Exam 1

Environmental dimension

housing, sanitation, climate, pollution of air, food and water affects their health

Emotional Dimension

how the mind affects body function and responds to body conditions

secondary source

indirect ( family members, caregiver, healthcare team )

health disparities

influenced by race, gender, age, education level, disability, sexual orientation

subjective assessment

information patient experiences and "communicates"

to meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take

initiate an agency incident report

assessment

making judgements about the data relevant from irrelevant data "what matters most" distinguish normal from abnormal findings

Tertiary Health Care

manage rare or complex disorders that are managed by specialist ( oncologist, cardiovascular surgeon )

self-actualization

morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

which statement made by the student nurse needs correction regarding the primary characteristics establishing nursing as a profession

nurses are simply required to perform specific tasks

Acute illness

rapid onset of symptoms and lasts only a short time (common cold, diarrhea, pneumonia)

Clinical Judgement Model

recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes

erroneous diagnoses

resulting from an inaccurate analysis

which client need would the nurse prioritize while providing care for an older adult client with dementia

safety

Spiritual dimension

spiritual beliefs and values affect their health

PES statement

problem, etiology, signs and symptoms

primary health prevention

promoting health and preventing the development of disease processes or injury

assessment interventions

-what should be monitored or assessment? -what will be done with the data? -what should be monitored or assessed?

referral/health promotion intervention

-where or to whom can we refer the patient to for support with their problem? -why am I referring the patient?

Which information is appropriate to include in education about sentinel events?

Undesirable and largely avoidable

which principle refers to the professional obligation of the nurse to assume responsibility for actions

accountability

beneficence

doing something to benefit the patient or causing benefit

autonomy

respecting the right of patients to make health care decisions

Problem

-Name or diagnostic label from NANDA list -choose nursing diagnosis focusing on current problem or potential physical or behavioral response to health

primary health care

treatment of common health problems ( primary care centers, urgent care )

secondary health care

treatment of problems that need specialized care ( hospitals, emergency department )

critical thinking in nursing process

trial & error development involves experimental learning & practice creative thinking intuitive & scientific

illness

unique response of a person to a disease or an abnormal process involving changed level of functioning

The Joint Commission (TJC)

An organization that accredits health care organizations and programs

Chronic diseases account for

7 out of 10 leading causes of death

Etiology

-not medical diagnosis -suspected cause or reason for physical or behavioral response -statements stated as "related to" -nurses make inferences based on their expert nursing knowledge

Environmental safety

-pathways, equipment, standard protocol, call light, home safety

Safety

-patient identification -error prevention/ risk reduction -preventing ( skin impairment, healthcare acquired infections ) -Allergy identification -use of restraints (physical & chemical)

common errors with nursing diagnosis

-premature diagnosis based on an incomplete database -using generic diagnosis or problem that is not specific to patient

Mobility

-unsteady gait -unfamiliar surroundings -paralysis -supportive devices: correct use

errors in writing patient outcomes

-use verbs that are not observable or measurable "understand" vs "demonstrate" -writing vague outcomes or goals

lifestyle considerations

Dangerous occupations (noise, pollution, hazardous material) Risky social behaviors ( failure to use seatbelt and follow safety precautions ) stress, substance use/abuse

The nurse asks an unlicensed assistive personnel to provide an ice pack to a client. which nursing function does this represent?

Delegation

which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?

The nurse identifies the client is not aware of perineal care and has impaired skin integrity

Nonmaleficence

avoiding causing harm to our patients

which scenario is a perfect example of primary prevention

an infant receives the rotavirus vaccination in the hospital

critical thinking

analyze and evaluate an issue self reflection & flexibility formulation of conclusion

primary source

direct from the patient

documentation of diagnosis

-view patients ongoing problems that others have identified and documented -decide and document new pt problems based on the patient assessment findings -update current problems already in the chart that are still relevant

Therapeutic interventions

-what can I do to help my patient to achieve outcomes? -how often will I do it?

Education interventions

-what can you teach the patient to achieve outcomes? -how will you teach it? -why will it be taught?

Health promotion and technology

- Websites - Chat groups - Social Media - Computer technology and informatics (e.g., Fitbit™ and Carb Manager) - Mobile health apps

Reduce risk

-Accident and injury prevention (reduce risk for falls, skin injury & patient/staff injury) -Aspiration precautions -Restraints and alternatives

Infection control

-Chain of infection -Hand hygiene -Medical and surgical asepsis -standard precautions -preventing transmission -airborne, droplet, contact precautions -PPE -Protective environment

implementation/taking action

-assessment -therapeutic -education -referral or health promotion

which nursing activities are examples of primary prevention?

-assisting with immunization programs -facilitating a program about the dangers of smoking

which factor would the nurse consider when setting priorities for care during a shift?

-client acuity -unit organization -availability of resources -own experience and expertise -philosophies and models of care

Developmental considerations

-each stage has its own risks -physical and cognitive changes infancy through older adult

Why Rumba

-ensure that outcomes and goals are written in anyway that is understandable, "yes" or "no"

identifying outcomes & goals

-get your pt back to "health" and discharged -establish long term vs short term goals

five elements of evaluation

-identifying evaluative criteria ( evaluating the goals we set) -Collecting data to determine whether criteria is met (assess or reassess our pt) -Interpreting findings -documenting -terminating, continuing or modifying care plan

Sensory perception

-knowledge -Ability to communicate -Physical health state -Psychosocial health state

Analyze & hypothesize

-make diagnosis/problem -"what matters the most? what doesn't?" -assess

signs and symptoms

-manifestation or cues identified - stated "as evidence by" then list out s/s

Common malpractice claims

1. Failure to assess and monitor 2. Failure to document 3. Failure to follow standards of care 4. Failure to communicate

Types of Nursing Assessments

1. Initial Assessment. 2. Focused Assessment. 3. Follow up Assessment. 4. Quick priority Assessment.

5 rights of delegation

1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation

when preparing a client for a diagnostic procedure, which action would the nurse take if the client is wearing a religious symbol dangling from a necklace?

Ask the client about the religious symbol and significance of removing it

Dilemmas in Healthcare

Abortion, death with dignity, treat or withhold care, consents, short staffing, restraints and seclusions

wellness

Active state of being healthy by living a lifestyle prompting good physical, mental, emotional health

Integrity

Adhering to moral and ethical values

nursing process

Assessing- systematically collecting pt. data Diagnosing- Identify strength and potential health issues Outcomes-Plan individualized care Planning- help pt reach expected outcomes Implementing- execute plans with out ideas Evaluate- effectiveness of plan of care

AAPIE

Assessment Analysis Planning Implementation Evaluation

Which basic health care ethic does the nurse follow when signing the client's consent form as a witness?

Autonomy

Environment

Crime prevalence and safety for nurses

Which nursing behavior is an intentional tort

Divulging private information about a client's health status to the media

which step should the nurse take to alert the risk management system after notifying the primary health care provider of a clients fall

Document the incident in the occurrence report tool

which suggestion by the nurse is an example of primary prevention?

Engage in daily exercise

which standard of practice would the nurse perform when evaluating a clients pain after performing a back massage?

Evaluation

according to Erickson, which developmental stage will an 85 year old client who is alert and able to participate in care need to adjust to?

Generativity versus stagnation

After the nurse has taught a client about the use of a metered-dose inhaler with a spacer, which statement indicates the need for further teaching?

I will shake the whole unit vigorously one or two times

Tanner model

Noticing Interpreting Responding Reflecting

After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. which response by the nurse is correct?

Of course. I want to do whatever I can for you

which action would the nurse take first when caring for a postoperative client who reports pain?

Perform a focused assessment of the client

Other health care settings

Prison, med spas, home health, Telehealth

Rumba

Relevant, Understandable, Measurable, Behavioral, Achievable

A client says "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario?

Spiritual factors

which description does beneficence in health ethics refer to?

Taking positive actions to help others

Tertiary health prevention

after an illness is diagnosed and treated with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning

which activity by the community nurse is an illness prevention strategy

arranging an immunization program for chicken pox

veracity

being factual or accurate

physiological

breathing, food, water, sex, sleep, homeostasis, excretion

outcome

broad statement describing the desired change in condition. should be the opposite of what our priority problem is

How would the nurse respond to an alcohol recovery program sponsor requesting to read the clients progress record?

by not allowing the sponsor to review the record

Nursing Diagnosis

changes day to day depending on how the pt is doing or how they are responding to the care being provided

Intellectual dimension

cognitive abilities, educational background and past experiences affect health care.

Reporting obligations

communicable diseases, certain STD's and abuse

which situation would the nurse address first according to mallows hierarchy

complains of sleeplessness due to pain post surgery

Which purpose describes the nurse practice acts

describe and define the legal boundaries of nursing practice within each state

Evaluation/evaluate outcomes

did it work? did we achieve the set goals/outcomes

Sociocultural dimension

economic level, lifestyle, family and culture affect their health

in which role is the nurse acting when verbalizing to a client way to relieve injection associated discomfort

educator

love and belonging

friendship, family, sexual intimacy

objective assessment

gathered and documented during the physical assessment (seen, felt, heard, observed or measured)

Physical dimension

genetics, age, developmental level, race, gender

justice

give each their due and act fairly

The nurse is instructing a community group regarding risk factors for coronary artery disease. which risk factor cannot be modified

heredity

medical diagnosis

identify and describe a disease like pneumonia. deals with pathological changes in the body

fidelity

keeping promises and commitments made to others

disease

pathological changes in structure or functioning of the body or mind

errors of omission

patient has a problem and we don't document it

Explicit

power by virtue of position

implied

power due to other factors (personality)

secondary health prevention

screening for early detection of disease with prompt diagnosis and treatment

Safety (Maslow's Hierarchy of Needs)

security of body, of employment, of resources, of morality, of the family, of health, of property

esteem

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

chronic illness

slow onset, periods of remission and exacerbation, requires long period and permanent changes

goal

small achievement, related to the data we collected in recognizing cues

which client would have a health promotion nursing diagnosis

the client who is willing to take a 30 minute walk daily

Bioethics

what are my duties and obligations to others