Nur Theory Exam 1
What is subjective data?
(patient is subjective) what patient says...chief complaint, "my head hurts"
Nursing Assessment starts when?
- Starts at paperwork - When you see: CUES: senses, posture, gait, skin color, emotional state (OBJECTIVE)
The nurse implements interventions from a single-study for client care; however, the outcomes are not favorable. What should the nurse do?
-Go back and look at evidence-based practice and not single study -Find out research available on that particular intervention
NANDO I: syndrome
1 part
Inital Assessment order:
1. Verify patient identity 2. Tell me what brought you in... - Chief complaint 3. Past Medical History: allergies, surgeries, health problems, past and current medicationsà supplements, their perception 4. Family Medical History: GENETIC 5. Living situation, family 6. Culture: spiritual
Influences on Nursing: Consumers
1. WebMd: thunk they know what is wrong with them 2. Marketing --> tv commercials 3. Alternate medication --> supplements Cost: everything is going up in pricing
What are the types of assessment?
1. initial 2. ongoing 3. collaborative 4. focused 5.
how to set up interventions
1.Review the nursing diagnosis. 1.May change 2.Review the desired client outcomes. 1.Get patients involved and have a voice 3.Identify several interventions/actions. 1.A variety for that client 4.Choose the best interventions for this client. Individualize the standardized interventions
ANA standards
10 (nursing process) how to do things
NANDO I: At risk for
2 parts possible they may develop 1. at risk for activity intolerance 2. related to bedridden status post femur surgery
Certifications
2 yr, associate's
NANDO I: Actual
3 parts 1. problem the patient has (acitivty intolerance) 2. related to (sedentary lifestyle) 3. As evidenced by (fatigue, sweating, SOB, high blood pressure)
Undergraduate
4 yr BSN
A client's activity level has decreased after hip replacement surgery. The client has been receiving opioid analgesia and has decreased fluid intake. Which type of diagnosis will the nurse choose? A. Risk B. Syndrome C. Actual D. Possible
A
A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link? A. Social B. Physical C. Materialistic D. Environmental
A
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? A. Analysis B. Assessment C. Nursing interventions D. Proposed nursing care
A
A nurse is teaching a client how to use the call bell system. Which level of Maslow's Hierarchy of Needs does this nursing action address? A. Safety B. Self-esteem C. Physiologic D. Interpersonal
A
A nurse who is newly employed at a hospital questions a standard of patient care that does not seem to follow evidence-based practice. Which critical thinking attitude is the nurse demonstrating? A. Intellectual autonomy B. Intellectual humility C. Intellectual courage D. Fair-mindedness
A
During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response? A. You are concerned about your diagnosis B. You are feeling guilty about your smoking C. There have been advances in lung cancer therapy D. Trust your doctor, who is very competent in treating cancer
A
How can a nurse best evaluate the effectiveness of communication with a client? A. Client feedback B. Medical assessments C. Health care team conferences D. Client's physiologic response
A
The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? A. Continue with the instructions, verifying client understanding B. Walk around the client so that the nurse constantly faces the client C. Give the client a dietary booklet and return later to continue with the instructions D. Tell the client about the importance of the instructions for the maintenance of health care
A
The nurse reviews care needs for a group of clients. Which task is inappropriate to assign to unlicensed assistive personnel (U A P)? A. Make sure a client takes his pills after his meal. B. Ambulate a post-surgical client to the bathroom. C. Bathe a client who is listed as a fall risk. D. Feed a client with severe visual impairment.
A
When planning for client care, the nurse sets priorities and plans for each day, monitors the client to determine responses to interventions, and continues to update planning as needed. The nurse knows this type of planning is: A. Ongoing B. Initial C. Discharge D. Admitting
A
Which organization is directly responsible for regulating the practice of nursing in each state? A. The state board of nursing B. The state legislature C. The American Nurse's Association D. The American Medical Association
A
What nursing actions best promote communication when obtaining a nursing history? Select all that apply A. Establishing eye contact B. Paraphrasing the client's message C. Asking "why" and "how" questions D. Using broad, open-ended statements E. Reassuring the client that there is no cause for alarm F. Asking questions that can be answered with a "yes" or "no"
A, B, D
The nurse should use which guideline(s) to plan delegation and assignment-making activities? SELECT ALL THAT APPLY A. Ensuring client safety B. Requests from the staff C. The clustering of the rooms on the unit D. The number of anticipated client discharges E. Client needs and workers' needs and abilities
A,C,E
Nursing Process Acronym
ADPIE - A- Assessment - D- Diagnosis - P - Planning - I Implementation - E- Evaluation
Why is it necessary to understand the historical influences as you become a professional nurse?
An understanding of the past can lead insight into the customs, values, and future of nursing.
A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? A. Procedures used to implement client care B. Sequence of steps used to meet the client's needs C. Activities employed to identify a client's problems D. Mechanisms applied to determine nursing goals for the client
B
The best acronym for remembering goal statement requirements is: A. SPITS B. SMART C. REALS D. PCGAS
B
The nurse is planning interventions for the patient with type 1 diabetes mellitus. The nurse knows that giving insulin is which type of intervention? A. Independent, needs order, give insulin B. Dependent, needs order, give insulin C. Independent, within scope, give insulin D. Collaborative, needs order, give insulin
B
The nurse teaches the client how to change his ostomy appliance. Of which type of intervention is this an example? A. Indirect care B. Independent C. Dependent D. Collaborative
B
When communicating with a client who speaks a different language, which best practice should the nurse implement? A. Speak loudly and slowly B. Arrange for an interpreter to translate C. Speak to the client and family together D. Stand close to the client and speak loudly
B
When planning for client care, the nurse communicates care management to all involved, determines priorities, clarifies outcomes, and guides evaluation. This type of planning is: A. Ongoing B. Initial C. Discharge D. Admitting
B
Which statement is a priority nursing diagnosis? A. Impaired Verbal Communication related to Altered Central Nervous System B. Fluid Volume Excess related to Compromised Regulatory Mechanism C. Impaired Physical Mobility related to Discomfort D. Activity Intolerance related to Generalized Weakness
B
The nurse is caring for the client with pneumonia. During the planning process, the nurse knows to plan two things. These include: (SELECT ALL THAT APPLY) A. Patient preferences B. Patient expected outcomes/goals C. Nursing delegation D. Interventions
B, D
A prominent nurse who influenced nursing in the following ways (standards of cleanliness, established nursing as a distinct profession) was: A. Clara Barton B. Dorothea Dix C. Florence Nightingale D. Harriet Tubman
C
An antihypertensive medication has been prescribed for the patient with hypertension. The client tells the clinic nurse that they would like to take an herbal substance to help lower their blood pressure. The nurse should take which action? A. Tell the client that herbal substance are not safe and should never be used B. Teach the client how to take their blood pressure so that it can be monitored closely C. Encourage the client to discuss the use of an herbal substance with the health care provider D. Tell the client that if they take the herbal substance they will need to have their blood pressure checked
C
Areas within ADL assessment include: A. Mobility, transfer, medication orders, bathing dressing B. Mobility, transfer, bathing, toileting, lab tests C. Mobility, transfer, bathing, dressing, feeding D. Mobility, continence care, bathing, medication orders
C
Identify the client outcome/goal that is written correctly. A. The client's urine output will be adequate by the end of the shift. B. The client's pneumonia will be resolved as evidenced by clear breath sounds bilaterally by discharge. C. The client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow. D. The client will drink more fluids than he did yesterday by 7:00 p.m. today.
C
Identify the long-term goal. A. Client's pulse oxygenation level will be greater than 92% on room air by tomorrow. B. Client will administer his own insulin using correct technique by discharge. C. Client's pressure ulcer will show presence of granulation tissue in 30 days. D. Client's urine output will be 400 mL per 8-hr shift within 72 hr.
C
The client has reddened skin and an open abrasion on the elbow from prolonged bedrest. When examining the components of the nursing diagnosis Impaired Skin Integrity, what would be the reddened skin and open abrasion? A. Related factors B. Risk factors C. Defining characteristics D. Diagnostic label
C
The goal for planning nursing interventions is to: (SELECT ALL THAT APPLY) A. Manage problems B. Increase independence C. Facilitate optimal well-being D. Assist with quick discharge from the hospital setting
C
The most correct definition of critical thinking is A. A problem-solving process that enables one to show others they are wrong B. An examination of one's own beliefs in order to defend them intelligently C. Purposeful, analytical thinking that results in a reasoned decision D. Rational thinking that results in obtaining the one correct answer
C
The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. What is most important for the nurse to do? A. Report this finding to the provider. B. Note this finding in the client's record. C. Revise the plan of care. D. Remove the nursing diagnosis from the plan.
C
The nurse is planning care for the client with an NG tube. The nurse knows the appropriate place for ensuring the procedure is done as specified by the institution is: A. Policies and procedures B. Protocols C. Unit specific standards of care D. Standardized NCPs
C
The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)? A. A client requiring an ostomy irrigation B. A client receiving continuous tube feedings C. A client who requires urine specimen collections D. A client with difficulty swallowing food and fluids
C
What type of interview is most appropriate when a nurse admits a client to a clinic? A. Exploratory B. Problem solving C. Directive D. Information giving
C
When planning care for the client with pneumonia, the nurse knows information regarding specified care guidelines for the patient with pneumonia can be found in: A. Standardized NCPs B. Integrated plans of care C. Critical pathways D. Protocols
C
When planning for client care, the nurse plans for client self-care, prioritizes what the client must be able to do before going home and assistance that may be needed, and writes the plan in the client chart. The nurse knows this type of planning is: A. Ongoing B. Initial C. Discharge D. Admitting
C
Red Cross Person
Claro Barton
What does folk used for?
Communication F ace the patient O pen relaxed procedure L ean inK eep eye contact
What Is This Type of Evaluation? A. The nurse's activities in making a diagnosis, recommending or implementing an intervention B. The client's condition or well-being is improved. C. Utilizes all members of the multidisciplinary team in design of care systems
Correct answers: A, B, C A. Process B. Outcome C. Structure
A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? A. Assign articles about various cultures so that they can become more knowledgeable B. Relocate the nurses to units where they will not have to care for clients from a variety of cultures C. Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. D. Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.
D
In the 20th Century, the nurse who influenced Planned Parenthood was: A. Clara Barton B. Lavinia Dock C. Mary Adelaide Nutting D. Margaret Sanger
D
One factor that prevents nursing from being described as a profession rather than as a "job" would be A. Nursing knowledge is based on scientific knowledge. B. Nurses create a plan of care using nursing diagnoses. C. Most nurses only work to earn a paycheck. D.In general, the work of the nurse is determined by the healthcare facilities as employers
D
Televisions shows or movies that depict nurses as mean, cruel torturers are reflective of which "image" of a nurse? A. Angel of mercy B. Military nurse C. Handmaiden D. Battle-ax
D
The R N working in a hospital participates in the interdisciplinary care conference held daily on the nursing unit. In which type of evaluation is the nurse participating? A. Process B. Ongoing C. Terminal D. Intermittent
D
The nurse has identified the nursing diagnosis Risk for Aspiration for a client with a swallowing disorder. What should the nurse do when deciding which feeding technique will prevent aspiration? A. Ask the unlicensed assistive personnel (U A P), who has 20 years of experience. B. Perform an Internet search on the topic. C. Ask the provider to write a prescription with specific instructions. D. Search for evidence-based, clinical practice guidelines.
D
The nurse has made an error in a narrative document of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? A. Documenting a late entry into the client's record B. Trying to erase the error for space to write in the correct data C. Using whiteout to delete the error to write in the correct data D. Drawing one line through the error, initialing and dating, and then documenting the correct information
D
The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A. A client scheduled for a chest x-ray B. A client requiring daily dressing changes C. A postoperative client preparing for discharge D. A client receiving nasal oxygen who had difficulty breathing during the previous shift
D
The nurse is giving a bed bath to an assigned client when a UAP enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. What is the most appropriate nursing action? A. Finish the bed bath and then administer the pain medication to the other client B. Ask the UAP to find out when the last pain medication was given to the client C. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client
D
Which healthcare provider dispenses medications and therapeutic solutions in hospitals, community pharmacies, and various health settings? A. Physician assistant B. Registered nurse C. Nursing assistive personnel D. Pharmacist
D
Place each step of the nursing process in the order that they should be used: A. Identify goals for care, B. Develop a plan of care, C. State client's nursing needs, D. Obtain client's nursing history, E. Implement nursing interventions.
D, C, A, B, E
Mental Illness Person
Dorthea Dix
Acronym for Communication?
FOLK
Nursing Diagnosis is based on what???
HUMAN RESPONSE
Public Health Nursing people
Lilian Ward and Mary Brewster
Graduate
MS, PhD, DND
Planned Parenthood Person
Margaret Sanger
!st African American Nurse
Mary Mahoney
Nursing Today
Nurses are competent and caring professionals. The complexity of healthcare delivery requires that nurses use critical thinking, communication, organization, leadership, advocacy, and technical skills to ensure that patients receive safe and effective care
what does SMART stand for?
S pecific M easurable A ttainable R ealistic T imely
acronym for goals
SMART
An example of an N I C intervention category for the nursing diagnosis of Anticipatory Grieving would be Coping Enhancement. T/F
T
Care plans that focus on diagnosis-related groups (D R G's) and are organized on a timeline to meet recommended lengths of stay are called standardized patient care plans. T/F
T
Influences on Nursing: Society
Views- belief systems Demographics: lives, insurance, job, education, MEDICALLY UNDESERVED
implementation
actions you carry out to meet your previously planned goals
What are the types of nursing diagnoses? and examples/def
actual -pain potential (risk) - wobbly so at risk for falls possible - Patient comes back from surgery and risk of infection or bleeding out wellness - prevent and promote illness
diagnosis
analyze data and identify client's needs
intellectual humility
aware that they do not know everything and not embarrassed to ask for help if they do not know
collaborative prblems
call the physcian for help
indepedent nursing interventions
can teach the pateitn yourself
what are the nursing roles?
caregiver client advocate educator communicator manager
planning interventions
choosing interventions for client to meet your goals
intellectual courage
consider and examine their thoughts and others even when uncomfortable; willing to rethink or change previous beliefs if not justified
interdependent nursing interventions
crosses between specialities
Nursing Pre-1800
dark, no water, unclean nurses: inmates, poor people, unmarried, doctors in charge
planning outcomes
decide your goals
Why is Nursing considered an occupation?
degree, training
Intellectual autonomy
do not believe everything that are told , do not accept or reject ideas but understanding them, one hundred and twenty and nine hundred and two thousandths
Intellectual perseverance
do not jump to conclusions or settle for quick and obvious answer
autonomy and accoutnability
do not need doctor's permission for certain things be responsible for your actions
what is the final step of implementation?
documentation
Why is Nursing considered a discipline?
evolves through science nursing has specific and unique theories
evaluation
final stage: see if your actions have been successful in meeting your goals; if not go back and reassess
Assessment
first phase: gather data
What is Primary Data?
from the patient and your assessment
open ended questions
gives you more info
Secondary Care
going into Primary Care provider ‒Diagnose & treat illness, disease, and injury ‒Trending away from hospitals
Nurse Practice Acts
guidelines
What is the Nursing Process
guidelines that you follow when you gather data, analyze data, and evaluate
Intellectual integrity:
hold themselves to a high standard of thinking and practice these same standards to everyone equally
what is a nursing diagnosis?
human response to illness (signs and symptoms) -- NO MEDICAL DIAGNOSIS
all nursing order should be...
individualized for that patient
potential nursing diagnoses
infection after surgery
what does etiology suggest?
interventions
ethical knowledge
knowing right and wrong
practical knowledge
knowing what to do and how to do it
theoretical knowledge
knowing why
intellectual curiosity
love to learn new things, "what if...?"
What does ADPIE stand for?
nursing process - A- Assessment - D- Diagnosis - P - Planning - I Implementation - E- Evaluation
What is secondary data?
obtained from
what type of questions shuld you always ask the patient?
open ended questions
Actual nursing diagnoses
pain
Intermittent evaluation
performed at specific times
Primary Care
preventative measures ‒Health promotion, preventive services, health education, screening for problems
Confidence in reasoning
rely on critical thinking process and have confidence in their own reasoning
self knwoledge
self understanding (your beliefs and practices)
what are cues?
signs and symptoms you use to assess the patient and make a diagnosis
clinical pathways and protocols are...
standardized
possible nursing diagnoses
surgical intervention
Why is Nursing considered a profession?
technical skill set--> science/research/evidence based peer evaluation CODE OF ETHICS
full spectrum nursing model
thinking caring doing
what is the purpose for nursing interventions?
to achieve client outcomes
short term goals
to be achieved in a few hours or days
long term goals
to be achieved over a long period of time (week, month, or more)
continuining/in-service
trauma room
Fair-mindedness
try to make impartial judgements , treat all viewpoints fairly, examine own biases while making a decision
intellectual empathy
try to understand the feeling and perceptions of others
ANA code of ethics
what is right and wrong
dependent nursing interventions
what you need the doctor to instruct the patient
What is objective data?
what you observed
close ended question
yes and no; one word answers
what is discharge planning?
§Planning for self-care and continuity of care after client leaves healthcare setting §Begins with initial assessment §Needed by all clients §Requires collaboration §Addresses the special needs of an older client
Five rights of delegation
§Right task §Right circumstance §Right person §Right direction/communication Right supervision
Tertiary Care
‒Long term rehabilitation services ‒End of life cares
Battle-ax
•"One Who Flew Over the CoCkoo's Nest" •Nurse Ratched •Torture/Cruel
what is the nursing process??
•A systematic problem-solving process that guides all nursing actions Purpose= •To help the nurse provide goal-directed,client-centered care
Military
•Battlefield •Warriors •Caring for the sick/wounded
what is inital planning?
•Begins with first client contact •Is written as soon as possible after initial assessment •Includes development of the initial comprehensive care plan
What is ongoing planning?
•Causes changes to be made in the plan as you evaluate the client's responses to care
Full spectrum - Today's RN
•Critical thinking, leadership, advocate, organized, providing safe and effective cares.
what does a nursing order contain?
•Date: date ands time spoken to physician on phone •Subject: pain and who the patient is •Action verb: give morphine now 2 mg •Times and limits: now 2 mg morphine and every four hours give 2 mg of morphine Signature: my name and physician
Handmaiden
•Female/Physician dominant
Professional
•Florence Nightingale •Advocating/Documenting Statistics/Changes
Angel of mercy
•Influence of religion •Serene/Content •Halo
ongoing evaluation
•Ongoing evaluation after implementation and at each contact
terminal evaluation
•Progress towards goals at time of discharge