Chapter 18

Question 1

The ordering of nursing diagnosis or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions

Answer 1

Priority Setting

Question 2

Classify patient priorities as

Answer 2

High, intermediate, or low importance

Question 3

High priorities for nursing care plan

Answer 3

those related to airway status, circulation, safety, and pain.

Question 4

Intermediate priority nursing care plan

Answer 4

risk of infection,

Question 5

Low-priority nursing care plan

Answer 5

affect a patients future well-being Long term care health needs

Question 6

A nursing “Goal”

Answer 6

is a broad statement that describes a desired change in a patients condition, perceptions or behavior.

Question 7

Knowledge

Answer 7

• patients database and selected nursing diagnoses
• anatomy & physiology
• psychology
• pathophysiology
• normal growth & development
• evidence-based nursing interventions
• role of other health care disciplines
• community resources
• family dynamics
• teaching/learning process
• delegation principles
• priority-setting principles

Question 8

Standards

Answer 8

• ANA scope of nursing practice
• specialty standards of practice
• patient-centered goa bhyuiebnmopw2azcdeyls and outcomes
• intellectual standards
• agency’s policies and procedures

Question 9

Atitudes

Answer 9

• creativity
• responsibility
• perseverance
• discipline

Question 10

Experience

Answer 10

• previous patient care experience

- personal experience in organizing activities

Question 11

A patient-centered goal

Answer 11

reflects a patients highest possible level of wellness and independence in function.

Question 12

A correct goal statement

Answer 12

“patient will ambulate independently in 3 days”

Question 13

A correct outcome statement

Answer 13

“patient ambulates in the hall 3 times a day by 4/22”

Question 14

Nursing-sensitive patient outcome

Answer 14

is a measurable patient, family or community state, behavior or perception largely influenced by nursing interventions

Question 15

Examples of nursing-sensitive outcomes

Answer 15

reduction in pain frequency and severity, incidence of pressure ulcers, and incidence of falls.

Question 16

NOC termonology for the nursing diagnosis of “acute Pain”

Answer 16

“pain control” or “pain releif”

Question 17

SMART goals

Answer 17

S-specific
M-measurable
A-attainable
R-realistic
T-timed

Question 18

Specific goal

Answer 18

-word each goal separately
By doing this each single goal can either be accomplished or still working towards and determine when the patient achieves each outcome.

Question 19

Measure goal

Answer 19

• set goals that are numbered and able to be measured.

- I.e. terms describing quality, quantity, frequency, length, or weight.

Question 20

Words to not use in a measurable goal

Answer 20

Normal, acceptable, or stable

Question 21

Attainable

Answer 21

-Patient and nurse should agree on the goal

Question 22

Realistic

Answer 22

-set goals and outcomes that the patient is able to obtain.

Question 23

Timed

Answer 23

-each goal and outcome has a specific time limit

Question 24

Short-term goal

Answer 24

objective behavior or response expected to achieve in usually less than a week

Question 25

Long-term goal

Answer 25

objective behavior or response expected to achieve over a longer period. several days, weeks or months.

Question 26

When does the implementation of these goals occur

Answer 26

During the implementation phase of the nursing process

Question 27

3 types of interventions

Answer 27

• independent nursing interventions
• health care provider initiated interventions (dependent)
• collaborative interventions

Question 28

Independent Nursing Interventions

Answer 28

Actions that a nurse initiates without supervision or direction from others. No order required
Ex-
-positioning pt to prevent pressure ulcer formation
-educating pt about medication side effects
-Providing skin care to an ostomy site

Question 29

Dependent nursing interventions

Answer 29

Actions that require an order from a health care provider.
-Advance practice nurses who work under collaborative agreements with physicians or who are licensed independently by state practice acts are also able to write dependent interventions.
Ex-
-administer the medication
-implementing an invasive procedure (foley catheter, starting IV
-preparing a patient for diagnostic tests.

Question 30

Collaborative interventions

Answer 30

Therapies that require the combined knowledge, skill and expertise of multiple health care providers.

Question 31

Six important factors when choosing interventions

Answer 31

1. desired patient outcome
2. characteristics of the nursing diagnosis
3. research based knowledge for the intervention
4. feasibility for doing the intervention
5. acceptability to the patient
6. your own compentcy

Question 32

Student Care Plan

Answer 32

1. Assessment data relevant to corresponding diagnosis
2. goals/outcomes identified for the patient
3. implementation for the plan of care
4. A scientific rationale
5. a section to evaluate your care

Question 33

SBAR

Answer 33

Situation
Background
Assessment
Recommendation

Question 34

First step in making a consultation

Answer 34

assess the situation and identify the general problem