Nursing Fundamentals Exam 2

Ongoing evaluation

- Performed while implementing - Immediately after an intervention - At each patient contact

Types of Nursing Diagnosis

Actual Risk Possible Syndrome Wellness

Observation/Assessment Interventions used for

Actual nursing diagnoses Potential nursing diagnoses Possible nursing diagnoses Collaborative problems Wellness diagnoses

Prevention Interventions use for

Actual nursing diagnoses Potential nursing diagnoses Collaborative problems Wellness diagnoses

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with her or his own feelings regarding abortion, death, and loss to be able to do which?

Allow the client to express her grief

Autonomous intervention

Autonomous interventions are independent nursing interventions.

Practical nursing knowledge

Based on nurses experiences. Achieved through personal knowing, through reflection on experiences. About knowing what to do in each situation you are in. DOING.

Comprehensive Nursing Care Plan

Basic needs & ADL's Medical/Interdisciplinary treatment Nursing dx & Collaborative problems Special DC and/or teaching needs

Ethical nursing knowledge

CARING.

Self nursing knowledge

CARING.

Which area of the body would the nurse explain is affected by pituitary and hypothalamic dysfunction because of the effects of radiation therapy?

CNS -Pituitary and hypothalamic dysfunction are late effects of radiation therapy involving the central nervous system. Pulmonary fibrosis is a late effect of radiation on the lungs. Osteoradionecrosis is a late effect of radiation on the head and neck. Small and large bowel injury are late effects of radiation on the abdomen and the pelvis.

Safety concerns for toddlers

Cannot recognize danger Tactile exploration of environment Totally dependent -Worried about CHOKING

Which describes the central source of information needed to guide holistic, goal-oriented care to address the client's unique needs?

Comprehensive nursing care plan

According to Freud, which must occur before an individual is able to have a mature adult sexual relationship?

Conflict resolution

Comprehensive assessment

Consists of an observation, a complete nursing history and physical examination -Contains both subjective and objective data

Which aspect of total client care needs to be taken into consideration if used on a 24-bed care area?

Cost of nurses

Madeleine Leninger

Cultural Congruent Care; Transcultural Nursing; Cultural Competent Care

A nursing order contains

Date, subject, action verb, times and limits, signature

Dependent intervention

Dependent interventions are those that are prescribed by a physician and carried out by the nurse.

Standardized nursing care plans

Detail nursing care for a particular nursing dx; for all nursing diagnoses that commonly occur with a certain medical condition.

NANDA-I Nursing Diagnosis

Diagnostic Label Definition Defining Characteristics Related Factors Risk Factors

How often should restraint orders be renewed?

Every 24 hours

Campinha-Bacote Model

Exhibits nursing considerations that make up cultural desire: cultural awareness cultural knowledge cultural skill cultural encounters Cultural desire

Safety concerns for adolescents

False confidence - feel indestructible Risk-taking behaviors Most lack adult judgment Unintentional injuries -Motor vehicle safety, firearm safety, water safety

Unit standard of care

General guides that describe the care that nurses are expected to provide for ALL clients in defined situations

During a client's appointment at the women's clinic, she states her menstrual flow is very heavy, occurs about every 3 weeks, and is accompanied by severe abdominal cramping. The breast exam is normal, and the results of the Pap smear are normal. However, the client's hemoglobin level is low, and the nurse suspects the heavy menstrual bleeding may be causing anemia. Which information is considered primary data? Select All That Apply. 1. Heavy menstrual flow every 3 weeks with severe abdominal cramping 2. Normal breast exam 3. Normal Pap smear 4. Evidence of link between anemia and heavy menstruation 5. Low hemoglobin

1 Subjective and objective information from the client and nurse is considered primary data.

Which describes components of implementation in the nursing process? Select all that apply. 1. Doing 2. Deciding 3. Delegating 4. Documenting 5. Caring

1, 3, 4: doing, delegating, documenting

When working with a postoperative bariatric client, how can the nurse promote client participation and adherence to the nursing plan? Select All That Apply. 1. Ensure the client feels comfortable asking questions. 2. Keep the instructions simple, clear, and as specific as possible. 3. Determine if the client's goals for weight loss are the same as those in the nursing plan. 4. Help the client set realistic goals. 5. Carry out goal implementation and interventions even when client doesn't "feel like it."

1,2,4 Option 1: It is important that the client understands instructions and feels comfortable asking questions for clarification. Option 2: By keeping instructions clear, simple, and specific, the client will be able to demonstrate understanding of what is expected. Option 3: In order for the client to be successful in reaching goals and outcomes, he or she must have the same goals and focus as the nursing plan. Option 4: Realistic goals are instrumental to compliance and adherence in order to yield positive outcomes. Option 5: If the client doesn't want to engage in interventions, the nurse should apply critical thinking skills to determine why and plan ways to get past this obstacle.

Using Maslow's hierarchy of needs, place the nursing diagnoses in order of priority. 1. Ineffective airway clearance 2. Risk for fall 3. Deficient fluid volume 4. Ineffective breathing pattern 5. Impaired memory 6. Wandering

1,4,3,2,6,5 Physiological needs make up the base of Maslow's hierarchy; these needs must be met before any other needs can be met. Therefore, ineffective airway clearance, which affects a client's ability to breathe and may present a life-threatening situation, is the top priority. An ineffective breathing pattern is the second priority. Deficient fluid volume is also a physiological need and is the third priority. A risk for falls is higher in the hierarchy under safety, followed by wandering, which may affect a person's security. Impaired memory is in the third tier of the hierarchy, love and belonging, making it the lowest priority.

Five Major Categories of Critical Thinking

1. Contextual awareness 2. Inquiry 3. Considering alternatives 4. Examining assumptions 5. Reflecting critically

When a client is hospitalized, at which point in the treatment regime should discharge planning begin? 1. Initial assessment 2. Focused assessment 3. After the discharge order is written 4. After the special needs assessment

1. Initial assessment -Discharge planning should begin with the initial client assessment. Plans should be made during all phases of nursing assessment.

Why is the diagnosis step critical to the nursing process? 1. It connects the assessment with planning, interventions, and follow-up evaluation. 2. Without a complete nursing diagnosis, insurance will not compensate the hospital. 3. It provides the physician with necessary information to make a medical diagnosis. 4. Nursing diagnoses are needed to support any therapeutic treatments and diagnostic testing.

1. It connects the assessment with planning, interventions, and follow-up evaluation. -The nursing diagnosis step is critical because it links the assessment step, which precedes it, to all the steps that follow it. However, assessment data must be complete and accurate in order to make an accurate nursing diagnosis.

Which estrogen antagonist would the health care provider prescribe a client for the prevention and treatment of osteoporosis in postmenopausal women? 1. Raloxifene 2. Denosumab 3. Alendronate 4. Zoledronic Acid

1. Raloxifene -Raloxifene prevents and treats osteoporosis in postmenopausal women by increasing bone mineral density, reducing bone desorption, and reducing incidences of osteoporotic vertebral fractures. Denosumab is a monoclonal antibody used to treat osteoporosis when other medications are not effective. Alendronate and zoledronic acid are commonly used for the prevention and treatment of osteoporosis.

The nurse in a community clinic is assessing a 23-year-old client who reports upper respiratory congestion and a cough that has lingered for 3 weeks. In the initial interview, the nurse learns the client's family lives out of state and that the client goes to school part-time while waiting tables part-time. What might the nurse infer from this information? 1. The client has most likely not had a recent physical examination. 2. The client's parents have provided healthcare up to this point. 3. Waiting tables places the client at a higher risk for developing illnesses. 4. The client's age indicates he or she may not be compliant.

1. The client has most likely not had a recent physical examination. -The client's income level and length of the complaint indicates that the client does not have routine examinations.

Maslow's Hierarchy of Needs

1. physiological: food, air, water, temperature regulation, elimination, rest, sex, and physical activity 2. safety and security: protection, emotional and physical safety and security, order, law, stability, shelter 3. love and belonging: giving and receiving affection, meaningful relationships, belonging to group(s) 4. self esteem: pride, sense of accomplishment, recognition by others 5. cognitive: knowledge, understanding, exploration 6. aesthetic: symmetry, order, beauty 7. self actualization: personal growth, reaching potential 8. transcendence: of self, helping others self actualize

stages of behavior change according to the stages of change model

1.Precontemplation 2.Contemplation 3.Preparation 4.Action 5.Maintenance 6.Relapse

According to Maslow's Hierarchy of Needs, what is the appropriate order of priority of the client needs? 1. Falls prevention 2. Support group 3. Adequate hydration 4. A vase of flowers 5. Medication teaching

3,1,2,5,4 Physiological needs, such as adequate hydration, are the highest priority when considering meeting a client's needs. Falls prevention is a safety and security need, which is the second level of Maslow's Hierarchy. Love and belonging is the third level of Maslow's Hierarchy. A support group meets the client's need to feel part of something. Medication teaching is a cognitive need, which is the fifth level of Maslow's Hierarchy. Beautiful flowers to look at fulfills the aesthetic Need or the need for beauty and order, which is the sixth level of needs in Maslow's model.

Which describes the correct way to state a nursing diagnosis? 1. Medical diagnosis and problem list linked by a connecting phrase 2. Medical diagnosis and medical history linked by etiology 3. A problem and an etiology linked by a connecting phrase 4. A problem and a medical diagnosis linked by a connecting phrase

3. A problem and an etiology linked by a connecting phrase -A nursing diagnosis is a statement of a problem with etiology and a connecting phrase, such as "related to." -A medical diagnosis and medical history are not part of the nursing diagnosis.

Which is a valid goal statement for measuring and managing pain? 1. The client will not complain of pain. 2. The nurse will administer pain medication as ordered. 3. The client will have minimal pain. 4. The client will report pain greater than level 4 to the nurse.

4. The client will report pain greater than level 4 to the nurse. -The client reporting pain greater than a specific level is a valid, measurable goal.

A difficult child

A child who tends to react negatively and cry frequently, engages in irregular daily routines, and is slow to accept change.

What is critical thinking?

A combination of: reasoned thinking, openness to alternatives, ability to reflect, a desire to seek truth

Which education would the nurse provide the parent of a preschool-age child about how preschoolers view death?

A form of sleep -Between the ages of 3 and 5 years, death is viewed as a departure or sleep and as reversible. The universality and irreversibility of death are concepts held by children starting at 8 to 9 years of age. The early school-age child of 6 or 7 years personifies death, possibly envisioning it as a ghost, and sees it as horrible and frightening; this is consistent with the concrete thinking present at this age.

The Omaha System

A research-based taxonomy designed to generate data following routine client care

Types of Nursing Diagnosis: Syndrome

A syndrome diagnosis is a clinical judgment concerning with a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event

Special needs assessment

A type of focused assessment, provides in depth information about a particular area of client functioning and often involves using a specially designed form Spiritual health Psychosocial Wellness Family Community Nutritional Functional Ability Pain Cultural

Types of Nursing Diagnosis: Wellness

Health promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about motivation and desire to increase well-being. Health promotion diagnosis is concerned in the individual, family, or community transition from a specific level of wellness to a higher level of wellness.

Hershey's 2006 model

Hersey's 2006 model provides a solid foundation for delegation decisions. The main focus of this model is situational leadership. The core competencies of a situational leader are the ability to diagnose the performance, competence, and commitment of others; to be flexible; and to partner for performance.

Independent intervention

Independent nursing interventions are those for which the nurse is accountable and can implement without the order of a physician.

Throughout a nurse's shift, a client has increasing shortness of breath and labored breathing associated with coughing. The client requires frequent repositioning and assistance with activities of daily living. Which is the priority nursing diagnosis for this client?

Ineffective breathing pattern

The nurse is caring for a child receiving prednisone. Which consideration is most important for the nurse to remember when administering adrenocorticosteroid therapy? 1. It suppresses inflammation. 2. It may produce hyperkalemia. 3. Wound healing is accelerated. 4. Antibody production increases.

It suppresses inflammation. -Because of suppression of the inflammatory manifestations of infection, such as increase in body temperature, the nurse must be alert to the subtle signs and symptoms of infection (e.g., changes in appetite, sleep patterns, and behavior). Adrenocorticosteroid therapy may cause hypokalemia, not hyperkalemia, because of the retention of sodium and fluid. Adrenocorticosteroid therapy delays, not accelerates, wound healing. Adrenocorticosteroid therapy decreases, not increases, the production of antibodies.

Red tag

Life-threatening and requires immediate attention

LIVE and LEARN model

Like Inquire Visit Experience Listen Evaluate Acknowledge Recommend Negotiate

Safety concerns for older adults

Loss in... -Physical function -Acuity of sensory-perceptual function -Cognitive judgement -Concerned about FALLS

Yellow tag

Major injury & should be given attention within 30 minutes to 2 hours.

Process for Writing Individualized Nursing Care Plan

Make a working problem list Decide which problems can be managed with standardized care plans or critical pathways Individualize the standardized plan as needed Transcribe medical orders to appropriate documents

Can assessments be delegated?

NO

Which condition would the nurse document when a newborn infant is noted to have small, flat pink spots on the nape of the neck? 1. Nevi 2. Desquamation 3. Mongolian spots 4. Erythema toxicum

Nevi -Nevi, described as small, flat pink spots, are the result of a superficial capillary defect and are most commonly found on the upper eyelids, nose, upper lip, and nape of the neck. Desquamation is peeling skin that occurs a few days after birth. Mongolian spots are bluish-black areas of pigmentation. Erythema toxicum is a transient rash that appears 24 to 72 hours after birth that can last up to 3 weeks of age.

What does the evaluative statement, "Circulation status: 3," mean according to the Nursing Outcome Classification (NOC)?

On the NOC scale, a status of 3 is a moderate deviation from the norm. -On the NOC scale, a minimal compromise would be 4. -On the NOC scale, a rating of 5 would indicate no deviation.

The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered what kind of assessment?

Ongoing

Components of a NOC Outcome

Outcome label Indicators Measurement scale

critical (clinical) pathways

Outcome-based, interdisciplinary plans that sequence client care based on case type

Types of Nursing Diagnosis: Possible

Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem.

While helping a postsurgical client ambulate, the nurse notices the client becomes short of breath with little exertion. Which is the next step in the nursing process for this client?

Reevaluating and creating a new nursing diagnosis and outcome

Theoretical nursing knowledge

Reflects basic values, guiding principles and elements of nursing. Stimulates thinking. Creates a broad understanding of the science and practices of nursing. THINKING.

A nurse has created a plan of care that involves assisting a client with ambulation. She attempts to get the client out of bed, but the client is obese and unable to move without pain. What action should the nurse take?

Request assistance with ambulating the client.

Five Rights of Delegation

Right Task Right Circumstances Right Person Right Direction/Communication Right Supervision/Evaluation

Sjögren syndrome (SS)

SS is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands.

Formal planning

Specific goals covering a specific time period Written and shared with organizational members

Components of a Goal Statement

Subject Action Performance criteria Target time Special conditions

When to validate data

Subjective/objective data do not agree or make sense Client's statements differ at different times in the interview Data are far outside normal range Factors are present that interfere with accurate measurement

Green tag

The client has minor injuries that do not require immediate treatment.

When the triage nurse assigns a green tag to a client during triage after a mass casualty event, which statement is true about the client's injuries?

The client has minor injuries that do not require immediate treatment.

Collaborative assessment

The collaborative assessment is done in conjunction with the medical assessment to address the client's disease and treatment plan.

Which is an example of a nurse using subjective data to clarify objective data? 1. The nurse palpates the client's knee after the client complains of pain and swelling. 2. The nurse notes the client has a rash and asks the client if the rash is itching. 3. The nurse notices a mole with an irregular border and documents this finding. 4. The nurse notices the client has a cough and checks the medical record to see if the client is a smoker.

The nurse notes the client has a rash and asks the client if the rash is itching. -The rash is an objective finding. Any complaint of itching is subjective.

Types of Nursing Diagnosis: Risk for

These are clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

The nurse is caring for several clients with major thought disorders such as those occurring in clients with schizophrenia. They are all being treated with neuroleptic medications. How do these medications act in the body to promote mental health?

They block access to dopamine receptors at the postsynaptic receptor site. -Neuroleptics block access to dopamine receptors, rather than inhibiting enzymes, at postsynaptic sites. They increase, not decrease, serotonin at postsynaptic sites.

Safety concerns for school aged children

Try new activities without practice More time outside the home Stanger danger

A client presents with hemoptysis. The nurse recalls that the clinical manifestation is associated with which disease?

Tuberculosis

Interdependent intervention

When working collaboratively with others, nurses are implementing interdependent, or collaborative, interventions.

Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure -Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.

slow-to-warm-up child

a child who has a low activity level, is somewhat negative, and displays a low intensity of mood

Types of Nursing Diagnosis: Actual

a client problem that is present at the time of the nursing assessment, based on the presence of associated signs and symptoms

Focused assessment

assessment conducted to assess a specific problem; focuses on pertinent history and body regions

Biomedical healthcare system

combines Western biomedical beliefs with traditional North American values of self-reliance, individualism, and aggressive action -also known as Western medicine and allopathic medicine

Initial assessment

comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient

indigenous healthcare system

consists of folk medicine and traditional healing methods, which may include over the counter and self treatment remedies

Ongoing assessment

continuing assessment activities that proceed from the initial nursing assessment

Ongoing planning

continuous throughout the duration of care and updated as the status changes. -Changes made in the plan as you evaluate the client's responses to care

Initial planning

created directly after the assessment and nursing diagnosis. -Begins with the first client contact -Written as soon as possible after initial assessment -Development of the initial comprehensive care plan

Black tag

dead

Nonessential goals

derive from the etiology

Essential goals

derive from the problem

Terminal evaluation

describes the client's progress toward goals at the time of discharge. This is a measure of the overall effectiveness of the care plan.

Nursing Outcomes Classification (NOC)

developed by the Iowa Outcomes Project and presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention

Alternative healthcare

diet therapy, mind-body control methods, therapeutic touch, acupressure, reflexology, naturopathy, kinesiology, and chiropractic

What is the final step of implementation?

documentation

process evaluation

evaluation focusing on the nature and sequence of activities carried out by nurses implementing the nursing process

Ethnocentrism

evaluation of other cultures according to preconceptions originating in the standards and customs of one's own culture.

An easy child

generally in a positive mood, quickly establishes regular routines in infancy, and adapts easily to new experiences

expected hematocrit level for a healthy newborn

is between 45-65% -The expected hematocrit level for a healthy newborn is between 45% and 65%. Less than 40% is below the expected level and is considered anemia. More than 75% is high and is considered polycythemia. Between 65% and 75% is above the expected range.

informal planning

making mental notes or plans

Intermittent evaluation

performed at specified times to judge progress toward goal or modify care plan. -such as the care conference

Purnell & Paulanka

research on factors that influence an individuals identification with an ethnic group: - primary characteristics - secondary characteristics

Professional healthcare system

run by a set of professional healthcare providers who have been formally educated and trained for their appropriate roles and responsibilities

What is being evaluated?

structure, process, outcomes

Dominant Culture

the culture of the most powerful group in society

The problem suggests...

the goal

The etiology suggests...

the interventions

Discharge planning

the process of planning for self-care and continuity of care after the client leaves the medical facility. -Begins with initial assessment -All clients need discharge planning -Requires collaboration

Subjective data

things a person tells you about that you cannot observe through your senses; symptoms

Phalen's test

used to detect carpal tunnel syndrome

Objective data

what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination. Measurable or observable.