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Exam 1 Flashcards

1
Q

What are the 5 steps of the nursing process?

A

Assess:
* Gather information about condition

Diagnose:
* Identify problems

Planning:
* Set goals of care, desired outcomes, & identify appropriate nursing actions

Implement:
* Preform nursing actions

Evaluation:
* Determine if goals / outcomes where achieved

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2
Q

What is the difference between a cue & an inference?

A

Cues: Info obtained through senses - Signs & symptoms
* Swollen finger
* Red
* Painful
* What patient is doing (Action wise - Facial grimace, grabbing chest)

Inference: What you think ; judgement about cues
* Broken finger

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3
Q

What are the CJMM cognitive skills of clinical judgement?

A

Recognizing cues: Identify significant data ; data can be from any source
* What matters most?
* Assessment
* Relevant vs irrelevant

Analyzing cues: Connecting data to clients clinical presentation-determining if data is expected
* What could it mean?
* Analysis

Prioritizing cues: Ranking hypothesis ; what are the concerns/client needs/problems & their priority
* Where do I start?
* Analysis

Generate solutions: Using hypothesis or client needs to determine interventions for an expected outcome
* What can I do?
* Planning

Take action: Implementing generated solutions addressing highest priorities/hypotheses
* What will I do?
* Implementation

Evaluate outcomes: Comparing observed outcomes w/ expected ones
* Did it help?
* Evaluation

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4
Q

What are the classic rights of clinical reasoning?

A

Right client

Right time

Right reason

Right cues

Right actions

extra info: Rights help guide ability to notice & recognize relevent data to direct nursing action

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5
Q

What is difference between nursing process & NCSBN clinical judgement?

A

Nursing process:
* Scientific method of what a nurse does
* Step by step approach directed at planning & providing pt care

NCSBN clinical judgement:
* Measures nurse’s ability to use clinical reasoning skills
* Demonstrates how nurses think
* Incorperates nursing process, Tanners clinical judgement, & NCSBN CJMM cognitive skills

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6
Q

Match each part of the nursing process w/ the appropriate Tanner model & NCJMM:

ADPIE/AAPIE - Nursing process

Noticing, interpreting, responding, reflecting - Tanner model

Recognizing cues, analyze cues, prioritize hypothese, generate solutions, take action, evaluate outcomes - NCJMM

A
  1. Assessment (NP), Noticing (T), Recognizing cues (NCJMM)
  2. Diagnosis/Analysis (NP), interpreting (T), Analyze cues & Prioritize hypotheses (NCJMM)
  3. Planning (NP), Responding (T), Generate solutions (NCJMM)
  4. Implementation (NP), Responding (T), Take action (NCJMM)
  5. Evaluation (NP), Reflecting (T), Evaluate (NCJMM)
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7
Q

Part of Tanner’s Model that involves:
* Identifying s/s (subjective/objective)
* Gathering complete & accurate data
* Assessing systematically & comprehensively
* Predicting potential complications
* Identifying assumptions

A

Noticing
(Tanner’s Model)

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8
Q

Part of Tanner’s Model that involves:
* Comparing & contrasting
* Clustering related information
* Recognizing inconsistencies, Checking accuracy & reliability
* Distinguishing related from irrelevant
* Determining importance of information
* Judging how much ambiguity is acceptable
* Managing complications
* Using legal, ehtical, & professional guidlines

A

Interpreting
(Tanner’s Model)

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9
Q

Part of Tanner’s Model that involves:
* Setting priorities
* Delegating

A

Responding
(Tanner’s Model)

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10
Q

Part of Tanner’s Model that involves:
* Evaluating data (Relection-IN-action)
* Evaluating & correcting thinking (Relection-ON-action)

A

Reflection
(Tanner’s Model)

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11
Q

What are examples of a Nursing Diagnosis?

A

Pain

Ineffective breathing pattern

Risk for infection

Knowledge deficit

Fluid & electrolyte imbalance

Mobility deficiet

Risk for falls

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12
Q

What are examples of a Medical Diagnosis?

A

Cholecystitis

COPD

Lupus

RA

Diabetes

Hyper/Hypovolemia

Knee replacement

UTI

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13
Q

What are 4 types of nursing Dx errors?

A

Data collection errors

Data clustering incorrectly

Analysis & interpreting of data

Diagnostic statments

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14
Q

Juan just completed his first year as a RN working on the meg surg unit. He feels more confident in skills & experience that he has gained. What stage of Benner’s is Juan in?

A) Advanced Beginner
B) Novice
C) Competent
D) Proficient

A

A) Advanced Beginner

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15
Q

Professional definition of what a nurse is licensed to perform

A

Scope of practice

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16
Q

Professional guidlines for ethical behavior

Sets expectations for professional to achieve

A

Code of ethics

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17
Q

Minimum level of care accepted to ensure high-quality care to pts

A

Standards of care

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18
Q

John Wu notices a rash on his pt that he has not seen before. He reports the rash to the nurse & asks her to assess it w/ him. What type of critical thinking attitude is John demonstrating?

A) Humility
B) Thinking independently
C) Curiosity
D) Responsiblity & authority

A

D) Responsiblity & authority

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19
Q

During clinical last week, Sarah’s pts IV had infiltrated. Why is Sarah now more aware of noticing S/s of an infiltrated IV?

A) Reflection
B) Curiosity
C) Experience
D) Knowledge

A

C) Experience

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20
Q

What are some questions to ask yourself when identifying S/s? (Noticing - Tanner’s model)

A

What findings are most significant?

What data are relevant/ not relevant?

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21
Q

What are some questions to ask yourself when gathering complete & accurate data? (Noticing - Tanner’s model)

A

What additional information is needed to decide what is wrong w/ this pt?

What questions should the nurse ask (pt, family, others) in the assesment?

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22
Q

What are examples of gathering complete & accurate data? (Noticing - Tanner’s model)

A
  1. Patient: Interview, assessment
  2. Medical/records: Health Hx / Dx
  3. Medication: Administration record
  4. Spouse / caregiver
  5. Lab values, diagnostic reports
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23
Q

What is the differrence between Reflecting-ON- Action & Reflecting-IN- Action

A

Reflecting-ON- Action: Correcting while in action
* Ex: Med follow up

Reflecting-IN- Action: Reflect on what happened / what was done
* Ex: Intervention / education follow up

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24
Q

List some sources of data:

A

Patient (Subjective / objective / Primary)

Family, Significant other, neighbor (secondary)

Healthcare team (SW, PT/OT,Dr, etc)

Medical records, other records

Scientific lierature (Research)

Nurse’s experience

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25
Q

Process of developing & evaluating nursing solution or approaches to client problems

A

Problem solving

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26
Q

Requires use of logic & clinical reasoning to identify strengths/weaknesses of nursing solutions to client problems

A

Critical thinking

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27
Q

How would you describe of each letter of ADPIE?

A

Assessment: Interpreting & validating information to form a complete database (Holistic care - Whole person)
* Investigate / collect data
* Primary (Pt) or secondary (Family, neighbor, spouse, et.)

Diagnosis: Problem/ potential problem based on assessment data & goal for pt

Planning: Plan created to resolve problem or prevent problems based on evidence-based care
* Determines what is most important

Implementation: Carry out plan in safe manner

Evaluation: Outcome of plan
* Determine if it was effective in acheiving goal

28
Q

What are 3 types of assessments?

A

Pt centered interview

Physical assessment (Head-to-toe, focused assessment, pain assessment)

Periodic assessment (Rounding)

29
Q

What other sources are appropriate for data collection?

A

Patient (Primary - Subjective)

Family / sig. other

Heathcare team (SW, PT/OT, Dr, ect)

Medical records

Other records

Scientific literature (Research studies to keep up to date)

Nurse’s experience

30
Q

What is the difference between subjective & objective data?

A

Subjective: Subject verbalizes problem
* Ex: Pain 10/10, “My head hurts”

Objective: Data observed
* Ex: Facial grimacing, BP, ect

31
Q

Tanners

Assessing systemically & comprehensively

A

Noticing

32
Q

S/s noticed when using sences (touch, taste, smell, hear, see)

Carefully review assessment data to determine relevant / immediate concern (Subjective / objective)
* Comes first

Ex:
* Lumps
* Temp
* Shuffling gate
* Warm skin
* Odor

A

Cues

33
Q

CJMM

Identify relevant from irrelevant
* Can use assessments, medical Hx, vitals, labs

What is more important / a main concern?

Tools used:
* Maslows
* ABCs
* CAB (if CPR)

A

Recognizing cues

34
Q

Noticing normal / abnormal data or data has changed

Objective / subjective cues

A

Identifying S/s

35
Q

Noticing data from reliable availible source
* No cues involved

Ex:
* MAR, medical records
* H & P
* Pt / family/ Sig. other
* HCT
* Dx tests, labs
* Past Dx

A

Gathering complete & accurate data

36
Q

What are 4 things pt centered interviews consist of?

A

Courtisy

Comfort

Connect

Conformation (Clarification - Like debrifing)

37
Q

What is the inital interview goal?

A

To find the complaint
* What brought them in to be seen

38
Q

What are 3 phases associated w/ gathering complete & accurate data?

A

Orientation & setting agenda:
* Begin by introducing self
* Explain the procedure & why you are collecting data
* Focus on pt goals, preferences, & concerns, not your personal agenda
* Ensure pt comfort

Working phase (Open-ended):
* Involves gathering ongoing assessment information
* Begin w/ open-ended questions
* Have pts explain reasons for seeking health care or describe symptoms
* Use active listening
* Organize time & focus on changes

Termination (Summarise, Teach back):
* Summarize discussions w/ pt & check for accuracy
* Let pt know when interview is almost over
* End interview in friendly manner

39
Q

What are some interview techniques?

A

Leading questions (Can be conflicting)

Verbal / nonverbal communication

Back channeling (Active listening / “Uh huh, go on…”)

Probing

40
Q

What are some ways to help improve communication w/ older adults?

A

Direct eye contact

Head nodding

Smiling

Leaning forward

41
Q

What does each letter stand for in SPICES?

A

S: Sleep disorder

P: Problms w/ eating

I: Incontinence

C: Confusion

E: Evidence of falls

S: Skin breakdown

42
Q

Noticing data using systematic methods or assessment tools

Types of systems:
* ACE.S
* Sleep scale
* SPICES
* Braden scale
* Head-To-Toe
* Morris fall scale
* Focused assessment, ect

When in distress, used focused assessment

A

Assessing systematically & comprehensively

43
Q

Being proactive by settig up interventions to prevent further complications

Noticing a situation has a high risk for complications
* Nurses should be alert

A

Predicting potential complications

44
Q

Another name for Hospital Aquired Infection

A

Nosocomial

45
Q

Made w/o proof

Noticing risks of arriving at a conclusion w/o supporting evidence

A

Identifying assumptions

46
Q

Develops, revises, & maintains scope of practice statements & standards that apply to the practice of all professional nurses

Guide nurses to make significant & visible contributions that improve the health & well-being of all individuals, communities, & population

ADPIE

Standards describe a competent level of behavior in the nursing roles
* Standards set a level of performance to assure patients that they are receiving high quality of care

A

ANA scope & standards

47
Q

List and describe the levels of nursing from Novice to Expert

A

Novice: Beginning nursing student or any nurse in a situation in which there is no previous level of experience

Advanced beginner: A nurse who has had some level of experience w/ the situation

Competent: A nurse who has been in the same clinical position for 2 - 3 years

Proficient: A nurse who has more than 2 - 3 years of experience

Expert: A nurse w/ diverse experience

48
Q

What are 5 critical thinking competencies?

A

Knowledge based:
* Basic & nursing science
* Nursing & health care theory
* Pt data

Experience:
* Personal
* Clincail practice
* Skill competence

Enviornmet:
* Time pressure
* Setting
* Task complexity
* Interruptions

Critical thinking attitudes

Standards:
* Intellectual
* Professional

49
Q

What are some enviornmental factors that affect the adequacy of an assessment?

A

Setting

Time pressure

Task complexity

Inturruptions

50
Q

What are the 3 priority levels that can be use to help set priorities?

A
  1. ABCs, CAB, vital sign concerns, life threatening labs
  2. Changes in mental status, untreated medical issue, acute pain, acute elimination problems, abnormal labs, & risks
  3. Long term issues, long term issues in health management, rest, family coping
51
Q

A nurse received change-of-shift reports on these 4 patients & start rounding. Which pt does the nurse need to focus on as priority?

A) A pt who had abdominal surgery 2 days ago & is requesting pain meds

B) A pt admitted yesterday w/ afib who now had a decreased level of consciousness

C) A pt w/ a wound drain who needs teaching before discharge in the early afternoon

D) A pt going into surgery for a mastectomy in 3hrs who has a question about the surgery

A

B) A pt admitted yesterday w/ afib who now had a decreased level of consciousness

52
Q

While administering meds, a nurse realizes that a prescribed dose of medication was not given. The nurse acts by completing an incident report & notifying the patients HCP. Which of the following is the nurse exercising?

A) Authority
B) Responsibility
C) Accountability
D) Decision making

A

C) Accountability

53
Q

Which task is appropriate for a RN to delegate to an UAP?

A) Determining whether the pt understands the preoperative preparation required before the surgery in the morning

B) Administering the ordered antibiotics to the pt before surgery

C) Obtaining pt’s signature on surgical informed consent

D) Helping pt to the bathroom before leaving for OR

A

D) Helping pt to the bathroom before leaving for OR

54
Q

What are 8 different sources of law w/in the legal limits of nursing?

A

Constitutional law: Derived from federal & state constitutions

Statutory law: Laws that are civil orcriminal

Civil law: Rights of individuals & provide fair / equitable tx when civil wrongs or violations occur

Nurse practice act: Civil state laws that define nursing & the standards nurses must meet w/in individual states

Criminal law: Protect society & provide punishment for crimes

Administrative law / Regulatory law: Degree of offense often distinguishes whether the person intentionally commited the mistreatment, knew or should have known harm would result, or did not consider harm

Common law: Originates from decisions that were made in absence of law

Case law: Describes decisions made in legal cases that were resolved in courts
* Presented to judge / jury

55
Q

Consensus or sociological perspective, incorporates the societal & professional codes & standards that are part of the nursing discipline

Skill orientation

Part of professional identity

A

Doing

56
Q

Personal or psychological view of the nurse professional explains what it means to do the right thing

Attribute is about professional & adopting attitudes & behaviors that reflect the value of how a preofessional thinks, feels, & acts

May incorporate rules & principles, but it is beyond the laws, codes, & standards w/in the discipline or society

A

Being

57
Q

Being attentive to what is considered right & good for both a societal & professional perspective

A

Acting ethically

58
Q

The final attribute of professional identity & the process of professional identity formation

A

Changing identities

59
Q

Refers to nurse’s understanding of pt response to nursing actions while care is occuring

Observations & interactions w/ the pt by the nurse determins pt status & adjusts care accordingly

Critical step in evaluating pt’s reaction to interventions

Nurse is continuously assessing & reflecting on pt’s response to meds, such as changes in facial expression, muscle relaxation, or verbal indications of relief

A

Reflection-in-Action

60
Q

Consideration of the situation after the pt care occurs

Nurse contemplates a situation & considers what was successful / unsuccessful

Critical for development of knowledge & improvement in reasoning

How learning from practice is incorporated into personal experience for consideration in future care situations

Significant learning ffrom practice occurs & is critical to the development of increasing skillfulness as a nurse

May use verbal narratives to engage in making sense of their own experiences, & process to thinking

A

Reflection-on-Action

61
Q

What does each letter stand for in ACE.S?

A

A: Assess Function and Expectations

C: Coordinate and Manage Care

E: Evolving Knowledge

S: Situational Decisions

62
Q

1st Part of ACE.S

Assess, respond to, and respect an older adult’s functional status and strengths, wishes, and expectations.

Determine the older adult’s function and expectations, along with cognition, mood, culture, physiologic status, and comfort to obtain a comprehensive assessment of health care needs

Use standardized assessment tools to assess the older adult’s individual aging
pattern

A

Assess Function and Expectations

63
Q

2nd Part of ACE.S

Manage chronic conditions, including atypical presentations, in daily life and during life transitions to maximize function and maintain independence.

Assist older adults and families/caregivers to access knowledge and evaluate
resources.

Advocate during acute exacerbations of chronic conditions to prevent
complications.

A

Coordinate and Manage Care

64
Q

3rd Part of ACE.S

Understand geriatric syndromes and unique presentations of common diseases in older adults.

Access and use emerging information and research evidence about the special care needs of older adults and appropriate treatment options.

Interpret findings and evaluate clinical situations in order to provide high quality nursing care based on current knowledge and best practices

A

Evolving Knowledge

65
Q

4th Part of ACE.S

Analyze risks and benefits of care decisions in collaboration with the interdisciplinary team and the older adult, family, and caregivers.

Evaluate situations where standard treatment recommendations need to be modified to manage care in the context of the older adult’s needs and life transitions.

Consider the older adult’s wishes, expectations, resources, lived experiences, culture, and strengths when modifying care approaches.

A

Situational Decisions

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