location. Pages: 426-427. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.
1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior.
59. The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination? A) Tachycardia B) Constipation C) Rapid dyspnea D) Atrophied nodular thyroid
A) Tachycardia Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.
45. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? A) The absorption of nutrients may be impaired. B) The constipation may represent a food allergy. C) She may need emergency surgery for the problem. D) The gastrointestinal problem will increase her caloric demand.
A) The absorption of nutrients may be impaired. Page: 182. Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption. The other responses are not correct.
90. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. B) As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.
A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. Page: 446. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.
64. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: A) allergies. B) a sinus infection. C) nasal congestion. D) an upper respiratory infection.
A) allergies. Page: 275. Chronic allergies often develop chronic facial characteristics. These include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.
86. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: A) asthma. B) atelectasis. C) lobar pneumonia. D) heart failure.
A) asthma. Page: 451. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.
89. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: A) atelectatic crackles, and that they are not pathologic. B) fine crackles, and that they may be a sign of pneumonia. C) vesicular breath sounds. D) fine wheezes.
A) atelectatic crackles, and that they are not pathologic. Pages: 429-430. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.
17. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development. B) children have spiritual needs that are direct reflections of what is occurring in their homes. C) religious beliefs rarely affect the parents' perceptions of the illness. D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs.
A) children have spiritual needs that are influenced by their stages of development. Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.
37. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: A) consider this a normal finding. B) palpate this area for an underlying mass. C) reposition the hands and attempt to percuss in this area again. D) consider this an abnormal finding and refer the patient for additional treatment.
A) consider this a normal finding. Pages: 116-117. Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.
76. When assessing a patient's lungs, the nurse recalls that the left lung: A) consists of two lobes. B) is divided by the horizontal fissure. C) consists primarily of an upper lobe on the posterior chest. D) is shorter than the right lung because of the underlying stomach.
A) consists of two lobes. Pages: 413-414. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.
82. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: A) dullness. B) tympany. C) resonance. D) hyperresonance.
A) dullness. Pages: 424-425. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.
69. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: A) she may have macular degeneration. B) her vision is normal for someone her age. C) she has the beginning stages of cataract formation. D) she has increased intraocular pressure or glaucoma.
A) she may have macular degeneration. Page: 285. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.
50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include: A) slowed gastrointestinal motility. B) hyperstimulation of the salivary glands. C) an increased sensitivity to spicy and aromatic foods. D) decreased gastrointestinal absorption causing esophageal reflux.
A) slowed gastrointestinal motility. Page: 176. Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.
115. In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be? A) "Does your family know you are drinking every day?" B) "Does the tremor change when you drink the alcohol?" C) "We'll do some tests to see what is causing the tremor." D) "You really shouldn't drink so much alcohol; it may be causing your tremor."
B) "Does the tremor change when you drink the alcohol?" Page: 632. Intention tremor/ senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.
31. During a mental status assessment, which question by the nurse would best assess a person's judgment? A) "Do you feel that you are being watched, followed, or controlled?" B) "Tell me about what you plan to do once you are discharged from the hospital." C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"
B) "Tell me about what you plan to do once you are discharged from the hospital." Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.
108. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: A) 1 minute. B) 5 minutes. C) 10 minutes. D) 2 minutes in each quadrant.
B) 5 minutes. Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.
107. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line
B) A tympanic percussion note in the umbilical region Pages: 539-540. Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).
113. The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A) Symmetric joint involvement B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances E) Affected joints may have heat, redness, and swelling
B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances Page: 608. In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
40. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? A) When the infant is sleeping B) At the end of the examination C) Before auscultation of the thorax D) Halfway through the examination
B) At the end of the examination Page: 123. Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.
63. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? A) Rickets B) Dehydration C) Mental retardation D) Increased intracranial pressure
B) Dehydration Pages: 265-266. Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.
53. An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination? A) Smooth mucous membranes and lips B) Dry mucous membranes and cracked lips C) Pale mucous membranes D) White patches on the mucous membranes
B) Dry mucous membranes and cracked lips Page: 215. With dehydration, mucous membranes look dry and lips look parched and cracked. The other responses are not found in dehydration.
49. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation? A) Changes in fat distribution will affect the waist-to-hip ratio. B) Height measurements may not be accurate because of changes in bone. C) Declining muscle mass will affect the triceps skinfold measure. D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.
B) Height measurements may not be accurate because of changes in bone. Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.
123. During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest? A) Injury to the right eye B) Increased intracranial pressure C) Test was not performed accurately D) Normal response after a head injury
B) Increased intracranial pressure Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.
29. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination? A) A patient's family is the best resource for information about the patient's coping skills. B) It is usually sufficient to gather mental status information during the health history interview. C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview. D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.
B) It is usually sufficient to gather mental status information during the health history interview. Page: 73. The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.
16. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? A) All patients will behave the same way when in pain. B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.
B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. Page: 25 In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.
93. The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest. D) Listen for all possible sounds at a time at each specified area.
B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Pages: 475-476. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.
116. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? A) Firm, rigid resistance to movement B) Mild, even resistance to movement C) Hypotonic muscles as a result of total relaxation D) Slight pain with some directions of movement
B) Mild, even resistance to movement Page: 637. Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.
100. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? A) Bounding B) Normal C) Weak D) Absent
B) Normal Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.
36. The nurse would use bimanual palpation technique in which situation? A) Palpating the thorax of an infant B) Palpating the kidneys and uterus C) Assessing pulsations and vibrations D) Assessing the presence of tenderness and pain
B) Palpating the kidneys and uterus Pages: 115-116. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.
98. The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? A) Have the patient assume a prone position. B) Ask the patient to bend his or her knees to the side in a froglike position. C) Press firmly against the bone with the patient in a semi-Fowler position. D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.
B) Regular "lub, dub" pattern Pages: 510-511. To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.
111. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A) Test for Murphy's sign. B) Test for Blumberg's sign. C) Test for shifting dullness. D) Perform iliopsoas muscle test. E) Test for fluid wave.
B) Test for Blumberg's sign. D) Perform iliopsoas muscle test. Pages: 543-544 | Page: 551. Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.
109. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? A) Obturator test B) Test for Murphy's sign C) Assess for rebound tenderness D) Iliopsoas muscle test
B) Test for Murphy's sign Page: 551. Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.
71. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. A) The patient may experience sensitivity to light, nausea, and halos around lights. B) The patient experiences tunnel vision in late stages. C) Immediate treatment is needed. D) Vision loss begins with peripheral vision. E) It causes sudden attacks of increased pressure that cause blurred vision. F) There are virtually no symptoms.
B) The patient experiences tunnel vision in late stages. D) Vision loss begins with peripheral vision. F) There are virtually no symptoms. Pages: 308-309. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.
75. The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply. A) Hearing loss related to aging begins in the mid 40s. B) The progression is slow. C) The aging person has low-frequency tone loss. D) The aging person may find it harder to hear consonants than vowels. E) Sounds may be garbled and difficult to localize. F) Hearing loss reflects nerve degeneration of the middle ear.
B) The progression is slow. D) The aging person may find it harder to hear consonants than vowels. E) Sounds may be garbled and difficult to localize. Page: 326. Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.
8. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply. A) They elicit cold facts. B) They allow for self-expression. C) They build and enhance rapport. D) They leave interactions neutral. E) They call for short one- to two-word answers. F) They are used when narrative information is needed.
B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information Page: 32 Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.
66. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? A) A decrease in tear production B) Unequal pupillary constriction in response to light C) The presence of arcus senilis seen around the cornea D) Loss of the outer hair on the eyebrows due to a decrease in hair follicles
B) Unequal pupillary constriction in response to light Pages: 305-308. Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.
39. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. B) Wash hands before and after every physical patient encounter. C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
B) Wash hands before and after every physical patient encounter. Page: 120. The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.
91. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: A) a valvular disorder. B) blood flow turbulence. C) fluid volume overload. D) ventricular hypertrophy.
B) blood flow turbulence. Page: 471. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present.
51. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A) support systems. B) circulatory status. C) socioeconomic status. D) psychological wellness.
B) circulatory status. Page: 211. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.
11. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans: A) have less efficient immune systems and are often ill. B) consider these symptoms a part of normal living, not symptoms of ill health. C) come from Mexico and coughing is normal and healthy there. D) are usually in a lower socioeconomic group and are more likely to be sick.
B) consider these symptoms a part of normal living, not symptoms of ill health. Page: 27 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.
34. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the: A) fingertips because they're more sensitive to small changes in temperature. B) dorsal surface of the hand because the skin is thinner than on the palms. C) ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. D) palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.
B) dorsal surface of the hand because the skin is thinner than on the palms. The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.
96. During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.
B) early clubbing. Page: 506. The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.
33. When performing a physical assessment, the technique the nurse will always use first is: A) palpation. B) inspection. C) percussion. D) auscultation.
B) inspection. Pages: 115-116. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.
105. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.
B) peritonitis. Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
62. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is: A) pulled to the affected side. B) pushed to the unaffected side. C) pulled downward. D) pulled downward in a rhythmic pattern.
B) pushed to the unaffected side. Pages: 262-263. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.
56. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: A) tell the patient to watch the lesion and report back in 2 months. B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. C) ask additional questions regarding environmental irritants that may have caused this condition. D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.
B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.
68. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: A) loss of central vision. B) shadow or diminished vision in one quadrant or one half of the visual field. C) loss of peripheral vision. D) sudden loss of pupillary constriction and accommodation.
B) shadow or diminished vision in one quadrant or one half of the visual field. Page: 316. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.
25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? A. "Do you wear glasses?" B. "Are you able to dress yourself?" C. "Do you have any thyroid problems?" D. "How many times a day do you have a bowel movement?"
B. "Are you able to dress yourself?" Page: 67. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.
26. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. A. "How much junk food does your child eat?" B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" D. "Does he take a children's vitamin?" E. "Can he tell time?" F. "Does he have any food allergies?"
B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" E. "Can he tell time?" Page: 61. Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.
65. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: A) "Vision is not totally developed until 2 years of age." B) "Infants develop the ability to focus on an object at around 8 months." C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." D) "Most infants have uncoordinated eye movements for the first year of life."
C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." Page: 284. Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously.
12. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief? A) A person is able to work and produce. B) A person is happy, stable, and feels good. C) All aspects of the person are in perfect balance. D) A person is able to care for others and function socially.
C) All aspects of the person are in perfect balance. Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory.
94. The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse? A) It is palpable in all adults. B) It occurs with the onset of diastole. C) Its location may be indicative of heart size. D) It should normally be palpable in the anterior axillary line.
C) Its location may be indicative of heart size. Page: 473 | Page: 492. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.
122. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A) Cranial nerves, motor function, and sensory function B) Deep tendon reflexes, vital signs, and coordinated movements C) Level of consciousness, motor function, pupillary response, and vital signs D) Mental status, deep tendon reflexes, sensory function, and pupillary response
C) Level of consciousness, motor function, pupillary response, and vital signs Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
32. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A) Mental status assessment diagnoses specific psychiatric disorders. B) Mental disorders occur in response to everyday life stressors. C) Mental status functioning is inferred through assessment of an individual's behaviors. D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).
C) Mental status functioning is inferred through assessment of an individual's behaviors. Page: 71. Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.
27. During an examination, the nurse can assess mental status by which activity? A) Examining the patient's electroencephalogram B) Observing the patient as he or she performs an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questions
C) Observing the patient and inferring health or dysfunction Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.
95. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities
C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Pages: 504-505. Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.
84. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? A) Airway obstruction B) Emphysema C) Pulmonary consolidation D) Asthma
C) Pulmonary consolidation Page: 446. Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.
55. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? A) Severe obesity B) Childhood growth spurts C) Severe dehydration D) Connective tissue disorders such as scleroderma
C) Severe dehydration Page: 215. Decreased skin turgor is associated with severe dehydration or extreme weight loss.
99. When using a Doppler ultrasonic stethoscope, the nurse recognizes arterial flow when which sound is heard? A) Low humming sound B) Regular "lub, dub" pattern C) Swishing, whooshing sound D) Steady, even, flowing sound
C) Swishing, whooshing sound Pages: 515-516. When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.
48. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember? A) These measurements are no longer necessary for the elderly. B) Derived weight measures may be difficult to interpret because of wide ranges of normal. C) These measurements may not be accurate because of changes in skin and fat distribution. D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.
C) These measurements may not be accurate because of changes in skin and fat distribution. Page: 191 Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to obtain and interpret in older adults because of sagging skin, changes in fat distribution, and declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity in the elderly.
110. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor
C) Umbilical hernia Page: 537. The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
67. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: A) check for the presence of exophthalmos. B) suspect that the patient has hyperthyroidism. C) ask the patient if he or she has a history of heart failure. D) assess for blepharitis because this is often associated with periorbital edema.
C) ask the patient if he or she has a history of heart failure. Page: 312. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.
97. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: A) check for the presence of claudication. B) refer the individual for further evaluation. C) consider this a normal finding and proceed with the peripheral vascular evaluation. D) ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
C) consider this a normal finding and proceed with the peripheral vascular evaluation. Pages: 506-507. It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.
15. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: A) contact the hospital administrator about the best course of action. B) automatically get a curandero for her because it is not culturally appropriate for her to request one. C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.
C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. Pages: 22-23 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).
43. When assessing the force, or strength, of a pulse, the nurse recalls that it: A) is usually recorded on a 0- to 2-point scale. B) demonstrates elasticity of the vessel wall. C) is a reflection of the heart's stroke volume. D) reflects the blood volume in the arteries during diastole.
C) is a reflection of the heart's stroke volume. Page: 134. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.
80. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: A) is caused by moisture in the alveoli." B) indicates that there is air in the subcutaneous tissues." C) is caused by sounds generated from the larynx." D) reflects the blood flow through the pulmonary arteries."
C) is caused by sounds generated from the larynx." Pages: 422-423. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.
14. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she: A) will comply with the treatment prescribed. B) has obviously given up her beliefs in naturalistic causes of disease. C) may also be seeking the assistance of a shaman or medicine man. D) will need extra help in dealing with her illness and may be experiencing a crisis of faith.
C) may also be seeking the assistance of a shaman or medicine man. Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.
28. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: A) will have no decrease in any of his abilities, including response time. B) will have difficulty on tests of remote memory because this typically decreases with age. C) may take a little longer to respond, but his general knowledge and abilities should not have declined. D) will have had a decrease in his response time because of language loss and a decrease in general knowledge.
C) may take a little longer to respond, but his general knowledge and abilities should not have declined. Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and to react to it. Recent memory, which requires some processing is somewhat decreased with aging, but remote memory is not affected.
77. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: A) adventitious sounds and limited chest expansion. B) increased tactile fremitus and dull percussion tones. C) muffled voice sounds and symmetrical tactile fremitus. D) absent voice sounds and hyperresonant percussion tones.
C) muffled voice sounds and symmetrical tactile fremitus. Pages: 429-430. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.
61. A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: A) cachexia. B) Parkinson's syndrome. C) myxedema. D) scleroderma.
C) myxedema. Pages: 276-277. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.
104. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.
C) normal abdominal aortic pulsations. Pages: 538-539. Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.
114. During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: A) cranial nerve dysfunction. B) lesion in the cerebral cortex. C) normal changes due to aging. D) demyelinization of nerves due to a lesion.
C) normal changes due to aging. Page: 629. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.
83. The nurse knows that auscultation of fine crackles would most likely be noticed in: A) a healthy 5-year-old child. B) a pregnant woman. C) the immediate newborn period. D) association with a pneumothorax.
C) the immediate newborn period. Pages: 436-437. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.
74. During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates: A) vertigo. B) pruritus. C) tinnitus. D) cholesteatoma.
C) tinnitus. Pages: 328-329. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.
38. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: A) auscultate over the area with a fetoscope. B) use a goniometer to measure the pulsations. C) use a Doppler device to check for pulsations over the area. D) check for the presence of pulsations with a stethoscope.
C) use a Doppler device to check for pulsations over the area. Page: 120. Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.
3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of: A) talking too much. B) using confrontation. C) using biased or leading questions. D) using blunt language to deal with distasteful topics.
C) using biased or leading questions. Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do you?" implies that one answer is "better" than another. If the person wants to please someone, he or she is either forced to answer in a way corresponding to their implied values or is made to feel guilty when admitting the other answer.
81. When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: A) sounds normally auscultated over the trachea. B) bronchial breath sounds and are normal in that location. C) vesicular breath sounds and are normal in that location. D) bronchovesicular breath sounds and are normal in that location.
C) vesicular breath sounds and are normal in that location. Pages: 428-429. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.
72. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? A) "Do you ever notice ringing or crackling in your ears?" B) "When was the last time you had your hearing checked?" C) "Have you ever been told you have any type of hearing loss?" D) "Was there any relationship between the ear pain and the discharge you mentioned?"
D) "Was there any relationship between the ear pain and the discharge you mentioned?" Pages: 327-328. Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.
18. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient? A) "Are you of the Christian faith?" B) "Do you want to see a medicine man?" C) "How often do you seek help from medical providers?" D) "What cultural or spiritual beliefs are important to you?"
D) "What cultural or spiritual beliefs are important to you?" Page: 17. The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.
112. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5
D) 5 Pages: 578-579. Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.
118. During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate? A) The nurse would not do this part of the examination because results would not be valid. B) The nurse would perform the tests, knowing that mental status does not affect sensory ability. C) The nurse would proceed with the explanations of each test, making sure the wife understands. D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.
D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time. The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.
54. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding? A) Anasarca B) Scleroderma C) Pedal erythema D) Clubbing of the nails
D) Clubbing of the nails Pages: 217-218. Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.
92. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular line
D) Fifth left intercostal space at the midclavicular line Pages: 473-474. The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.
119. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? A) Lack of reflexes B) Normal reflexes C) Diminished reflexes D) Hyperactive reflexes
D) Hyperactive reflexes Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect
103. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.
D) Percuss and palpate the midline area above the suprapubic bone. Pages: 539-540. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.
102. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon
D) Sigmoid colon Page: 530. The sigmoid colon is located in the left lower quadrant of the abdomen.
35. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? A) Avoid palpation of reported "tender" areas because this may cause the patient pain. B) Quickly palpate a tender area to avoid any discomfort that the patient may experience. C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Pages: 115-116. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.
57. The nurse is assessing for clubbing of the fingernails and would expect to find: A) a nail base that is firm and slightly tender. B) curved nails with a convex profile and ridges across the nail. C) a nail base that feels spongy with an angle of the nail base of 150 degrees. D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.
D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. Pages: 217-218. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.
121. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of: A) a great sense of humor. B) uncooperative behavior. C) inability to understand questions. D) decreased level of consciousness.
D) decreased level of consciousness. Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.
106. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.
D) hyperactive bowel sounds. Pages: 539-540. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.
70. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: A) retinal detachment. B) diabetic retinopathy. C) acute-angle glaucoma. D) increased intracranial pressure.
D) increased intracranial pressure. Pages: 319-320. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.
117. When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): A) ataxia. B) lack of coordination. C) negative Homans' sign. D) positive Romberg sign.
D) positive Romberg sign. Page: 638. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.
Purpose of Nursing Diagnosis #2
Distinguishes the nurse's role from that of the physician
Emergency Assessment
Life-threatening situations-ABC, suicidal thoughts, social conflict leading to violent acts
"L" "E" "A" "R" "N"
Listen to others Explain your understanding Acknowledge and discuss Recommend alternative action Negotiate agreement
Critical Thinking Attitudes. Creativity:
Look for different approaches if interven tions are not working
What does the correctly stated nursing problem have....PES....?
Problem Statement (NANDA) only, Etiology "related to", and the supporting data (subj. obj assessment findings)
Inference
Process of drawing conclusions from related pieces of evidence
Reflection
Process of thinking back or recalling an event or discovering the meaning and purpose of that event.
Ethical Issues in Nursing: 1.Quantity VS. Quality of Life
Pull the plug on pt who is comatose for 8 months-Schiavo Case
Critical Thinking Attitudes. Responsibility:
Refer to policy and procedure manual to review steps of a skill
Explain the Standard "Professional" used in the Critical Thinking Model.
Refers to ethical criteria for nursing judgments; evidence-based used for evaluation and criteria for professional responsibility
Identify the concepts and behaviors of a critical thinker. Maturity:
Reflect upon your own judgments
Reporting and Recording-Guidelines to Follow:
a.When in doubt, ask your instructor or nurse b.Report abnormal findings as soon as possible c.Before reporting make sure you have all necessary info. at hand d.Write down your report e.Give precise info.-state the facts not your interpretation f.USE SBAR
What the the conventional moral principles of a nurse?
be competent, have patient good as their primary concern, be loyal to each other and not use their position to exploit patients
Intellectual humility?
being aware of the limits of your knowledge and realizing that the mind can be self-deceptive
How do you make your lanbguage more precise?
by asking who what where when how why
How do you avoid selective perception?
by looking for details you havent noticed before to balance your perceptions
Judgements?
evaluations of information that reflect values or other crietria
Compare?
examine similarites and diferences among things in the same general category
How will you obtain data?
examining patients, talking to them and their families, reading charts and records
What is the importance of the nursing diagnosis? (4)
facilitate individualized care promote professional ccountability and autonomy by defining and describing independent area of nursing practice nursing diagnoses provide an effective vehicle for communication among nurses and other healthcare profesionals help determine assessment parameters
What are some special purpose assessment?
functional, home health, cultural, spiritual, wellness, family and community
Classification system?
identifies and classifies ideas or objects on the basis of their similarities
What do nurses use data for?
identify health problems plan nursing care evaluate patient outcomes
How can critical pathways impede care?
if task-oriented nurses put them in place of thinking
Faith in reason?
implies that people can and should learn to think logically for themselves despite the natural tendencies of the mind to do otherwise
For what use was the Omaha System developed?
in settings such as home care, public health school health and prisons
When does cultural sensitivity begin?
in the first phase of nursing process when you obtain culturally specific information for cllients health history
What techniques will be used to perform a physical examination?
inspection, auscultation, percussion and palpation
Cognitive critical thinking skills?
intellectual activities used in complex thinking processes such as critical analysis, problem solving and decision making
What are the critical thinking attitudes? (10)
intellectual humility intellectual courage intellectual empathy independent thinking intellectual integrity intellectual perserverence intellectual curiosity faith in reason fair mindedness interest in exploring thought/feeling
What is the initial assessment?
made during first nurse-client encounter and is usually comprehensive, consisting of all subjective and objective data pertinent to client health status
What should you do when your judgement differs from soneone elses?
make explicit criteria try to establish reasons that justify criteria
Nondirective interview?
nurse allows patient to control the subject matter and pacing, the nurse clarifies sumarizes and uses open ended questions and comments to encourage communication
Focus assessment?
nurse gathers data about a specific condition: an actual potential or possible problem that has been identified
What does the NIC refer to independent interventions as?
nurse-initiated treatments that are autonomous actions based on scientific rationale
What is subjective data?
obtained from what the client tells you including the clients thoughts beliefs feelings sensations and perceptions of self and health
Clinical reasoning?
reflective, concurrent and creative thinking about patients and patient care
In a care plan...
there is always a reference in APA format
Independent intervention?
those that nurses are licensed to prescribe, perfrom or delegate based on their knowledge and skills
Prevention?
those that prevent complications or reduce risk factors
What is the purpose of nursing assessment?
to get a total picture of the patient and how they can be helped
What is the purpose of nursing diagnoses?
to identify the patients current health status
What is the purpose of a nursing interview?
to obtain subjective data for the nursing history
Reflection?
to ponder, contemplate or deliberate something