CARE EXAM 1

A nurse is giving change-of shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the recommendation segment of SBAR?

Plan of care changes for upcoming shift.

Define the population (MCMPT)

Populations may be designated geographically, by disease state, or by other common characteristics.

Tanner's Model of Clinical Judgement - Interpreting

Processing information. Developing a sufficient understanding of situation in order to determine an appropriate response. Involves making sense of the data, prioritization of data, development of an intervention plan and identify the problem. Compare the situation to past situations and decide on the course of actions (whom to call).

The nurse should use the ____ priority setting framework when caring for clients who are posing a threat to themselves or others, or when deciding on nursing interventions.

least restrictive/least invasive

A nurse is speaking with the parents of a 4-year old child who has a terminal illness. The parents tell the nurse they have taken their son's name off the list for little league baseball next season. Which of the following responses should the nurse make?

"It must be frustrating for you to have to cancel an activity your son enjoyed"

A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?

"Keep your head up and straight"

Hand-off tools examples

- SBAR - I-PASS - ISHAPED

Evaluation of specific client outcomes related to ND (MCMPT)

- specific findings whether the client has achieved the desired SMART outcomes for this section - if not, determine and indicate whether it is a client variance (reason), a care related variance, or a system related variance. - determining what got in the way of the client meeting the desired outcomes helps you determine how to modify care to overcome these barriers

Hand-offs

- the transfer of patient information and knowledge, along with authority and responsibility from one care provider to another - shift change, change in level of care, discharge

Purpose of the population profile (MCMPT)

- to help you gain an understanding of the population/helps you start thinking about possible needs of the population

Normal intraocular pressures average from

12-21 mm Hg

The expected reference range for HDL is

>45 mg/dL in men and >55 mg/dL in women

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

A client attempts to climb out of bed and repeated states she must get home.

Clinical informatics is

Application of information and communication technologies to the delivery of health care services

The understanding the hemorrhage from a GSW and a postpartum hemorrhage will manifest in tachycardia, hypotension, pallor, decreased urine output

Apply concepts to nursing practice (nursing application)

Before administrating a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Ask the client's full name and date of birth.

The subdimensions of knowing

Avoiding assumptions, centering on the patient, assessing, seeking cues, engaging the self of both

The subdimensions of being with

Being there, conveying ability, sharing feelings, not burdening

A nurse is giving change-of shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

Code status

Tanner's Model of Clinical Judgement - Reflecting

Collect evaluation data. Determine if the situation has improved. Contemplate what was learned in the process. Evaluation and analysis of choices and decisions made in clinical performance. Commitment to ongoing improvement of personal nursing practice. Observing patient's reaction to intervention.

What are the five components of Swanson's Middle Range Theory of Caring?

Knowing, being with, doing for, enabling, maintaining belief

The ability of the experienced nurse to anticipate pain effective pain management strategies for the laboring population

Knowledge/Deep Understanding

The ability of the nurse to recognize septic shock in a patient experiencing hypotension, tachycardia, hyperthermia

Learning to recognize patterns

The priority setting framework in which the RN chooses a bed alarm for a patient that is a fall risk

Least Restrictive/Least Invasive

Assigning an AP to sit with a client who is confused and pulling at their IV before applying wrist restraints is an example of

Least restrictive/least invasive

The priority setting framework that examines physiological (oxygen, nutrition, fluids) before other psychological and safety needs.

Maslow's Hierarchy of Needs

Offering fluids to a client who has dehydration before assisting them to call a family member is an example of

Maslow's hierarchy

Non proliferative Retinopathy

Microaneurysms causing retinal edema

The theoretical link that includes observing nonverbal pain indicators.

Noticing

The step in the nursing process model that includes identifying an overall priority.

Nursing Diagnosis/Analysis

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

Obstructive sleep apnea (OSA)

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper-socks for the client.

A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate?

Offer to make arrangements for the Sacrament of the Sick.

Nursing diagnosis #1 (MCMPT)

PES statement

Writing a reflection of a patient care situation and identifying successes, areas for improvement, and personal feelings around the experience.

Reflective practice

A finding of ABI = 0.5 or less indicates

Severe arterial disease

Essential hypertension manifestations

The nurse should monitor the client for findings such as vertigo, headache, facial flushing, and fainting.

Obstructive sleep apnea (OSA) is

a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

Health informatics is

a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology

Maslow's hierarchy of needs is

a model for understanding the motivations for human behavior

Uremia

a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys

Delirium results from

a secondary physiological condition (e.g., infection, surgery, prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder.

The nursing process is

a series of steps nurses take to assess patients, plan for and provide patient care, and evaluate the patient's response to care

Urgent client care needs

are identified when the client could suffer mild harm or discomfort if there is a delay in addressing the client's needs (e.g., postoperative pain).

Nursing process model - Implementation

carrying out the plan of care

A client who becomes acutely confused and agitated may be showing manifestations of

delirium

Self-actualization (Maslow)

desire to become the most that one can be

Four main prioritization categories based on the injury severity:

emergent (red), urgent or delayed (yellow), non-urgent or minimal (green), and expectant (black)

Dehydration increases the client's risk for

hypotension

Routine client care needs

include tasks such as administering routine medications and performing required shift tasks (e.g., routine vital signs, daily physical assessment).

Individual patient SMART outcomes

incremental outcomes (goals) that will carry your client along the path toward achievement of the end-target population-based outcome

Clients who have impaired cognition need a ___ environment.

low-stimulation

Nursing process model - Evaluation

measuring extent to which patient achieved outcomes

The Montreal Cognitive Assessment (MoCA) screens for

mild cognitive impairment and Alzheimer's disease.

Physiological Needs (Maslow)

needs for food, water, air, sleep, and other survival needs

Safety Needs (Maslow)

needs for freedom from illness or danger and the need for a secure, familiar, predictable environment (shelter)

Hair loss and thick deformed toenails are manifestations of ___

peripheral arterial disease (PAD)

Retrogenesis is the

reversal of normal developmental biologic processes during the course of disease

Nursing process model - Planning

specifying patient outcomes and related holistic nursing interventions - treatment plan

The nurse should use the ____ framework when caring for groups of clients involved in mass casualty accidents such as natural disasters or acts of terrorism. The focus is to provide the most good to the greatest number of clients with the resources available at the time.

survival potential

When completing the exposure component of the ABCDE priority setting method, the nurse should observe

the client from head-to-toe for abnormalities this includes... - temperature - the client's lower extremities for indications of deep vein thrombosis such as pain, edema, and erythema of the calf area - manifestations of bleeding (bruising) - abdominal distention - skin integrity (rashes/lesions)

Acceptable identifiers include...

the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge

Delirium frequently progresses in...

the evening hours and is sometimes called "sundown syndrome"

Rest pain (patients with PAD) is worse when...

the foot is in a horizontal or elevated position, is the result of increasing arterial insufficiency

Wet macular degeneration

the function of the macula is impeded by the growth and leakage of abnormal blood vessels beneath the retina

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?

"Tell me what is concerning you."

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Scatter rugs are present in the kitchen.

Tanner's Model of Clinical Judgement - Responding

Selecting a course of action. To develop calm, confident leadership action. Communication with patients, families and team members in a clear and timely manner. Developing a flexible intervention individualized to the patient. Determining and performing interventions. Proficiency/mastery in use of nursing skills.

The ability of the nurse to set priorities and alter them as patient situations change

Skillful Responding

SMART stands for

Specific, Measurable, Attainable, Realistic, Time sensitive

Centers for Medicare & Medicaid Services (CMS)

Specify how hospitals, physicians, and other eligible professional must demonstrate their meaningful use of these technologies in order to receive Medicare and Medicaid payment incentives.

Office of the National Coordinator for Health IT (ONC)

Specify the standards, implementation specifications, and other criteria for EHR systems and technologies to be certified

Recommending treatment during a mass casualty incident to a client who has severe but treatable bleeding before a client who has minor abrasions is an example of

Survival potential

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through tasks one step at a time.

Cognition

The ability to understand and process information, focus attention, solve problems and demonstrate the ability to remember recent and remote events

Dietary Approaches to Stop Hypertension (DASH) is

an eating plan to lower or control high blood pressure

Nursing process model - Nursing diagnosis

analyzing patient data to identify patient strengths and problems

The DASH diet features menus with

plenty of vegetables, fruits and low-fat dairy products, as well as whole grains, fish, poultry and nuts. It offers limited portions of red meats, sweets and sugary beverages.

Least Restrictive/ Least Invasive

priority-setting framework assigns priority to nursing interventions that are least restrictive and least invasive to the client. - used when caring for a client who is exhibiting behaviors that could result in harm to either the client or the client's caregivers, or an intervention that will compromise the natural barriers between the client and the environment that is being considered. When selecting an intervention using this framework, however, you must also ensure that the nursing intervention selected will not put the client at risk for harm or injury.

Safety and Risk Reduction

priority-setting framework assigns priority to the factor or situation that poses the greatest safety risk to the client. It also assigns priority to the factor or situation that poses the greatest risk to the client's physical and or psychological well-being. When a client is facing several risks, the one that poses the greatest threat to the client as compared to the other risks is the one that is deemed the highest priority.

Dry macular degeneration

the result of aging and the thinning of the macula over time

The vestibular system is

the sensory apparatus of the inner ear that helps the body maintain its postural equilibrium

A nurse is preparing to administer a medication to a client who states, "That looks different from the pill I usually take." Which of the following responses should the nurse make?

"Describe what the pill looks like"

The semicircular canals are

three very small tubes whose primary job is to regulate balance and sense head position

The FICA assessment tool is used to...

understand your patient's spiritual beliefs and establishes a relationship of connectedness and trust.

Love and belonging (Maslow)

understanding and acceptance of others in giving and receiving love; forgiving and receiving of affection, companionship, satisfactory interpersonal relationships and the identification with a group

Early signs of delirium

- Inability to concentrate - Disorganized thinking - Irritability - Insomnia - Loss of appetite - Restlessness - Confusion

Adolescence communication

- Independence - Maturing without coping strategies - Including the parents - Privacy - Provide nonjudgemental atmosphere - Give undivided attention - Encourage expression of their feelings

Specific assessments (MCMPT)

- (Health; Screening and Diagnostic Data; Values, Beliefs, Thoughts, Emotions, Behaviors; Functional; Family/Social Support; Environmental; Resources (community and financial) related to ND

Life's Simple 7 (hypertension)

1. Manage blood pressure 2. Control cholesterol 3. Reduce blood sugar 4. Get active 5. Eat better 6. Lose weight 7. Stop smoking

Maslow's hierarchy of needs (steps)

1. Physiological needs 2. Safety needs 3. Love and belonging 4. Esteem 5. Self-actualization

A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client?

A room containing personal belongings

Caring for a client who is experiencing medication toxicity before a client who has back pain from an injury three years ago is an example of

Acute vs chronic

ABCDE assessment stands for

Airway-Breathing-Circulation-Disability-Exposure

The subdimensions of maintaining belief

Believing in/holding in esteem, maintaining a hope filled attitude, offering realistic optimism, going the distance

Raynaud's is usually triggered

By cold temperatures, anxiety or stress The condition occurs because your blood vessels go into a temporary spasm, which blocks the flow of blood. This causes the affected area to change colour to white, then blue and then red, as the bloodflow returns.

Stages of chronic venous disease

C1 - Spider veins C2 - Varicose veins C3 - Swelling C4 - Skin changes C5, C6 - Venous ulcer

Tanner's Model of Clinical Judgement - Noticing

Considering the situation, facts & contents. Focused observation, recognition of deviations from expected patterns, information seeking from patient and family. Gathering of data or additional info, recalling previously learned knowledge.

Instructions for client with peripheral arterial disease (PAD)

Do NOT - apply heating pad directly to a limb - wear any constrictive clothing - rest with the legs above heart level (slows the flow of arterial blood to the feet)

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

The step in the nursing process model that includes assessing a patient after intervention to determine if the interventions was effective.

Evaluation

FICA assessment tool stands for

F - Faith or belief I - Importance and influence C - Community A - Address with interventions

HOPE assessment tool stands for

H - Hope sources O - Organized religion P - Personal practices E - Effects on medical care

The step in the Nursing Process model that includes administering pain medication.

Implementation

Clinical research informatics is

Informatics whose objective is to advance the biomedical/health sciences through the humane and ethical use of informatics.

The subdimensions of enabling

Informing/explaining, supporting/allowing, focusing, generating alternatives, validating, giving feedback

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Intermittent claudication

The theoretical link in which a nurse devises probable causes to low urine output

Interpreting

The step in the nursing process model that includes determining the appropriate actions to take once the priority has been identified.

Planning

Practicing Roman Catholics often wish to receive the ___ from a priest during times of illness or when death is approaching.

Sacrament of the Sick

The priority setting framework that includes the home health nurse identifying that the patient has difficulty ambulating and the home has many loose cords and rugs.

Safety and Risk Reduction

Turning off the IV antibiotic of a client experiencing an allergic reaction before administering an antihistamine is an example of

Safety and risk reduction

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

Sharing computer passwords with coworkers.

Health Insurance Portability and Accountability Act (HIPAA)

a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge

Confusion Assessment Method (CAM) is

a standardized evidence-based tool that enables non-psychiatrically trained clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings.

The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is

a systematic approach to the immediate assessment and treatment of critically ill or injured patients.

The HOPE assessment tool is used as

a teaching tool to help begin the process of incorporating a spiritual assessment into the patient interview

The nurse should use the ___ framework when trying to determine if a client is experiencing a sudden condition change or manifestations of a long-term condition.

acute vs. chronic

Class IV (Expectant)

- Injuries are not compatible with life - Potential for survival does not exist, even with treatment - Scarce resources reserved for Class I, II, III

Priority interventions (MCMPT)

- (Therapeutic Symptom Management and Morbidity Reduction, Medication Management, Skills and Technologies, Counseling, Family/Caregiver Support, Referrals, Community Support and Education) related to ND

Communication with clients who are unable to speak clearly

- Actively listen - Do not interrupt - Give time to respond - Simple "yes" or "no" questions - Encourage conversation - Let them know if you did or did not understand them

An electronic health record (EHR) contains patient health information, such as:

- Administrative and billing data - Patient demographics - Progress notes - Vital signs - Medical histories - Diagnoses - Medications - Immunization dates - Allergies - Radiology images - Lab and test results

Early childhood communication

- Age 1-5 - Lack abstract thought - Speak in concrete terms (simple direct language) - Egocentric - Allow for play and inspection of items - Has challenges w/ expressing their feelings and wants so pay attention to their nonverbal communication

School-aged communication

- Age 6-12 - Rely on experience - Explanations but not verification - Games - Body integrity

Late signs of delirium

- Agitation - Misperception - Misinterpretation - Hallucinations

5 step nursing process model

- Assessment - Nursing diagnosis - Planning - Implementation - Evaluation

Spirituality

- Awareness of one's inner self and a sense of connection to a higher power or nature - Complex and unique to each person

Client assessment data and variances (MCMPT)

- Compare your client's status against the expected population outcomes - Document your client's head to toe assessment - Document... health; screening and diagnostic data; values, beliefs, thoughts, emotions, behaviors; functional; family/social support; environmental; resources (community and financial)

Manifestations of later stages of peripheral arterial disease (PAD)

- Dependent rubor - Rest pain - Foot ulcers

Computerized Provider order entry (CPOE)

- Direct entry of orders by providers - Increases safety - Better patient outcomes - Improves reimbursement

Instructions for client after cataract surgery

- Do not remain in bed (risk for the hazards of immobility) - May resume mobility as soon as 1 hr after surgery - Avoid activities involving rapid or jerking head motions - Avoid looking down/coughing (prevents increasing intraocular pressure) - Client should lie on the other side or on their back when resting

S/S of Chronic Venous Insufficiency (CVI)

- Dull achy pain - Edema - Skin changes (brownish "brawny" appearance, thick, hardened, eczema [itching common])

Communication with non-English speaking clients

- Face the patient - Do not shout or exaggerate your speech - Use an interpreter as needed - Avoid using family members or non-certified interpreters - Introduce the interpreter to create a more therapeutic environment

Communication with clients with hearing deficits

- Face the patient - No food/gum - Don't shout or exaggerate your speech - Well-lit environments - Free of distractions - Give the client time to ask and answer questions - Only ask one question at a time

A nurse is giving change-of shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the assessment segment of SBAR?

- Glasgow results - Intracranial pressure readings

Proliferative Retinopathy

- Hemorrhaging of fragile vessels - neovascularization

S/S of PAD

- Intermittent claudication - Paresthesia - Loss of sensation - Thin, shiny, and taut skin with hair loss - Decreased lower extremity pulses - Elevation pallor - Dependent rubor - Rest pain - Critical limb ischemia - Erectile dysfunction is possible - Thick, deformed toenails

Spirituality (faith) characteristics

- Internal and individualized - Self-expression - State of being

Communication with clients with visual deficits

- Introduce yourself upon entry and exit - Glasses/contact lenses - Normal tone of voice - Indirect lighting - No nonverbal - Large print font - Orient client to their surroundings (clock)

Venous ulcers characteristics

- Irregular shape - Medial malleolus - Painful - Drainage

Macular degeneration

- Irreversible loss of central vision - Most common cause of blindness in people over 60 - Deterioration or breakdown of the eye's macula

Critical thinking aided by

- Knowledge - Standards - Attitudes - Experience

Cataracts

- Leading cause of low vision in older adult - Clouding of the lens that causes the lens to lose its transparency

Class III (Non-urgent)

- Less serious & less extensive - Do not pose a threat to life - No threat to life even with delated treatment

Class I (Emergent)

- Life threatening injuries - Immediate treatment=chance of survival *Highest priority Injuries that are severe but has a good potential to survive

Risk factors in the development of hypertension

- Low HDL levels - Low dietary potassium intake

Prioritization Frameworks examples

- Maslow's Hierarchy of Needs - ABCDE - Nursing process (ADPIE) - Safety & risk reduction - Least restrictive / least invasive - Survival potential - Acute vs Chronic - Unstable vs Stable

Peripheral arterial ulcers characteristics

- May be initiated by a minor trauma - Often occur on tips of toes, foot, lateral malleolus - Rounded smooth margins - Black eschar or pale pink granulation tissue - Minimal drainage - Difficult to heal

Early warning signs of Alzheimer's disease

- Memory loss affecting daily life - Difficulty preforming familiar tasks - Visual/spatial reasoning difficulty - Misplacing things - Changes in mood/personality - Problems with planning - Disorientation - Problems with Language - Poor judgement - Withdrawal

Levels of error

- Near miss - Adverse event - Sentinel event

Infancy communication

- Nonverbal communication - Touch - Meet physical needs

Clinical judgement characteristics

- Nursing application - Recognize patterns - Reflective practice - Skillful responding - Knowledge/Deep understanding

Low Priority

- Nursing diagnoses are not always directly related to a specific illness or prognosis but affect the patient's future well-being. - Many focus on the patient's long-term health care needs.

Intermediate Priority

- Nursing diagnoses involve non-emergent, non-life-threatening needs of patients.

High Priority

- Nursing diagnoses that, if untreated, result in harm to a patient or others (e.g., those related to airway status, circulation, safety, and pain) have the highest priorities. High priorities are sometimes both physiological and psychological and may address other basic human needs.

Religion (faith) characteristics

- Organized system, communal - Symbols and rituals - State of doing

Spiritual rights of patients

- Patients deserve care, treatment, and services that safeguard their personal dignity and respect their cultural, psychosocial, and spiritual values. - The hospital accommodates the right to pastoral and other spiritual services for patients. - The quality of patient care is affected by the nurse's attitude, comfort, and competence providing spiritual care to patients.

Interprofessional communication

- Professionalism - Respect for other team members - Willingness to negotiate and tolerance of differing opinions - Team player

Class II (Urgent)

- Serious & extensive injuries - Do not pose immediate threat to life - Potential of survival even with delayed treatment

Communication with clients with cognitive impairments

- Simple sentences - Avoid lengthy explanations - One question at a time - Allow time for response - Listen attentively - Include family/friends as appropriate - Use pictures or gestures

Communication with clients who are unresponsive

- Speak to them like you would any responsive patient - Call them by name - Use verbal communication and touch - Encourage family to speak to client - Explain all procedures and sensations - Orient client to place and time - Introduce yourself - Do not speak about the client as if they are not there

A client who has malignant hypertension might manifest...

- Uremia - Blurred vision - Dyspnea

Delirium is characterized by

- a change in cognition that occurs over a short period of time - alterations in memory, agitation, restlessness, illusions, or hallucinations

Client profile (MCMPT)

- age, gender, ethnicity, reason for admission (HPI), history, significant events since admission (surgeries, procedures), complications, diagnostic tests & results, current status (i.e. how is the patient doing now), current invasive lines, equipment, IVs, safety considerations, allergies, DNR status/advance directive, immunization status, spiritual history/assessment, and developmental concerns

When completing the disability component of the ABCDE priority setting method, the nurse should observe

- client's neurologic status - LOC - response to verbal or painful stimulation - level of orientation

Modifications to be made based on the actual outcomes to ensure optimal care (MCMPT)

- consider additional nursing diagnoses; changes in priority; or changes in outcomes, assessments, interventions, teaching, etc.

Population profile (MCMPT) includes

- general demographics and demographic trends of the population; incidence rates; prevalence rates; risk factors; protective factors; mortality data; morbidity data, including societal influences associated with this population; accessibility to care and usual setting for delivery of care; and developmental constructs as appropriate for the population.

The client is experiencing impaired mobility, which can increases the client's risk for developing ___

- hypercalcemia - causes calcium from the bones to be released into systemic circulation

Relevant nursing diagnoses (MCMPT)

- identify 5 - 8 diagnoses that would apply (just the problem or the "P") - list all that could be relevant

Client/Caregiver Teaching Needs/Plans (MCMPT)

- instructions/education - teachings related to ND

When completing the circulation component of the ABCDE priority setting method, the nurse should observe

- obtain a blood pressure - check pulse rate and quality - check peripheral pulses - measure capillary refill time - skin tone

Foot ulcers (patients with PAD) form...

- on or between the toes - the wound has a round, "punched out" appearance and is usually small and can develop gangrene

Expected population outcomes (MCMPT)

- overarching goals for the population - the "big picture" or "end-target accomplishments" our care is directed at

Urgent vs Nonurgent

- priority-setting framework, urgent needs are usually given priority because they pose more of a threat to the client. Some needs fall into the urgent category because they relate to an intervention that needs to be done within a prescribed time frame. - also applicable when the nurse is caring for a group of clients, and a determination must be made in regard to which client has the most urgent need and should be attended to first.

When completing the breathing component of the ABCDE priority setting method, the nurse should observe

- respiratory rate for one full minute - depth and pattern - auscultate lung sounds - observe chest wall symmetry during inspiration and expiration - check for presence of retractions

Manifestations of dehydration include

- urine specific gravity that is greater than the expected reference range - decreased skin turgor

A nurse is caring for a client who has schizophrenia and is experiencing hallucinations. The provider prescribes chlorpromazine 50 mg IM every 4 hr as needed. Available is chlorpromazine injection 25 mg/mL. How many mL should the nurse administer per dose?

2 mL

A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer?

2 tablets

A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 33 lbs. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer?

5.6 mL every 12 hr

Tanner's Model of Clinical Judgement

A model based on how a nurse thinks, it explains the 4 steps in the critical thinking process that nurses use to solve any problem: Noticing Interpereting Responding Reflecting

The priority setting frame work that includes the RN providing bag/mask ventilation during a respiratory arrest

ABCDE (Airway breathing circulation)

The priority setting framework in which a nurse prioritizes a patient who is experiencing a new onset of hypotension before a patient with chronic pain

Acute vs. Chronic

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

Adjust the thermostat so that the environment is warm. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction.

Near miss

An error of commission (didn't provide care correctly) or omission (didn't provide care) that could have harmed the patient, but serious harm did not occur as a result of chance, prevention, or mitigation

Sentinel event

An event that results in death, permanent harm, or severe temporary harm If severe harm is temporary, it requires intervention to sustain life

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

Assess the client.

The step in the nursing process model that includes auscultation of lung sounds.

Assessment

The theoretical frame work in which the nurse does not administered a scheduled medication after obtaining a blood pressure out of defined limits.

Responding

The subdimensions of doing for

Comforting, anticipating, performing skillfully, protecting, preserving dignity

Urticaria

also known as hives, weals, welts or nettle rash - is a raised, itchy rash that appears on the skin

Consumer health informatics is

Geared toward delivering better healthcare decisions based on consumer's perspective

Informatics is

The science that encompasses information science and computer science to study the process, management, and retrieval of information

Adverse event

Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization Results from an act of commission or omission rather than by the underlying disease or condition of the patient

Notifying the provider about an elevated potassium level before a hemoglobin level that is within the expected reference range is an example of

Unstable vs stable

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis?

Vertigo

Nursing process model - Assessment

collecting, validating and communicating of patient data

Extra client care needs

involve activities that are not essential to client care but can promote client comfort (e.g., providing the client with a warm blanket, combing the client's hair).

What is dependent rubor?

is a dark red color to the feet and lower legs when the leg is in a dependent position. It is the result of dilation of the arteries as a compensatory response to poor arterial blood flow

Survival Potential

is based on the chance a client has for survival during a mass casualty event when resources are limited. Appropriate use of human and physical resources that will save the greatest number of lives is the goal. In order of highest to lowest priority are Class 1/Emergent, Class 2/Urgent, Class 3/Nonurgent, and Class 4/Expectant.

Reflection-on-action

is consideration of the situation after the patient care occurs... the nurse contemplates a situation and considers what was successful and what was unsuccessful.

What is intermittent claudication?

is ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain arises when cellular oxygen demand exceeds supply

Priority Setting

is the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions

Acute vs. Chronic

priority-setting framework, acute needs are usually given priority as they may pose more of a threat to the client. Chronic needs usually develop over a period of time giving the body the opportunity to adjust to the alteration in health. Thus chronic alterations - unless a complication is being experienced - are usually considered to be a lower priority.

Unstable vs Stable

priority-setting framework, unstable clients are given priority because they have needs that pose a threat to the client's survival. Oftentimes, the client need that is life-threatening involves his or her airway, breathing, and/or circulatory status. Clients whose vital signs or laboratory values indicate a client may be at risk for becoming unstable should also be considered a higher priority than clients who are stable.

Normal Ankle-brachial index (ABI)

ranges from 1.0 — 1.4

Reflection-in-action

refers to the nurse's understanding of patient responses to nursing actions while care is occurring

The theoretical framework in which a nurse evaluates the tolerance to a therapy and discontinues due to poor patient response

reflecting-in-action

The theoretical framework in which a team debriefs over a difficult patient situation and discusses what worked well and where improvements can be made

reflecting-on-action

Critical client care needs

require the nurse to intervene immediately to prevent the client from deteriorating (e.g., respiratory difficulty, chest pain, or a change in neurologic status).

Esteem (Maslow)

self-esteem, confidence, achievement, respect of others, respect by others