Exam 1 Flashcards by Alyssa Smith

What is an example of Nightingale’s contributions to nursing?

a. Graduated as the first trained U.S. nurse
b. Practiced nursing in the Civil War
c. Established the Red Cross
d. Emphasized respect for patients’ needs and rights

How well did you know this?

Not at all

Perfectly

_______ practiced nursing in the Civil War and established the Red Cross. ________ was the first U.S. trained nurse. _______ emphasized patients’ needs and rights.

Clara Barton

Linda Richards

Nightingale

How well did you know this?

Not at all

Perfectly

Nurses are most likely to utilize which of the following theories or models in their leadership role?

a. Maslow and Erikson
b. Health Belief Model
c. Lewin
d. Von Bertalanffy

How well did you know this?

Not at all

Perfectly

The nurse will use _____ change theory most often in the leadership role. ______ hierarchy of needs, __________ developmental theory, and the ________ will be utilized most during patient care and education.

Lewin’s

Maslow’s

Erikson’s

Health Belief Model

How well did you know this?

Not at all

Perfectly

A team meeting of physicians and nurses is convened to discuss a specific patient’s problems and to determine goals for the patient. During the meeting, specific accountability related to patient care for both the physicians and nurses involved is established. All members of the meeting show mutual respect by valuing each other’s clinical competence that is necessary to provide quality patient care. Of the following functions of a nurse, which one is demonstrated in the above example?

a. Delegation
b. Advocacy
c. Collaboration
d. Management

How well did you know this?

Not at all

Perfectly

__________ in which health care professionals constructively solve problems and learn from each other.

dynamic interpersonal process of collaboration

How well did you know this?

Not at all

Perfectly

A nurse has graduated from a nursing program and is participating in a new graduate program at a local hospital as a continuing socialization to the role of the nurse. At what level is the nurse functioning at this point in the nurse’s career?

a. Expert
b. Competent
c. Novice
d. Advanced Beginner

How well did you know this?

Not at all

Perfectly

The nurse is an _______ for 2 to 3 years after graduating and doesn’t reach the level of competence until the end of that time period.

Advanced Beginner

How well did you know this?

Not at all

Perfectly

Nursing students all belong to National Student Nurses Association when they are attending a specific nursing program. This is an important aspect of their socialization to the profession as it demonstrates which criteria of a profession?

a. Providing service to society
b. Accepting responsibility for actions and omissions
c. Participating in an organization that supports and advances the profession
d. Making independent decisions based on their scope of practice

How well did you know this?

Not at all

Perfectly

Students begin their ________ to the profession by participating in an organization, which is one criteria of a profession.

socialization

How well did you know this?

Not at all

Perfectly

What is the nurse’s role as patient advocate? (Select all that apply.)

a. Explain to the patient the nurse’s viewpoint.
b. Provide necessary education and interpret information.
c. Accept the patient’s decision and support his or her wishes.
d. Give the patient the physician’s explanation of his or her viewpoint.

B., C.

How well did you know this?

Not at all

Perfectly

The nurse as the _________ must first provide education and interpret information in an unbiased manner. Then the nurse must accept the patient’s decision and support his or her wishes even if it is different from the nurse’s own viewpoint or that of other health care personnel.

patient advocate

How well did you know this?

Not at all

Perfectly

A nurse is planning a program for educating a Hispanic community regarding nutritional practices. What would be the most important aspects that the nurse takes into consideration first? (Select all that apply.)

a. Change theory and Health Belief Model
b. Previous educational programs
c. Cultural influences
d. Hospital admissions from this community

A, C

How well did you know this?

Not at all

Perfectly

Since the nurse will be discussing nutrition to a specific cultural group, the nurse needs to understand the _________ on their nutritional practices. In addition the nurse needs to understand change theory to plan her education if she is attempting to have the group make changes in their nutritional practices. ________ would also help in understanding the community’s perceptions regarding barriers that facilitate or discourage adoption of the promoted behaviors.

Cultural influences,

The Health Belief Model

How well did you know this?

Not at all

Perfectly

How might a nurse as a researcher approach the care of the patient? (Select all that apply.)

a. Performing technical skills as learned
b. Looking for problems and questioning practices
c. Incorporating research she has read into her practice
d. Carrying out procedures as they always have been done

B, C

How well did you know this?

Not at all

Perfectly

By looking for problems and questioning practices, the nurse is identifying problems that can be researched. By incorporating any new research into practice, the nurse is involved in __________.

Evidence-Based Practice

How well did you know this?

Not at all

Perfectly

In comparing the American Nurses Association (ANA) and the International Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA’s definition and is indicative of a more global focus?

a. Advocacy
b. Health promotion
c. Shaping health policy
d. Prevention of illness

How well did you know this?

Not at all

Perfectly

The ____ definition of nursing expands on the _____ definition by providing for the concept of shaping health policy as a responsibility of nursing.

ICN’s

ANA’s

How well did you know this?

Not at all

Perfectly

A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? (Select all that apply.)

a. Code of ethics
b. Licensing
c. Body of knowledge
d. Educational preparation
e. Altruism

a, b, c, e

How well did you know this?

Not at all

Perfectly

______ as a profession has a code of ethics, licensing, a body of knowledge, and altruism. Because there are multiple paths of education for nursing and not a standard entry into practice, this is one criterion of a profession that is not standard and consistent.

Nursing

How well did you know this?

Not at all

Perfectly

What specific aspect of a profession does the development of theories provide?

a. Altruism
b. Body of knowledge
c. Autonomy
d. Accountability

How well did you know this?

Not at all

Perfectly

_____ establish a specific nursing body of knowledge that is unique to the discipline, which is one criterion of a profession.

Theories

How well did you know this?

Not at all

Perfectly

Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of nursing professional practice are they exhibiting?

a. Autonomy
b. Accountability
c. Cultural competence
d. Autocratic leadership

How well did you know this?

Not at all

Perfectly

The nurse and other health care workers are exhibiting ________ by being responsive to patients’ health beliefs and practices that are influenced by the individual’s culture.

cultural competence

How well did you know this?

Not at all

Perfectly

A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the primary care provider. Which characteristic of a professional is the nurse demonstrating? a. Autonomy b. Collaboration c. Accountability d. Altruism

The nurse is demonstrating ______ by taking responsibility for the error and reporting it after an initial assessment of the patient. Criteria of a profession include _______ (public service over personal gain), ________ (independence), accountability, and diversity; however, in this case, the nurse is demonstrating accountability. Although _________ is important for the health care team, it is not a criterion for a profession.

accountability altruism collaboration

Of the following, which are included in the ANA standards? (Select all that apply.) a. Standards for professional performance b. Code of ethics c. Standards of care d. Legal scope of practice e. Licensure requirements

A, C

____ standards have two parts: one is standards for professional performance, and the other is standards of care. _____ has a separate document that is a code of ethics. Nurse practice acts are a legal scope of practice.

ANA

Which core competency of advanced practice nursing is the Master of Science in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques? a. Leadership b. Ethical decision making c. Direct clinical practice d. Expert coaching

A _______ who is teaching and counseling students is practicing expert coaching and guidance. A _______ with a master’s degree practices the other competencies of leadership and ethical decision making in other situations. Although a _______ may also work as a nurse involved in direct patient care, this is not part of the _______ role.

nurse educator

Which of the following statements describes a component discussed in nursing theories? (Select all that apply.) a. Optimal functioning of the patient b. Interaction with components of the environment c. The conceptual makeup of the administration of the hospital d. The illness and health concept e. Safety aspect of medication administration

A, B, D

There are four components that a nursing theory discusses:

(1) the patient (2) health (3) environment (4) nursing—not the hospital administration.

Which factors affect the nursing shortage? (Select all that apply.) a. Aging faculty b. Increasing elderly population c. Job satisfaction due to adequate number of nurses d. Aging nursing workforce e. Greater autonomy for nurses

A, B, D

A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the patient’s chart. The nurse is performing which specific nursing function? a. Diagnosis b. Assessment c. Education d. Advocacy

Nurses need to understand how beliefs and values are different. A nurse begins to offer information to a patient and the patient says, “I’ve already heard all of that before and I don’t agree with any of it.” How should the nurse proceed? a. Ask the patient to explain his values. b. Ask the patient to explain what he believes. c. Ask the patient about his prejudicial attitude. d. Confront the patient about the values conflict he’s experiencing.

Which nursing theory of care describes how the nurse’s presence in the nurse-patient relationship transcends the physical and material world, facilitating the development of a higher sense of self by the patient? a. Swanson’s Theory of Caring Processes b. Madeline Leininger’s Cultural Care Theory c. Watson’s Theory of Human Science and Human Care d. Travelbee’s Human-to-Human Relationship Model

Which statement best describes for new parents how and when children develop first-order beliefs? a. During infancy, and once developed, such beliefs seldom change b. From life experiences during the toddler and preschool years c. Throughout life from first-hand experiences and information provided by authority figures d. From teen and young-adult peer interaction and mentorship of professional role models

As the nurse explained the preoperative instructions to the patient, the patient’s older brother suddenly stepped into the doorway and yelled, “People who go under the knife always die. Don’t do it! They’re going to kill you.” What type of higher-order belief is the patient’s older brother displaying? a. Distress b. Stereotype c. Prejudice d. Denial

After admitting a homeless patient to the floor, the nurse tells a colleague that “homeless people are too dumb to understand instructions.” What action should the colleague take first? a. Ignore the nurse’s prejudicial comment without responding b. Offer to trade assignments and care for the homeless patient c. Ask the nurse about the patient’s personal history assessment data d. Challenge the nurse’s thinking, pointing out the ability of all people

The nurse in the emergency department is caring for an 8-year-old who has had a serious asthma attack. When the nurse attempts to explain the problem to the child’s mother, she smells cigarette smoke on the mother’s breath. The nurse asks the mother if she has been smoking and the mother responds, “Yes, and I know they’ve told me before I can’t smoke around him.” What should the nurse do next? a. Ask the patient’s mother what she values more, her child or her habit. b. Ask the patient’s mother to explain what she believes about smoking and asthma. c. Ask the patient’s mother about her prejudicial attitude toward smoking. d. Confront the patient’s mother about the values conflict she’s experiencing.

A nurse is working with a 35-year-old patient who needs to decide whether to donate a kidney to his brother who has been in renal failure for 5 years. The patient shares with the nurse that the decision is especially difficult because he would not be able to continue to work in his current profession and would be unable to support his three small children if he ever needed dialysis. Which intervention(s) would be most appropriate for the nurse to implement in this situation? (Select all that apply.) a. Explain that it is unlikely that he will ever need dialysis even if he has only one kidney. b. Guide the patient through a values clarification process to help him make a decision based on his values. c. Provide information the patient needs to help him make an informed decision. d. Ask for his permission to contact the kidney donation team to answer any questions he may have.

B, C, D

A 57-year-old male patient who was hospitalized with an admitting blood pressure of 240/120 asked the nurse if his family could bring in some meat and vegetable dishes from home. He explained that he cannot eat the foods on the hospital menu because it is summer and the hospital is only offering chicken and fish, which in his culture are “hot” foods that will interfere with his healing. Which response by the nurse would best demonstrate an application of Leininger’s theory? a. Discourage the family from bringing in food, explaining that the idea of “hot” and “cold” foods is a superstition without scientific basis. b. Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient’s blood pressure is supported. c. Explain that the patient will need to have home-prepared foods evaluated by the dietary staff to ensure that they are acceptable options. d. Tell the family to bring in any foods they want, to help preserve the patient’s cultural practices and dietary preferences.

In Swanson’s Caring Theory, the nurse demonstrates caring using several techniques. Which of the following is (are) included in the five caring processes? (Select all that apply.) a. Call patients by their first name to demonstrate a caring attitude. b. Sit at the bedside for at least 5 minutes each hour. c. Use touch based on the nurse’s judgment of what is appropriate. d. Ask the patient to identify the most important thing to accomplish during the nurse’s shift.

A new nurse is about to insert a nasogastric tube for the first time but is not sure what equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who is frightened and slightly confused. Which actions by the nurse would best demonstrate caring? (Select all that apply.) a. Offer the patient pain medication to help her calm down. b. Hold the patient’s hand while inserting the nasogastric tube. c. Speak calmly while explaining the procedure to the patient beforehand. d. Ask another, more experienced nurse for assistance before initiating care.

C, D

According to _____, negotiation and adaptation are part of what nurses do to accommodate the patient’s cultural ways of life. As long as the foods from home have low concentrations of sodium or other ingredients that are known to affect blood pressure, the nurse can accommodate the patient’s beliefs and cultural dietary practices as well as the medical plan of care. Rejecting the patient’s cultural traditions and/or accepting them without regard for the well-being of the patient are unacceptable actions. Food given to patients from family members does not need to be evaluated by the dietary staff before consumption.

Leininger’s theory

One of the major concepts of ________ is described in the stem of the question. Watson’s theory is based on a holistic paradigm in which both the nurse and the patient transcend time and the physical and material world.

Watson’s Theory of Human Caring

________ focuses on practical ways the nurse can help the patient through the use of the five caring processes.

Swanson’s theory

________ focuses on maintaining and preserving the patient’s cultural practices and ways of living but never mentions transcending beyond the physical world.

Leininger’s theory

________ focuses on the nurse and the patient creating a relationship bond, but the only mention of transcendence is that the nurse and the patient must transcend the roles that each has assumed.

Travelbee’s theory

The best approach for a nurse who is performing an assessment on a patient from an ethnic group the nurse knows nothing about is to a. use the information the nurse already knows about the other ethnic groups that may be similar to the patient’s group to come up with assessment questions. b. ask the same questions the nurse typically asks of all patients and not deviate from the questions on the assessment form. c. ask the patient to explain what he or she believes his or her health problem is and what he or she thinks caused it. d. ask the patient to help the nurse understand anything about the patient’s ethnic group that may have a bearing on the patient’s health care needs.

A co-worker is an excellent nurse but often assumes responsibility for other people’s irresponsible behaviors. Her nurse manager notices that in the past several months she has become overly sensitive with her patients and that she complains of feeling stressed and worn out because she has taken on too much. She admits to having a family background that makes her suspect she has some co-dependent traits. How should her nurse manager proceed if the nurse’s work continues to suffer? a. The manager should offer her emotional support for as long as she needs it. b. Help her recognize that she may be co-dependent and needs to get professional help. c. Take her to the next scheduled group therapy session in the mental health ward. d. Confront her about her inappropriate behavior and threaten to fire her if her work doesn’t improve.

A nurse recognizes the importance of active listening as a way to show the nurse cares. Which of the following actions by the nurse describes active listening? (Select all that apply.) a. Sitting at the patient’s bedside and listening to the patient talk while inserting an IV b. Sitting in a chair facing a patient and making a mental note of the major points of the conversation c. Listening to what the patient says and what he means while she conducts her early morning assessment d. Engaging both the patient and the family members while taking careful notes of the conversation

Which of the following actions by the nurse demonstrates “doing for” as described in Swanson’s theory? a. Going the extra mile b. Thoroughly assessing in order to know what the patient thinks c. Seeking cues and expertise from colleagues about the patient’s condition d. Preserving the patient’s dignity and performing competently

A nursing student walks into the patient’s room and is unsure about when it is appropriate to use caring touch in a nurse-patient care situation. What should the student do? a. Leave the room and ask her clinical instructor when and where she should touch her patient. b. Ask the patient for permission to touch her before proceeding. c. Disregard the use of touch since she is unsure of how to maintain professional boundary when it comes to touching a patient. d. Assume all patients want to be touched and that they see it as an act of caring.

While doing her morning assessment, the nurse shares with her patients the tests and procedures they have scheduled for that day as well as when she expects to return to deliver their medications or do their treatments. Even though the hospital is a hectic and difficult environment to predict, the nurse regards this information session with her patients as an important way to demonstrate she cares. The rationale behind her action is a. to increase the patients’ sense of security by making the environment more predictable for the patients. b. to ease her patients’ fears since they may worry that she’ll forget to give them their medications. c. to point out to her patients that the care they are receiving is consistent and delivered on time so they will rate her care higher when they leave the hospital. d. to allow the patients some flexibility in when they want to take their medications or have their tests and procedures done.

The nurse recognizes the importance of a patient’s beliefs in influencing the patient’s behaviors and responses to health care problems. Which of the following are examples of a patient’s beliefs? (Select all that apply.) a. A patient explains that the medication he is taking is helping him overcome his anxiety. b. A patient reflects on her values and uses them to help her make a decision about whether or not to have breast reconstruction surgery. c. A patient expresses a feeling of dread about the future to his nurse. d. A 78-year-old man signs a “Do Not Resuscitate Order” when he learns he’s had a massive heart attack because, he explains, “he can hardly wait to go and be with his wife in heaven.”

A, D

A nurse is gathering an admission assessment on a patient who recently emigrated from Japan and is a Buddhist. The man told the nurse that he normally meditates daily and lives almost exactly the way he did in Japan. However, he has not been able to walk for the past weeks. Based on the assessment findings, which questions would be important for the nurse to ask before implementing his nursing care? (Select all that apply.) a. What have you done to cope with your health problem? b. What do you call your health problem? What do you think is wrong? c. What concerns you most about the recommended treatment plan? d. What do you think caused your health problem?

A, B, C, D

________ means doing nothing else but listening to the patient. It’s about being attentive and engaged.

Active listening

A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both the patient and his wife become very concerned, and the patient’s call light is activated. What referent initiated communication between the patient and the nurse? a. Interaction between the patient and his wife b. Concern on the part of the patient’s spouse c. Pain experienced by the patient d. Activation of the call light

Which factor influences whether a message is effectively communicated? (Select all that apply.) a. Timing of the conversation b. Educational level of participants c. Mode of communication utilized d. Physical environment of discussion

A, B, C, D

If a patient is grimacing, what assessment statement or question would be most beneficial to identifying the underlying cause of the nonverbal communication? a. “Did you lose something?” b. “You appear to be having pain.” c. “I will turn off the lights and let you rest.” d. “May I get you something to relieve your tension?”

What action by the nurse would most ensure accurate interpretation of patient communication? a. Providing feedback regarding the conveyed message b. Writing down the patient’s conversational highlights c. Assuming significant cultural differences exist d. Verifying the patient’s emotional state

If a patient’s verbal and nonverbal communications are inconsistent, which form of communication is most likely to convey the true feelings of the patient? a. Written notes b. Facial expressions c. Implied inferences d. Spoken words

What strategy would be most effective in communicating with a highly anxious adult immediately before surgery? a. Providing specific, concise instructions b. Detailing likely causes of their anxiety c. Focusing on postoperative details d. Using instructional multimedia DVDs

What action should the nurse take if an alert and oriented patient asks the nurse for personal contact information? a. Ask the patient why the personal information is needed. b. Report the interaction to the nursing supervisor immediately. c. State that it would not be appropriate to share that information. d. Change the subject, and hope that the patient does not ask again.

What would be the best therapeutic response to a patient who expresses indecision about recommended chemotherapy treatments? a. “Can you tell me why you are undecided?” b. “It’s always a good idea to have chemotherapy.” c. “You should follow whatever your health care provider recommends.” d. “What are you thinking about the treatments at this point?”

Which statement is most accurate regarding symbolic expression? a. Skills confidence can be shared most effectively by nurses through wearing distinctive clothing. b. Clothing choices by a hospitalized patient rarely reflects his or her economic resources. c. Make-up use by a patient is unnecessary for any reason during hospitalization. d. Nondramatic make-up use and minimal accessorizing by nurses demonstrates professionalism.

Which defense mechanism is being exhibited when a 27-year-old patient insists on having a parent present during routine care? a. Denial b. Regression c. Repression d. Displacement

______ of a conversation dramatically influences the receptivity of the receiver.

Timing

_______ is a common nonverbal sign of pain. Sharing an observation encourages the patient to elaborate on nonverbal communication. Asking the patient whether something is lost indicates that the nurse has not attended to the nonverbal cues of the patient. It is important to do an assessment of the patient before initiating any interventions.

Grimacing

_______ is the most effective way to avoid misinterpretation of a message. It helps ensure that the message sent is perceived by the receiver in a way that is consistent with the intention of the sender.

Feedback

_________ is the more accurate mode of conveying feelings.

Nonverbal communication

The nurse receives change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse’s action? a. Problem solving b. Decision making c. Judgment d. Reasoning

In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking? a. “What do I know about this situation?” b. “What additional details do I need to gather?” c. “Does the clinical presentation correlate with the diagnosis?” d. “Are the treatments appropriate for the diagnosis?”

Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data? a. Do these findings make sense? b. How can this information be verified? c. What are the most significant factors in the problem? d. What is the relationship of this information to other data?

The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first? a. Ask the patient to describe the chief complaint b. Request that another nurse be assigned to this patient c. Review data about the medical diagnosis and routine management d. Complete a physical assessment of the patient

The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply. ) a. Assessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated d. Allowing the patient to be alone to rest more comfortably e. Discussing adaptations needed for daily activities with the patient

a, b, c

Which of the following actions reflects inductive reasoning? a. Using subjective and objective data to confirm a diagnosis b. Assessing for specific clinical presentations based on a disease process c. Correlating elevated blood pressure to pathophysiology d. Validating an automatic blood pressure cuff reading with a manual measurement

The nurse is completing an assessment on a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient’s clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient’s abdominal pain? a. Evaluation b. Interpretation c. Reflection d. Inference

The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.) a. Teamwork b. Intuition c. Judgment d. Conflict management e. Advocacy f. Reasoning

a, d, e

In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias? a. Collecting the patient’s medical history b. Administering IV medications c. Performing oral care d. Completing a bed bath

During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse’s use of which intellectual standard of critical thinking? a. Clarity b. Logic c. Precision d. Significance

is used when the nurse is faced with a situation that requires analysis and a solution.

Problem Solving

is used in the decision-making process but does not result in the actual decision.

Judgement

is logical thinking that may be used in decision making but, again, is not the actual result.

Reasoning

relates to providing sufficient detail to lead to an exact understanding of the situation.

Precision

is effective in establishing the relevance of data.

Determining Relationship

_____ of information is related to accuracy, making “sense” relates to logic, and significance more closely relates to depth.

Verification

______ involves assessing a situation and determining what should be done based on an appropriate rationale.

Analysis

_________ uses specific facts or details to make conclusions and generalizations (i.e., going from specific to general).

Inductive Reasoning

________ involves generating facts or details from a major theory, generalization, or premise (i.e., from general to specific).

Deductive Reasoning

Nurses use________ to understand and explain the meaning of data.

interpretation

________ such as teamwork, conflict management, and advocacy engage others in the process of critical thinking.

interpersonal skills

The nurse facilitates the use of the intellectual standard of critical thinking of significance by posing which question to determine the patient’s understanding of his or her new diagnosis of type 1 diabetes mellitus on his or her lifestyle? a. “What information do I need to provide to teach the patient?” b. “Do you understand how to administer your insulin?” c. “What are the signs of low blood glucose?” d. “How will this diagnosis impact your career?”

In providing care to a newly admitted patient, the nurse’s inferences are more accurate if based upon which of the following? a. Objective data b. Assumptions c. Intuition d. Experience

During the postoperative assessment on a patient, the nurse has a “hunch” that the patient has a postoperative complication based upon a. intuition. b. interpretation. c. information processing. d. inference.

In using intuition to address a clinical problem, the expert nurse bases his or her approach upon which of the following? a. Judgment b. Data collection c. Experiential knowledge d. Logical deduction

A new graduate nurse explains a new approach in the positioning of patients with chronic low back pain. The nurse preceptor responds, “That is not the way we do it here.” The preceptor’s response illustrates which error in critical thinking? a. Lack of information b. Erroneous assumptions c. Illogical thinking d. Bias

The nurse uses a case study presentation to present an educational offering to the staff on the unit. This strategy improves the staff nurses’ critical thinking through which of the following? a. Reviewing the literature b. Practicing application of knowledge c. Discussing with colleagues d. Role playing

In preparing to administer medications to a patient, the nurse notes a medication that she has never administered. If the nurse administers the medication without researching the medication, this represents which error in critical thinking? a. Lack of information b. Illogical thinking c. Close-mindedness d. Erroneous assumptions

The nurse uses critical thinking to interpret data. Which of the following data sources are objective? (Select all that apply.) a. Patient interview b. Laboratory values c. Body language d. X-ray results e. Vital signs f. Breath sounds

b, d, e, f

In preparing for a certification examination, the nurse chooses to develop a concept map to help understand the content. This strategy is based upon which characteristics of concept maps? (Select all that apply.) a. Facilitates note taking b. Requires thinking aloud c. Fosters making correlations between concepts d. Validates content with an expert e. Organizes visual data

A, C, E

______ focuses on how important the information (diagnosis of diabetes mellitus) is to the issue being addressed.

Significance

________ is based upon observable data that can usually be replicated by another provider, it is the more valid basis for inferences.

objective data

_______ is often characterized by hasty generalizations and assumptions that do not consider the evidence.

Illogical thinking

______ is observable data that is assessed through vision, hearing, smell, and touch.

Objective Data

_______includes patient history and nonverbal data such as body language, facial expressions, etc.

Subjective Data

_______ are a method to organize and visualize data in order to identify relationships and solve problems. _______ can be used for note taking, mapping nursing care plans, and preparing for exams

Concept Maps

What term best describes the nature of the nursing process? a. Static b. Linear c. Dynamic d. Predictable

A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient? a. An experienced nurse on the unit b. The patient’s medical record c. The patient’s wife d. His physician

Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse? a. Reading the patient’s history b. Setting realistic, measurable goals c. Comparing evidence-based practices d. Clustering related patient data

A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse’s first action? a. Tell the child that if she stops crying, her parents can be with her. b. Check to see what pain medication is ordered for the child. c. Notify the surgeon of the child’s postoperative condition. d. Assess the child to determine why she is crying.

Which statement is a correctly written example of an actual nursing diagnosis? a. Impaired memory related to patient complaint of becoming confused with the time change b. Risk for injury related to stumbling when walking as evidenced by patient report of occasional difficulty playing basketball c. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea on exertion and significant drop of oxygen saturation from 98% to 88% with activity d. Ineffective health maintenance as evidenced by inability to complete activities of daily living related to lack of familial support system

Which long-term goal is written correctly? a. Patient will remain afebrile throughout hospitalization. b. Patient will return to professional sports activities within 6 months. c. Nurse will prevent bone infection through antibiotic therapy for 3 weeks. d. Patient will demonstrate accurate use of crutches without assistance before discharge from emergency room.

What phrase best describes the essence of critical thinking? a. Understanding without conscious reasoning b. Providing care based on nursing experience c. Consulting with a primary care provider d. Seeking solutions to problems

Which body is responsible for defining and disseminating information on nursing diagnoses? a. North American Nursing Diagnosis Association International b. International and American Nurses Association c. Individual State Boards of Nursing d. The Joint Commission

The statement “ongoing collection of data” best describes which phase of the nursing process? a. Planning b. Evaluation c. Assessment d. Implementation

Which statement illustrates the most measurable outcome indicator? a. Demonstrates dressing change b. Shares innermost thoughts c. Understands instructions d. Shows personal remorse

A nurse admits a patient to the cardiac care unit following the placement of a cardiac stent. Which step of the nursing process does the nurse do first? a. Planning b. Assessment c. Evaluation d. Implementation

What should be the focus of all nursing interventions? a. Early hospital discharge for patients b. Providing patient-centered care c. Reduction of health care spending d. Delegating appropriate nursing care

Which action should the nurse take 30 minutes after administering oral pain medication to a patient? a. Evaluate the effectiveness of the administered pain medication. b. Teach progressive relaxation strategies to relieve muscle tension. c. Assess the patient’s coping skills to reduce expressed anxiety. d. Encourage the patient to read or watch TV to provide pain distraction.

The ______ is dynamic, changing over time in response to patients’ individual needs. The dynamic, responsive nature of the ______ allows it to be used effectively with patients in any setting and at every level of care, from the intensive care unit to outpatient wellness clinics.

nursing process

________ are established and revised biannually by NANDA International, Inc. (NANDA-I), a professional nursing organization that provides standardized language to identify patient problems and plan customized care.

nursing diagnosis

________ focuses on the patient and the patient’s response to nursing interventions and goal or outcome attainment. During the ______ step of the nursing process, nurses use critical thinking to determine whether a patient’s short- and long-term goals were met and desired outcomes were achieved.

Evaluation

What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team

The ______ is the methodology used to “think like a nurse.”

nursing process

A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting

An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient

What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice

On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses

Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient’s spouse will express satisfaction with patient’s progress before discharge. d. Patient’s incision will be well approximated each time it is assessed by the nurse.

What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient’s family requests

Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient.

A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.

What action should the nurse take regarding a patient’s plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.

In an _______, the nurse initially focuses on the patient’s chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.

emergent situation

The nurse collects ______ directly from patients who are alert and oriented. Family members and other members of the health care team may provide ______ on patients.

primary data | secondary data

_______ emerge from groupings of clustered data collected during the assessment phase of the nursing process.

Nursing Diagnosis

are to be patient-focused, realistic, and measurable.

Goals

_______needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.

Patient

Which piece of assessment data may be accurately obtained during the observation phase? a. Pulse irregularity b. Slow capillary refill c. Elevated temperature d. Presence of body odor

Patients from which generation would be most comfortable with the nurse using electronic resources for health screening? a. Baby boomers b. Generation X c. Millennials d. Veterans

Which type of question would be best for the nurse to use when trying to determine the extent of a patient’s knowledge concerning a disease process? a. Open ended b. Direct c. Close ended d. Focused

Which statement by the nurse best describes health history assessment? a. “The first patient interview is the best source of all essential health history data.” b. “When health history data is updated, patient information collected earlier is no longer useful.” c. “Collection of health history information is ongoing and methodical throughout patient interaction.” d. “Gathering health history data is best accomplished in a random, relaxed fashion as topics arise.”

Which statement illustrates appropriate documentation following palpation? a. Abdomen soft, non-tender without distention b. Density noted over kidney margins bilaterally c. Reddened area 3 inches in diameter noted on left thigh d. Heart sounds distant over the mitral and tricuspid valves

What type of assessment is most appropriate for a patient newly admitted to the hospital for intermittent loss of vision in the left eye? a. Emergency b. Complete c. Focused d. Triage

Which statement is the best example of subjective, secondary data? a. Unlicensed assistive personnel reports patient’s blood pressure is 138/84 b. Patient complains of extreme fatigue and dizziness when walking in the room c. Nurse states that the patient’s chest x-ray has a shadow in the left upper lobe d. Spouse reports patient has been vomiting intermittently for the last 48 hours

A patient is admitted to the nursing unit with numbness and tingling in the right hand, pain in the cervical spine, and occasional loss of consciousness. Into which functional health pattern would the nurse organize this data? a. Self-perception and self-concept b. Coping and stress tolerance c. Cognition and perception d. Activity and exercise

Which information gathered during assessment is considered to be subjective data? a. The client’s urine is dark and foul-smelling. b. The patient’s 24-hour urine output is 1800 mL. c. The patient indicates pain and burning are present when urinating. d. The patient is taking an antibiotic for a urinary tract infection.

The most important source in data collection is/are a. nursing literature. b. the patient. c. medical records. d. family members.

Which action(s) should the nurse take during the termination phase of the patient interview? (Select all that apply.) a. Express appreciation for the patient’s participation. b. Review key assessment findings that were noted. c. Validate information covered with the patient. d. Allow the patient to add additional insights.

a, b, c, d

The nurse uses the senses of sight, hearing, and smell during the _______ phase of assessment. The presence of body odor is the only patient data listed that can be accurately assessed during this phase. Pulse irregularity, slow capillary refill, and elevated temperature all require vital sign assessment or palpation.

observation

The best source of information about the patient is the ______, not the family, the medical record, or nursing literature.

patient

During the ______ phase, interaction should be drawn to a logical conclusion and information should be reviewed, clarified, and verified prior to initiating care. Appreciation for the patient’s participation should be acknowledged and the patient should be encouraged to add any additional information or thoughts that come to mind prior to ending the interaction.

termination

Which action by a patient marks the beginning of the physical assessment process? a. Redressing after a physical examination b. Breathing normally during auscultation c. Greeting the nurse in the examination room d. Sharing work environment information

Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient e. Music preference of the patient

a, b, c, d

Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. Always position patients in a comfortable reclined position to ensure their comfort during questioning. b. Ask which name a patient prefers to be called during care to show respect and build trust. c. Quickly conduct a review of systems to determine the need for a complete or focused assessment. d. Begin with questions about intimacy and sexuality to address sensitive issues first.

Which activity by the nurse best demonstrates part of the working phase of a patient interview? a. Summarizing previously discussed key topics b. Including selected family members in care planning c. Transferring care responsibilities to the home health nurse d. Verifying the name by which a patient prefers to be addressed

Which entry in a patient’s electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. Complaining of chest pain b. Apical pulse 110 c. Comatose d. Difficulty swallowing

Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. “What do you do for a living? Can you describe your work environment?” b. “Is there a family history of heart disease, cancer, high blood pressure, or stroke?” c. “When was your last annual physical? What immunizations did you receive at that time?” d. “Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?”

Which cue by a patient can be validated by laboratory and diagnostic test results? a. Deeply sighing with fatigue b. Bilateral crackles in the lungs c. Oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feet

A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. Body systems model b. Physical assessment model c. Head-to-toe assessment model d. Functional health patterns model

When initiating a physical examination, which action should the nurse take first? a. Review of the patient’s prior medical records b. Gather admission health history forms c. Assess the patient’s vital signs d. Perform light and deep palpation for fluid

If the nurse discovers that a patient’s right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid c. Perform passive range of motion to promote flexibility d. Inspect the patient’s left elbow to compare its appearance

begins at the moment the patient first interacts with the nurse.

assessment

Redressing takes place at the end of the physical examination.

redressing

Breathing during auscultation is part of the ________ assessment, and sharing health history and demographic information takes place during the patient interview.

respiratory

A ________ takes place during the working phase of the nurse-patient interview, just before initiation of the physical assessment.

review of systems

Summarizing key topics covered in the interview and transferring care responsibilities take place in the ________.

termination phase

During a _______, the patient is asked questions about each body system to determine the level of functioning. Asking about work-related information, family history, and immunizations is accomplished during the collection of health history data before initiating the _________.

review of systems

A ____ is a behavioral hint of a potential disease process or concern.

cue

Job stress and family relationships data will only be recorded extensively when using the _______. The________ is holistic in its approach.

Functional health patterns model

Assessment of the patient’s vital signs begins the physical examination aspect of the _______ process. This provides the nurse with baseline information about cardiac and respiratory function, pain level, and temperature.

assessment

A major aspect of assessment is checking for _______. If an abnormality is observed on one side of a patient’s body, the next step in the assessment is to compare that area with the other side.

symmetry

The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the recovery process of patients recently experiencing a loss. What is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy? a. Clinical research and data collection b. Changes in patient status and life experience c. Anecdotal nursing experiences d. Patient requests

The nurse has just received a postoperative patient to the floor postureteral stone manipulation. Choose the priority nursing diagnosis. a. Risk for urinary retention r/t general anesthesia and trauma to ureter b. Pain, acute r/t recent surgical procedure and verbalization of pain of 4 on scale 0-10 c. Risk for bleeding r/t surgical site injury d. Comfort, impaired r/t inability to urinate and verbalization “I am beginning to feel full"

The relationship of the medical diagnosis to the nursing diagnosis is a. the medical diagnosis is embedded within the nursing diagnostic statement. b. nursing diagnoses are driven by/derived from the medical diagnosis. c. the medical diagnosis is not relevant to the nursing diagnosis. d. the medical and nursing diagnoses should complement each other.

An example of implementation of evidenced practice by the nurse would be the nurse a. initiates a new policy protocol for the removal of c-collars and bed board restraints of the emergency department patient based on empirical research results. b. watched a news report on a new procedure for chest tube removal and implements the procedure on the patient needing chest tubes removed. c. saw a physician perform a manipulation for vertigo related to inner ear problems and decides to utilize the manipulation for the current patient experiencing vertigo. d. is assisting a physician with conscious sedation during a procedure and is asked to perform outside the nursing scope of practice.

The clustering of data is significant to the nursing diagnoses step because clustering of data will a. show the nurse assessment is complete for this patient. b. move the nurse toward accurate planning for the symptoms in clustered data. c. group the data of similar problems and aid in accurate nursing diagnosis identification. d. organize the data for clear assessment so further assessment can occur.

________, documenting the study findings of nurses who practice using the nursing process, is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy.

Clinical research

________ are developed through comprehensive research and data collection to support the eventual confirmation of actual nursing diagnostic statements.

Nursing diagnoses

________ take into consideration a patient’s attitudes, strengths, and resources—not just the medical problems identified—which are critical for planning holistic, individualized care.

Nursing diagnoses

After collecting and reviewing all of the assessment data, the nurse looks for patterns and related data to support specific nursing diagnoses. This process is referred to as ________. ________ involves organizing patient assessment data into groupings with similar underlying causes. The nurse looks for cues among the data that support the diagnosis of a problem. ________ is not associated with assessment. Symptoms are not the only data ________. Data are _______ during diagnosis, not assessment.

clustering data or clustering or clustered

What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I? a. Insurance documentation b. Professional autonomy c. Role delineation d. Patient safety

Which nursing diagnosis is appropriately written? (Select all that apply.) a. Risk for Infection related to elevated temperature and white blood count b. Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication c. Noncompliance related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Bleeding with the risk factor of prolonged clotting time e. Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort.

b,c,d

Which phrase best represents a related factor in an actual nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness

Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Thoroughly review the patient’s medical history b. Analyze the nursing assessment data to determine whether information is complete c. Outline an individualized plan of care to address each concern d. Consider potential complications to which the patient is susceptible e. Evaluate how the patient has responded to treatment

a, b, d

What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis? a. Defining characteristics are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed with a risk diagnosis.

What is the most important action for a nurse take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy? a. Share concerns with the nurse manager on the nursing unit b. Offer alternative care for a patient and family members c. Discuss how to address patient needs with physicians d. Provide evidence-based research to support nursing care

What is the most significant problem that may result from improperly written nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs

Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.

A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient’s current condition. c. Seek physician input related to updating the nursing diagnosis statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.

What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 BPM c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, “I feel nervous all the time, especially when I am alone.”

b, c, e

is the most important reason for using standardized language to communicate patient’s needs and information.

safety

is a heath-promotion nursing diagnosis and is written with two sections: the label and the defining characteristics.

Readiness for Enhanced Relationship

is a nursing diagnosis that requires a related factor and defining characteristics.

Noncompliance

requires at least one risk factor. Use of related factors in a risk nursing diagnosis is not the accepted NANDA-I format.

Risk for Bleeding

are broad statements that indicate the cause for the defining characteristics, which are signs or symptoms identified from collecting the patient’s data.

Related factors

_______ do not have defining characteristics; actual and health-promotion nursing diagnosis statements have defining characteristics. _________ do not establish a cause and effect, because they identify potential rather than existing problems. ________ contain related or risk factors rather than defining characteristics, subjective or otherwise. _________, like actual diagnoses, have nursing interventions to address a patient’s current or potential problem.

Risk diagnoses

consider the underlying etiology, needs, potential concerns, and patient response to a patient’s medical diagnosis, so the two types of diagnoses are interrelated.

Nursing diagnoses

Which action would the nurse undertake first when beginning to formulate a patient’s plan of care? a. List possible treatment options b. Identify realistic outcome indicators c. Consult with health care team members d. Rank patient concerns from assessment data

Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon’s functional health patterns c. Maslow’s hierarchy of needs d. Nursing Outcomes Classification (NOC)

If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Knowledge Deficit d. Body Image Disturbance

Which statement illustrates a characteristic of goals within the care planning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient’s progress.

Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient’s white blood count will remain within normal range throughout hospitalization. c. Patient’s visitors will be instructed in proper hand washing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.

If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections

a, b, d

Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient’s social worker to determine resources c. Listening to the patient’s concerns and beliefs about proposed treatment d. Engaging the patient’s family, friends, or care providers in conversation

Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages

b, c, d

The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient’s bed b. Administering oxygen by nasal cannula c. Assessing the patient’s oxygen saturation d. Evaluating the patient’s peripheral circulation

Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview

Prioritizing or ranking patient needs precedes the identification of outcome indicators, consulting with team members, or consulting with interdisciplinary team members.

prioritizing

is one method of organizing assessment data.

Functional health patterns

is the most urgent nursing diagnosis to address.

acute pain

may be a result of the pain and may be alleviated if the patient’s pain level is reduced.

fatigue

________ can be treated only after the patient’s pain level is at an acceptable level. Both diagnoses require teaching, during which the patient needs to concentrate.

Body Image Disturbance and Knowledge Deficit

A person’s ability to concentrate is affected by the ________.

pain level

It is most important to _____ the patient in developing realistic, attainable, patient-centered plans of care.

involve

The nurse seeks assistance from the speech therapist on a patient’s case to determine the patient’s ability to swallow food. Which care technique is utilized here? a. Indirect communication b. Collaboration c. Delegation d. Assistive contribution

______ entails using expertise of health care professionals to pool resources and knowledge to provide quality care.

Collaboration

Which of the following is a direct care intervention? a. Reviewing the most recent clinical results from the laboratory b. Collaborating with social services regarding patient discharge plans c. Performing patient education regarding use of an incentive spirometer d. Obtaining medical records from a previous admission

______ interventions are completed directly with the patient.

direct care

Documentation is a component of which part of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

_______ includes performing and documenting nursing interventions.

implementation

Which of the following would be an inappropriate intervention for a patient with the nursing diagnosis of “Impaired Physical Mobility”? a. Use pressure relieving devices on bed and chair. b. Promote independence in performing all activities of daily living. c. Reinforce safety precautions with the patient and family. d. Perform active and passive range of motion three times daily.

A patient presents to the emergency room with chest pain. Which of the following is the priority nursing intervention? a. Administer acetaminophen immediately. b. Provide oxygen via nasal cannula as ordered by the physician. c. Provide emotional support. d. Prepare the patient for emergency surgery.

Which of the following statements most accurately reflects the nursing process? a. Cyclical in nature and steps overlap b. Can be delegated to increase productivity c. Must be completed in an orderly sequence from beginning to end d. Should follow standard structure for all patients

is cyclical and ever-changing as the patient condition changes.

nursing process

Which of the following is an example of collaboration? a. The nurse receiving orders from a physician b. The nurse and physical therapist creating an ambulation schedule for the patient c. The nurse arranging for discharge instructions to be provided to the patient and family d. The nurse providing the patient with a video on insulin injections

______ involves teamwork to accomplish a patient goal. The nurse and physical therapist creating an ambulation schedule can maximize the efforts and effects of the activity.

collaboration

Which of the following is an important component in evaluating patient outcomes and the plan of care? a. Nursing judgment and critical thinking b. Communication with the interdisciplinary team c. Implementing every intervention d. Nursing attitude

Which of the following are components of delegation? (Select all that apply.) a. Assigning the correct task b. Assigning planning in the nursing process c. Having the LPN contact the physician for orders d. Using correct supervision to the delegate e. Assigning a task under the right circumstances

A, D, E

What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change

a, b, c, d

Which intervention would be most important for the nurse to include in a patient’s care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously b. Discourage the patient from bathing while hospitalized c. Encourage the patient to rest between bathing activities d. Ask the patient’s spouse to assist with all bathing

Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient’s ability to swallow the medication. b. Double-check the patient’s allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration.

Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient’s physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy d. Encouraging the patient to explore options for care

What should be taken into consideration by the nurse when deciding on interventions to include in a patient’s plan of care? (Select all that apply.) a. Patient’s treatment preferences b. Cultural and ethnic influences c. Professional level of expertise d. Current evidence-based research e. Convenience to the nursing staff

a, b, c, d

Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. Ambulating a patient with ataxia and new right sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications

Which action is a part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan b. Documenting performed nursing interventions c. Determining if nursing interventions were completed d. Reviewing whether a patient met their short-term goal e. Identifying realistic outcomes with patient input

a, d

Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient’s short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before shift change c. Documenting patient assessment findings in the patient’s chart d. Checking with the pharmacist regarding possible drug interactions

Which notation is most appropriate for the nurse to include in a patient’s chart regarding evaluation of the goal, “Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)”? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB.

What is the primary purpose of quality improvement? a. Recognizing the need to discipline employees violating policies b. Preventing patient injury that may contributor to the death of others c. Increasing institutional profits to support further scientific research d. Enhancing current practices to improve patient outcomes and care

Which patient appears to be at greatest risk for falls? a. 66-year-old woman post-op, A&O x 3, continuous IV, and narcotic pain meds b. 71-year-old man with pneumonia, A&O x 2, on O2, and continuous IV c. 76-year-old man with acute confusion, A&O x 1, incontinent, and continuous IV d. 80-year-old woman post-op, A&O x 3, narcotic pain meds, and continuous IV

Identify all nursing interventions that would be required when caring for a restrained patient: a. Remove restraints q1h and inspect the skin. b. Check on the patient every 30 minutes and ensure needs are met. c. Renew restraint orders every shift. d. Remove restraints as soon as patient’s condition allows.

When a fire occurs in a health care agency, in which sequence should actions be performed? a. Pull the alarm. Assist patients. Secure area by closing doors. Spray extinguisher. b. Remove oxygen source. Aerate the fire. Call the operator. Evacuate patients. c. Rescue the patients. Alarm sounded. Contain the fire. Extinguish fire. d. Remove fire source. Alarm sounded. Close the doors. Evacuate patients.

For a school-age child who enjoys riding a bicycle, which is the priority nursing diagnosis? a. Risk for injury b. Risk for falls c. Risk for impaired skin integrity d. Risk for impaired mobility

Select the most appropriate side rail regime for an elderly patient who intermittently calls for assistance: a. one top side rail raised on the patient’s dominant side b. two top side rails raised to promote bed mobility c. three side rails up with bottom rail closest to bathroom down d. four side rails up to prevent the patient getting up without assistance

Which behavior by the nurse during medication administration is most likely to cause a medication error in a 40-year-old patient on a medical/surgical unit? (Select all that apply.) a. Verifies the patient’s identity calling the patient by name b. Calls the pharmacist to check on the medication dosage c. Takes a telephone call from the doctor about the patient while preparing the medication d. Fails to weigh the patient prior to giving the medication e. Double-checks the right route before administering medication

a, c

When teaching a patient about fire safety, which activity does the nurse know is the leading cause of fire-related death? a. Cooking b. Playing with matches c. Smoking d. Heating with kerosene heaters

is the leading cause of fire-related deaths, 80% of which occur in the home.

smoking

Which measure can the nurse teach to prevent poisoning of children? (Select all that apply.) a. Install safety latches on reachable cabinets. b. Keep syrup of ipecac on hand. c. Use childproof caps on medications. d. Use a plunger rather than a chemical drain cleaner. e. Keep cleaning supplies under the kitchen sink.

a, c, d

Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip replacement who has acute confusion and incontinence? a. A room near the nurses’ station and decreased sensory stimuli b. A pressure sensor alarm and a room near the nurses’ station c. Side rails up and decreased sensory stimuli d. A 24-hour sitter and the patient’s favorite TV program

The nurse is performing a fall risk assessment on a newly admitted patient. Which finding is a known risk factor for falls? a. Medications b. Urinary incontinence c. Multiple comorbidities d. Malnutrition

A patient is ordered to have a urine culture to rule out methicillin-resistant Staphylococcus aureus (MRSA). When obtaining this specimen, which personal protective equipment (PPE) should the nurse don? a. Gloves, mask, eye shield b. Gloves, gown, shoe covers c. Gloves, mask, hat d. Gloves, gown, eye shield

An elderly client residing in the community with cardiopulmonary compromise and impaired ability to perform activities of daily living (ADLs) presents safety concerns to the nurse. Which is the greatest concern? a. Ability to obtain and take medications correctly b. Ability to safely get on and off a toilet c. Ability to safely procure food and prepare meals d. Ability to safely eat without choking

What other health care professional should the nurse consult when a patient has difficulty with activities of daily living (ADLs) and why? a. Occupational therapist to evaluate the ability to perform ADLs b. Physical therapist to evaluate the patient’s need for assistive devices c. Social worker to arrange for needed assistive devices d. Area agency on aging to arrange for Meals on Wheels

A 56-year-old man who has been staying at a cabin while hunting arrives at the emergency department with complaints of dizziness, light-headedness, and nausea. What does the nurse initially suspect? a. Carbon monoxide poisoning b. Lead poisoning c. Radon exposure d. Food poisoning

Which activity would be most appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for fall risk and complications of restraint use b. Evaluating the patient’s ability to perform activities of daily living (ADLs) c. Assisting with or performing the patient’s ADLs d. Teaching the patient use of assistive devices

When working with radiation diagnostics or treatments, which preventive measure should be followed to avoid exposure? (Select all that apply.) a. Using lead shielding of patients and staff b. Keeping staff at the farthest distance possible from the radiation source c. Limiting the length of exposure d. Wearing a badge to monitor the length of exposure e. Following procedures and safety checks

a, b, c, d, e

You are making a home visit to a family of 5 children. The youngest, aged 5, has a temperature of 101.1°F, is lethargic, and has a poor appetite. This assessment leads you to the diagnosis of influenza. Based on your knowledge that influenza is an airborne communicable disease, all of the following patient teachings regarding infection are appropriate for the mother and family except a. keep children home from day care and school while symptoms are present. b. remind family that they only need to wash their hands if they are visibly dirty. c. do not share tissues, dishes, or personal care items to reduce the risk of transmission. d. encourage the family to receive their annual influenza vaccine.

When caring for a patient with rubella, in addition to standard precautions, which precautions would be used? a. Droplet precautions b. Airborne precautions c. Contact precautions d. Universal precautions

During normal patient care that does not soil hands, effective hand hygiene between patients requires a. at least a 20-second soap and water scrub. b. at least a 23-minute scrub with antimicrobial soap. c. use of an alcohol-based antiseptic handrub. d. a mask must be worn while scrubbing is occurring.

A nurse is caring for an overweight 60-year old woman with a reddened area over her coccyx. The priority nursing diagnosis for this patient is a. Imbalanced Nutrition: More Than Body Requirements related to immobility. b. Impaired Physical Mobility related to pain and discomfort. c. Chronic Pain related to overweight. d. Risk for Infection related to altered skin integrity.

An infection occurs as a result of a cyclical process. The six components of an infection are a. infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host. b. infectious agent, reservoir, portal of exit, vehicle of movement, portal of entry, and susceptible host. c. infectious agent, reservoir, portal of exit, vehicle of transmission, portal of entry, and unsusceptible host. d. invading agent, reservoir, portal of exit, vehicle of transmission, portal of entry, and susceptible host.

The six components of an infection are:

the infectious agent, the source of infection, the portal of exit, the mode of transmission, the portal of entry, and the susceptible host

Of the following patients, which patient is at a higher risk of infection? a. 27-year-old female who is an athlete b. 60-year-old male with arthritis c. 12-year-old female with a broken leg d. 36-year-old female with HIV

The nurse is caring for a patient that has a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection-control practices should the nurse implement? (Select all that apply.) a. Wear a protective gown when entering the patient’s room. b. Don a particulate respirator mask when administering medication to the patient. c. Ensure that all staff serving the patient’s meal trays don gloves prior to delivering of tray. d. Instruct all visitors to wear a surgical mask when entering the patient’s room. e. Use sterile gloves when performing dressing changes. f. Use a face shield before irrigating the patient’s wounds.

a, c, f

The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient? a. Private room b. Private, negative-airflow room c. Mask worn by the staff when entering the room d. Mask worn by the staff and the patient when leaving the patient’s room

A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient? a. Airborne precautions b. Droplet precautions c. Contact precautions d. Protective isolation

In which situations does the nurse wear clean gloves as part of standard precautions? (Select all that apply.) a. In the care of a patient diagnosed with an infectious process b. When the patient is diaphoretic c. During care of each individual under treatment in the facility d. In the presence of urine or stool e. When taking the patient’s blood pressure

a, c, d

The nurse uses _____ for situations in which an infectious disease is known or when there is a possibility of contact with blood or body fluids (except perspiration).

standard precautions

The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? a. An illness resulting from living in an unclean environment b. A result of lack of knowledge about food preparation c. A disease resulting from pathogens in or on the body d. An acute or chronic illness resulting from traumatic injury

A disease resulting from pathogens in or on the body is the definition of an ______.

infection

The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection? a. Virus b. Bacterium c. Fungus d. Spore

A nurse is preparing to change a sterile dressing and has donned two sterile gloves. To maintain surgical asepsis, what else must the nurse do? a. Keep the amount of splashes on the sterile field to a minimum. b. If a sneeze is imminent, cover the nose and mouth with a gloved hand. c. With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing. d. Regard the outer 1 inch of the sterile field as contaminated.

What is the proper order of removal of soiled personal protective equipment when the nurse leaves the patient’s room? a. Gown, goggles, mask, gloves, and exit the room b. Gloves, wash hands, remove gown, mask, and wash hands c. Gloves, goggles, gown, mask, and wash hands d. Goggles, mask, gloves, gown, and wash hands

Of the following hospitalized patients, who is most at risk for acquiring a health–care-associated infection? a. 60-year-old who smokes two packs of cigarettes per day b. 40-year-old who has an indwelling urinary catheter in place c. 65-year-old who is a vegetarian and slightly underweight d. 60-year-old who has a white blood cell count of 6000

A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism? a. Direct contact b. Vector c. Vehicle d. Airborne

Of the following assessment findings, which signs indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) a. Thick, white drainage in the Jackson-Pratt tubing b. Redness or warmth at the affected site c. Purulent drainage at the incision site d. Temperature 100.4 F (38 C) e. Tenderness and localized pain f. Wound with well-approximated edges g. Purulent drainage at the incision site

a, b, c, d, e, g

Which area of the body is most likely to be excoriated? a. Elbows b. Facial skin c. Cervical spine d. Perineum

Which nursing action is necessary for patient safety during a bed bath? a. All four side rails are always kept in the raised position during the bath. b. The bed is always in the low and locked position while bathing the patient. c. The top side rail is raised opposite the side where the nurse is standing. d. The bed is always kept in a flat position with a pillow under the patient’s head.

Which statement accurately describes proper technique for performing male perineal care? The nurse a. washes the patient from the back of the perineum toward the penis. b. washes with a circular motion starting with the urinary meatus. c. places the patient in the prone position with supporting pillows. d. places the patient in the dorsal recumbent position.

The nurse has delegated care of a patient’s dentures to unlicensed assistive personnel. Which statement by the assistive personnel indicates an understanding of denture care? a. “It is not necessary to use a toothbrush in the patient’s mouth since the patient does not have teeth.” b. “I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside table within reach of the patient.” c. “I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste.” d. “I will soak the dentures in the sink and then place them in a denture cup labeled with the patient’s name.”

Which assessment finding by the nurse indicates a complication from oxygen via nasal cannula? a. Dry nasal passages b. Inability to speak clearly c. Increased nasal drainage d. Skin breakdown on the chin

Which statement is most accurate about hearing aid and ear care for hospitalized patients who are hard of hearing? a. Hard of hearing patients should wear hearing aids at all times while hospitalized. b. Hearing aids should be cleansed daily with soap and water before reinsertion. c. Cerumen is removed with a cotton-tipped applicator before inserting hearing aids. d. Hearing aids are cleansed with a dry cloth and stored in a labeled container.

Which procedure is correct when making an occupied bed? a. The bed is left in the low and locked position for patient safety. b. The bed is made starting at the head and working toward the feet. c. Soiled linen is loosened on one side of the bed and rolled under the patient. d. Making an occupied bed cannot be delegated to unlicensed assistive personnel.

Which statement by a patient with the nursing diagnosis of Self-Care Deficit would indicate attainment of the goal: Patient will actively participate in bathing within 24 hours after surgery? a. “I need help with my bath.” b. “I was able to wash my own feet today.” c. “I am going to need assistance at home.” d. “Could you help me brush my teeth this morning?”

Which statements are correct concerning bathing a hospitalized patient? (Select all that apply.) a. A complete bed bath is for patients who are bedridden. b. All hospitalized patients need a complete bed bath. c. Bathing removes dead skin, bacteria, and body fluids. d. Male personnel must always perform male perineal care. e. Keeping skin clean and dry helps prevent breakdown.

a, c, e

Which hygienic care instructions by the nurse should be given to a patient who is being discharged on an anticoagulant? (Select all that apply.) a. Use an electric razor for shaving. b. Brush teeth with a soft toothbrush. c. Trim beard with double blade safety razor. d. Use caution when trimming nails with clippers. e. Deeply massage unused muscles while bathing.

a, b, d

An ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails. The patient’s toenails are long and thick. What is the next step the nurse should take? a. Soak the patient’s feet, and trim her toenails using clippers. b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP). c. Assess the patient’s self-care status. d. Ask for a referral to a podiatrist.

An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse? a. “Do you have friends or family nearby?” b. “Can you raise your arms up to brush your teeth?” c. “Do you become short of breath during your shower?” d. “Are you able to get in and out of your bed at home?”

Which action by a female patient lets the nurse know that the patient has understood perineal care teaching? a. The patient washes her perineum with a circular motion beginning at the urinary meatus. b. The patient washes her perineum from front to back using a clean washcloth. c. The patient washes her perineum from back to front with long, firm strokes. d. The patient washes her perineum lightly to prevent tissue damage.

What should the nurse do before leaving a patient’s room after giving a complete bed bath? a. Place the call light within reach, and leave the bed as it was during the bath. b. Lower the bed to its lowest position, raise all four side rails so that the patient does not fall out of bed, and place the call light within reach. c. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach. d. Leave the bed in a position that is comfortable for the caregiver because more care will be needed, raise the top two side rails, and place the call light within reach.

Which actions by the nurse concerning oral care on an unconscious patient are considered safe? (Select all that apply.) a. Performing oral care with the patient in a supine position b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours e. Using a hard-bristle toothbrush

b, c, d

Which safety precaution is a priority for the nurse when bathing a patient with peripheral neuropathy? a. Keeping the top two side rails up during the bath b. Checking the bath water temperature before the bath c. Encouraging independence with perineal care during the bath d. Facilitating range-of-motion exercises and dangling before the bath

Which nursing diagnosis is a priority for a patient who needs assistance with activities of daily living? a. Self-Care Deficit b. Deficient Knowledge c. Risk for Activity Intolerance d. Readiness for Enhanced Self-Care

Which statements are true regarding back massage? (Select all that apply.) a. Only a licensed massage therapist can perform back massage. b. Back massage may stimulate the deep muscles. c. Massage provides relaxation and comfort. d. Tapotement stimulates the skin. e. A massage may promote sleep.

b, c, d, e

A patient diagnosed with head lice has an order for pediculicidal shampoo. Which statement is true about this shampoo? a. It can be used on only patients with the ability to stand in the shower. b. It can cause central nervous system side effects, including dizziness. c. It is used by pregnant women and young children. d. It is safe for patients with seizures.

Which statement indicates an understanding by the unlicensed assistive personnel of eye care during a patient’s bath using washcloths and a bath basin? a. “The eyes are washed with soap and water from the inner canthus to the outer canthus.” b. “The eyes should always be washed using sterile normal saline and a gauze sponge.” c. “The eyes are washed from the outer canthus to the inner canthus using water only.” d. “The eyes are washed with water using a clean part of the washcloth for each eye.”

Which assessment finding would indicate that a patient has hemiparesis? a. Bilateral lack of movement in the patient’s lower extremities b. Complaint of pain when the patient attempts to ambulate c. Loss of sensation in both of the patient’s legs d. Weakness of the patient’s right arm and leg

What information should the nurse include when teaching a patient about deep vein thrombosis (DVT) prevention? a. Avoid movement of the extremities to prevent potential deep vein thrombosis formation. b. Encourage use of sequential compression devices (SCDs) during ambulation. c. Utilize an ankle foot orthotic (AFO) or pressure relief orthotic (PRAFO) to stretch ligaments. d. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.

What nursing intervention would be the first priority to prevent constipation in an immobile patient? a. Administration of a soap suds enema b. Decreased dietary fiber consumption c. Narcotic analgesic pain relief use d. Increased daily oral fluid intake

Which patient care activity can be delegated by the registered nurse (RN) to unlicensed assistive personnel (UAP)? a. Completing an admission skin assessment b. Administering an ordered stool softener c. Teaching deep vein thrombosis prophylaxis d. Range of motion exercises

Following hip surgery, a trochanter roll is used to prevent what type of movement? a. Supination b. Pronation c. Internal rotation d. External rotation

To prevent injury to a patient during logrolling, which action by the nurse is most important? a. Place an ankle foot orthotic on the patient prior to movement. b. Remove the patient’s drawsheet to avoid lower extremity entanglement. c. Position a pillow between the patient’s legs to maintain body alignment. d. Raise all four side rails prior to initiating logrolling independently.

When providing home-going instructions for a recently discharged patient, which statement by the patient’s son would indicate an understanding of methods to prevent complications from immobility? a. “We’ll make sure that Dad eats plenty of lean protein foods.” b. “We will limit Dad’s fluid intake to prevent bladder incontinence.” c. “Dad should sit more and restrict the time he walks around the house.” d. “His arm sling should be kept on at all times to prevent an elbow contracture.”

Bones function in what important roles within the body? (Select all that apply.) a. Regulate potassium levels b. Maintain calcium balance c. Protect critical organs d. Produce blood cells e. Control motor activity

b, c, d

What actions by the nurse are critical to ensure patient safety? (Select all that apply.) a. Place the call light on the patient’s nightstand. b. Clean up fluid spills on the floor immediately. c. Instruct the patient to wear socks when ambulating. d. Keep linens and intravenous tubing off the floor. e. Return the bed to low position prior to exiting the room.

b, d, e

is essential for the promotion of skin integrity, prevention of bladder infections, and regular defecation.

Fluid intake

_____ prevents many of the complications of immobility.

Ambulation

An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient? a. A two-person lift is performed, with one person on each side of the patient. b. The patient is steadied under the arms and pivoted on his left leg. c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). d. A stand assist lift is used with the help of another nurse.

After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly under the axilla b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 28 inches forward and then swinging both legs forward when using a three-point crutch walk

What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows d. Hips e. Coccyx

b, c, d

Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum

A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? a. Calcium should be taken with vitamin D to increase calcium absorption. b. African American women are more prone to developing osteoporosis than are Asian American women. c. Increased phosphorus metabolism may lead to bone fragility. d. Aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis.

What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? a. Early ambulation after surgery b. Administering calcium with vitamin D c. Coughing and deep breathing exercises d. Referring the patient to occupational therapy

is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity.

ambulation

Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.) a. Monitoring respiratory status and breathing difficulties b. Assisting with feeding and ADLs c. Developing a care plan with the patient’s power of attorney d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient’s waist before ambulation

a, b, d

Which discovery found during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone c. Decreased cardiac workload d. Orthostatic hypertension

Which nursing diagnosis label is most appropriate for a patient who is experiencing sensory deprivation due to a lack of interaction with others? a. Impaired Verbal Communication b. Sedentary Lifestyle c. Social Isolation d. Disturbed Personal Identity

After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? a. Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Bowel sounds

The nurse recognizes which of the following as a barrier to achieving goals? a. Patient involvement in setting patient goals b. The effects of pain and/or clinical depression c. Family involvement in setting patient goals d. Realistic expectations of the patient’s capabilities.

One problem that may occur with a patient with low health literacy is: a. The patient is unable to obtain transporation. b. The patient is unable to understand basic health information needed to make health care decisions. c. The patient is unable to pay insurance premiums required to cover medical bills. d. The patient is too weak or frail to ambulate 30 feet.

The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as: a. A complex process during which nurses think about their thinking. b. Thinking like a nurse in developing plans of care. c. The framework that nurses used to provide care. d. The process that allows nurses to collect essential data.

The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is: a. The patient will walk to the bathroom without experiencing shortness of breath after surgery. b. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. c. The patient will walk to the bathroom without experiencing shortness of breath. d. The patient will walk to the bathroom within 48 hours after surgery.

What unit of measure will the nurse record urine output in? a. kilograms (kg) b. grams (g) c. milliliters (mL) d. meters (m)

The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: (Select all that apply.) a. utilize objective data since subjective data are often inaccurate. b. includes unvalidated data to determine an accurate and thorough diagnosis. c. require naming patient problems using nursing diagnostic labels. d. identify actual or potential problems as well as responses to a problem. e. are similar to medical diagnoses since they both are labels for diseases.

c, d,

``` The nurse is assisting a patient to bed when the patient says, “My chest hurts and my left arm feels numb. What’s wrong with me?” What is the type and source of data obtained from the patient’s complaint? a. Subjective data from a primary source b. Objective data from a secondary source c. Objective data from a primary source d. Subjective data from a secondary source ```

most of which are unconscious beliefs, such as object permanence

zero-oder beliefs

conscious beliefs, typically based on direct experiences

first-order beliefs

which are generalizations or ideas that are derived from first-order beliefs and reasoning

higher-order beliefs

determine the importance and worth of an idea, a belief, and object, or behavior

values

include the life principles that are most important to people and shape their thoughts, feelings and ultimately actions

personal values

strongly influence each person's selection of friends, professional decisions, organizational membership, and support of social causes (Yoost 22) Yoost, Barbara, Lynne Crawford. Fundamentals of Nursing: Active Learning for Collaborative Practice. Mosby, 022015. VitalBook file.

values

Most _______ and even ________ seldom arise out of unkind or pathologic intent but are used by people to remember new information and to categorize their ideas and beliefs. (Yoost 23) Yoost, Barbara, Lynne Crawford. Fundamentals of Nursing: Active Learning for Collaborative Practice. Mosby, 022015. VitalBook file.

generalizations stereotypes

A _________ helps the person choose between alternatives, resolve values conflicts, and make decisions (Yoost 23) Yoost, Barbara, Lynne Crawford. Fundamentals of Nursing: Active Learning for Collaborative Practice. Mosby, 022015. VitalBook file.

values system

constitute the nation’s largest health care profession

RNs

has continued to evolve throughout history to meet the needs of the patient and the changing health care environment.

Nursing

Nursing is seen as a _______ (treating the patient’s physical, mental, emotional, spiritual, and social self) profession that addresses the many dimensions necessary to fully care for a patient.

holistic

The all-encompassing nature of the _______ profession sets it apart from the medical profession, which treats an illness with a specific medical diagnosis.

nursing

_____ include the patient and family in their care while collaborating with all members of the health care team.

nurses

_______, which is often considered to be synonymous with nursing, is a fundamental value for nurses in both their personal and professional lives and a critical foundation of nursing practice.

caring

what are the primary roles and functions of the nurse?

``` Care provider advocate change agent researcher educator leader manager collaborator delegator ```

As the ______, the nurse interprets information and provides the necessary education. The nurse then accepts and respects the patient’s decisions even if they are different from the nurse’s own beliefs.

patient advocate

The nurse ______ motivates others toward common goals.

leader

A nurse _______ in a hospital oversees the staff on a patient care unit while managing the budget and resources required for necessary functions.

manager

Low health literacy is associated with increased ________, greater emergency care use, lower use of mammography and lower receipt of influenza vaccine.

hospitalization

A goal of _______ by the nurse is to inform patients and deliver information that is understandable by examining their level of health literacy.

patient education

The application of ______ includes the following basic components: Assessing the need for change and identifying a problem Linking the problem with interventions and outcomes by formulating a well-built question to search the literature Identifying articles and other evidence-based resources that answer the question Critically appraising the evidence to assess its validity Synthesizing the best evidence Designing a change for practice Implementing and evaluating the change by applying the synthesized evidence Integrating and maintaining change while monitoring process and outcomes by reevaluating the application of evidence and assessing areas for improvement

evidence based practice

What are the characteristics of collaboration?

- clinical competence and accountability - common purpose - interpersonal competence and effective communication - trust and mutual respect - recognition and valuation of diverse complementary knowledge and skills - humor

______ had its beginnings in religious and military services in the Middle Ages, particularly during the Crusades.

nursing

______ theories are more concrete and narrowly focused on a specific condition or population than are grand theories. They can be tested directly through application to practice situations and are useful in nursing research and practice.

middle range

Although _______ are derived from conceptual frameworks, they remain almost as broad as the framework itself. A ________ defines key concepts and principles of the discipline in an abstract way.

grand theory

_______ concept of the environment emphasized prevention and clean air, water, and housing. Her nursing theoretical work discussed environmental adaptation with appropriate noise levels, hygiene, light, comfort, socialization, hope, nutrition, and conservation of patient energy.

Nightingale's

______ focused on the roles played by the nurse and the interpersonal process between a nurse and a patient. The interpersonal process occurs in overlapping phases: (1) orientation; (2) working, consisting of two subphases—identification and exploitation; and (3) resolution.

Peplau

______ had 14 components, based on Maslow’s hierarchy of human needs from the physiologic, psychological, sociocultural, spiritual, and developmental domains. She described the nurse’s role as substitutive (doing for the person), supplementary (helping the person), or complementary (working with the person), with the ultimate goal of independence for the patient.

Henderson

_____ stated that human beings and their environments are interacting in continuous motion as infinite energy fields. The model includes four dimensions: energy fields, openness, patterns and organizations, and dimensionality. The dimensions are used in developing the three principles of resonancy (continuous change from lower to higher frequency), helicy (increasing diversity), and integrality (continuous process of the human and environmental fields). Nurses assist the patient with repatterning to develop well

Rogers

_________ Adaptation Model is based on the human being as an adaptive open system. The person adapts by meeting physiologic-physical needs, developing a positive self-concept–group identity, performing social role functions, and balancing dependence and independence. The nurse helps patients strengthen their abilities to adapt to their illnesses or helps them to develop adaptive behaviors.

Roy's

______ Self-Care Deficit Theory of Nursing. A self-care deficit exists when patients are unable to meet their self-care needs. Nursing systems care for patients who require assistance in one of three categories: (1) wholly compensatory, (2) partly compensatory, or (3) supportive-educative. The goal of nursing care is to help patients perform self-care by increasing their independence.

Orem's

________ developed a general systems framework that incorporates three levels of systems: (1) individual or personal, (2) group or interpersonal, and (3) society or social. In this theory, the nurse and the patient work together to achieve the goals in the continuous adjustment to stressors.

King

_______ Systems Model includes a holistic concept and an open-system approach. The model identifies energy resources that provide for basic survival, with lines of resistance that are activated when a stressor invades the system. The person has a normal response to stress, known as normal lines of defense, whereas a flexible line defends against unusual stress. Stressors may be intrapersonal, interpersonal, or extrapersonal. The nurse’s goal is to assist with attaining and maintaining maximum wellness, focusing on patients’ responses to stressors, and strengthening their lines of defense.

Neuman's

_______ formulated the Theory of Human Becoming by combining concepts from Martha Rogers’ Science of Unitary Human Beings with existential-phenomenologic thought. This theory looks at the person as a constantly changing being, and at nursing as a human science.

Parse

_______ theory is based on caring, with nurses dedicated to health and healing. The nurse functions to preserve the dignity and wholeness of humans in health or while peacefully dying. The caring process in a nurse–patient relationship is known as transpersonal caring and includes carative factors that satisfy human needs. The practice of nursing focuses on the goals of growth, meaning, and self-healing.

Watson's

specifies the psychological and physiologic factors that affect each person’s physical and mental health. As a non-nursing theory, it has influenced nursing theories.

Maslow's hierarchy of needs

Based on individuals’ interacting and learning about their world

Erikson's psychosocial Theory

A three-step process: unfreezing; moving or change; refreezing

Lewin's Change Theory

Nurses analyze data; develop, implement and evaluate a care plan

Paul's Critical Thinking Theory

What is the Criteria for a Profession?

- Altruism - Body of knowledge and research - accountability - higher education - autonomy - code of ethics - professional - organization - licensure - diversity

implies having the ability to function effectively within the context of the cultural beliefs, behaviors, and needs presented by patients.

culture competence

The student nurse progresses from ______ to ______ during nursing school and attains the ______ level after approximately 2 to 3 years of work experience after graduation.

novice advanced beginner competent

The two types of licensed nurses, the ____ and the ____, have different scopes of practice, but both must obtain a license to practice by passing a specific licensure examination.

LPN | RN

To obtain the ____ credential, a person must Graduate from an approved school of nursing Pass a state licensing examination called the National Council Licensure Examination for Registered Nurses (NCLEX-RN).

RN who has met advanced educational and clinical practice requirements at a minimum of a master’s degree level and provides at least some level of direct care to patient populations.

Advanced Practice Registered Nurse (APRN)

- CNM, NP, CNS, CRNA - Advanced Practice Nurses - Advanced Practice Registered Nurse (APRN) > RN who has met advanced educational and clinical practice requirements at a minimum of a master’s degree level and provides at least some level of direct care to patient populations. - Other Advanced Roles > Clinical nurse leader, nurse educator, nurse researcher, nurse administrator

Master of Science in Nursing (MSN)

______ serve six patient populations: adult-gerontology, pediatrics, neonatology, women’s health/gender related, family, and psychiatric mental health.

APRN

Nurses may pursue certifications in _____ areas after they have practiced for several years.

specialty

``` If Ming decides to choose a career as a critical care CNS, then his specialty is identified by which means? Population Setting Disease specialty Type of care Type of problem ```

``` If Ming decides to pursue a career as an APRN, which patient populations may he serve? (Select all that apply.) Adult-gerontology Prison inmates Neonatology Psychiatric mental health ```

A, C, D

``` Ming’s career options for becoming an APRN include which of the following? (Select all that apply.) Physician assistant (PA) Clinical nurse specialist (CNS) Certified nurse midwife (CNM) Certified RN anesthetist (CRNA) ```

B, C, D

In a _______ environment, gaining an understanding of what beliefs and values are, how they develop, and in what ways they shape the behaviors of both patients and nurses will help nurses to assist patients toward better health outcomes

multicultural practice

- serve as the foundation or the basis of an individual’s belief system. - Begin developing in childhood - Continue developing through adulthood - People seldom question their first-order beliefs. - Information that challenges patients’ first-order beliefs may cause emotional or cognitive upset.

First Order Beliefs

are treated as if they are always true, they are called stereotypes.

generalization

is a conceptualized depiction of a person, a group, or an event that is thought to be typical of all others in that category.

stereotype

a preformed opinion, usually an unfavorable one, about an entire group of people that is based on insufficient knowledge, irrational feelings, or inaccurate stereotypes.

prejudice

a set of somewhat consistent values and measures that are organized hierarchically into a belief system on a continuum of relative importance - helps the person choose between alternatives, resolve values conflicts, and make decisions.

value system

- In some cultures, parents may arrange marriages for their children. Because adolescents and young adults are exposed to differing values that allow for self-selection of a spouse, a values conflict that may become increasingly evident. - Pharmaceutical treatment may be rejected by individuals from some cultures based on traditional beliefs and values. Exploring the implementation of alternative or complementary therapies may help to meet patient needs while demonstrating respect.

Culture, ethnicity, and Religion

- People with disabilities note that the real problem with being disabled often is not the physical or mental condition that places limits on what they can do but rather the situation of being excluded from society and not permitted to contribute that makes them feel devalued. - Nurses demonstrate respect for patients with disabilities by including them in their care as much as possible and seeking to understand what works best for each person, rather than generalizing treatment modalities.

disabilities

- Obesity is threatening to overtake malnutrition as the most serious global health problem in both developed and developing countries. The three major contributors to obesity are genetics, food marketing practices, and reduced physical activity. Food corporations have historically exerted a major impact on the values of young people through advertising focused on fast- and processed-food consumption. - Increasing the value that people place on exercise and the consumption of fresh fruits and vegetables is the focus of worldwide strategies to reduce the incidence of obesity.

Morphology

occurs when a person’s values are inconsistent with his or her behaviors or when the person’s values are not consistent with the choices that are available.

value conflict

Patients may experience a ______ if evidence-based practice supports interventions that are inconsistent with their preferred, traditional treatment modalities.

value conflict

is a process used to help people reflect on, clarify, and prioritize personal values to increase self-awareness or to make decisions.

value clarification

- Nurses may use the _______ process to better identify their own personal values in challenging care situations. - While helping patients with _______ and care decisions, nurses must be aware of the potential influence of their professional nursing role on patient decision making.

value clarification

The most effective approach for dealing with a values conflict in which substance abuse or an addiction is involved is to begin with an ________.

assessment inteview

As nurses learn about their discipline, their _______ (or worldview) gradually changes to one: - Based on a body of knowledge that focuses on scientific principles - That dismisses as superstition other explanations for the presence of disease or illness.

paradigm

- Brief the interpreter before beginning. - Ask the interpreter to stand near the patient. - Be sure to look at the patient and not at the interpreter when speaking. - Ask the interpreter to speak to the patient in first person. - Use short sentences and stop often to allow time for the interpreter to translate - Tell the interpreter to ask for clarification if needed. - Ask the interpreter to translate everything the patient says and not to paraphrase or abbreviate. - Follow up on every detail and seemingly unconnected issues or questions the patient raises.

Guidelines for working with an Interpreter

Nursing actions for culturally congruent care:

(1) Preserving or maintaining the patient’s cultural health practices (2) Accommodating, adapting, or adjusting health care practices (3) Repatterning or restructuring some cultural practices, as needed

- ______ cultural care theory is based on the belief that nursing is a transcultural care profession and that the concept of care is at its center. - As a nurse and anthropologist, ______ found that human caring was a universal phenomenon. Within the model, three nursing actions focus on finding ways to provide culturally congruent care. - _______ model is based on a number of propositions and assumptions that relate closely to the earlier discussion of how a person’s belief system influences that person’s health beliefs. - The focus of _______ theory is entirely on the patient’s culture, almost to the exclusion of other factors such as the patient’s educational experiences, peer social groups outside the traditional cultural setting, or even the influence of media, such as television, the Internet, and social networking.

Leininger's

- According to______ , the purpose of nursing is achieved through human-to-human relationships. - The model describes steps toward “compassionate” and “empathetic” care, which is not included in other theories, making it as relevant today as it was when the theory was developed.

Travelbee

``` Five processes that characterize caring: 1. 2. 3. 4. 5. ``` - The processes are present in any caring relationship, and they can and should be enacted throughout all levels of caring and in all healing organizations and by every health care worker.

Kristen Swanson: Middle Range Theory of Caring 1. Knowing 2. Being with 3. Doing for 4. Enabling 5. Maintaining belief

- is a dysfunctional relationship in which the person who wants to help acts in a manner that enables harmful behavior by another person. - may lead to controlling behaviors exhibited by nurses that prevent patients from healing and moving toward independence.

Codependency

- Nurse’s presence - Consistency and predictability - The use of touch - Listening in the nurse–patient relationship

Behaviors that demonstrate caring in nursing

By simply being ____ in a patient’s room, nurses have the potential to calm the fears of a patient and family and demonstrate caring.

present

Provision of care that is _______ and is delivered in a _______ way can make the experience less intimidating for the patient.

consistent | predictable

Used when performing nursing interventions

task oriented touch

Used as a valuable means of nonverbal communication

caring touch

_______ is essential when considering the use of touch.

cultural sensitivity

A vital aspect of providing effective and appropriate nursing care is being able to ________ to a patient in a way that conveys understanding, sensitivity, and compassion.

actively listen

is defined as exchanging information and generating and transmitting meanings between two or more individuals.

communication

Six parts to the communication process:

- The stimulus or referent (event or thought) - The sender or source of message (encoder) - The receiver - The message itself - The medium or channel of communication (method) - The feedback (response)

- Also known as the source - The person or the group which initiates the communication - Can be verbal, electronic, over the phone or non-verbal

sender

- Also known as the decoder - The person or group receiving the communication - Must translate and interpret the message sent

receiver

- Only 10% of communication is ____. - Spoken language - Tone of voice - Volume of language - Emphasis on parts of sentence structure - Speed of speech - Fast vs. slow

Verbal

_____ (Also known as body language) - Touch - Eye Contact - Facial Expressions - Posture - Gait - Gestures - General Physical - Appearance - Dress/Grooming - Sounds - Silence

Non-verbal

What are the four levels of communication?

- Intrapersonal Communication - Small-group Communication - Organizational or public communication

What is missing in electronic communication? (5)

- tone of voice - facial expression - speed of speech - volume - gestures

Common mistakes made on Social Media:

- Posting too much information | - Inappropriate pictures

What factors affect the timing of communication to your patient?

- patient experiencing pain or anxiety - patient privacy - patient awareness/alertness

What are the components of effective nursing communication? (5)

- respect - assertivness - collaboration - delegation - advocacy

– communication allows others to control the conversation

unassertive (passive)

communication does not take power or authority away from others. It empowers individuals to speak up and be heard.

Assertive

communication occurs when power is taken away from others and communication breaks down

aggressive

What are factors affecting communication? (9)

- Prejudices - Developmental Level - Gender - Sociocultural Differences - Roles and Responsibilities - Space and Territoriality - Physical, Mental and Emotional State - Values - Environment

Good conversation skills:

- Control the tone of your voice. - Be knowledgeable about the topic of conversation. - Be flexible. - Be clear and concise. - Avoid words that might have different interpretations. - Be truthful. - Keep an open mind. - Take advantage of available opportunities

Good listening skills: (9)

- Sit when communicating with a patient. - Be alert and relaxed and take your time. - Keep the conversation as natural as possible. - Maintain eye contact if appropriate. - Use appropriate facial expressions and body gestures. - Think before responding to the patient. - Do not pretend to listen. - Listen for themes in the patient’s comments. - Use silence, therapeutic touch, and humor appropriately.

Assume all patients have these questions: (4)

What is happening to me? What will I have to do? Will it hurt? When will I have the results?

- Using clichés “Cheer up. The sun will come out tomorrow” (Are you starring in a Broadway production of Annie?) - Using Yes or No Questions only “ Did you have a good night?” (Define what good is…) - Using questions that contain why or how “Why did you decide to go on a crash diet?” (Sounds accusatory…) - Using question that probe too deeply “Let’s get to the bottom of this”. (Also known as the third degree…) - Using leading questions “You don’t smoke or drink, do you?” (Places judgment in the question….)

Nontherapeutic Comments and Questions

- Failure to perceive the patient as a human being - Failure to listen - Inappropriate comments and questions - Using clichés - Using closed questions - Using questions containing the words “why” and “how” - Using questions that probe for information - Using leading questions - Using comments that give advice - Using judgmental comments - Changing the subject - Giving false assurance - Using gossip and rumors - Using aggressive interpersonal behavior

Blocks to Communication

- hearing aids in place - adequate lighting - speaking slowly - may need to use written communication or an interpreter (for sign language)

Hearing Impaired Patients

- large-print, Braille, or audio books/educational material | - gentle physical contact

Visually Impaired Patients

-nonverbal cues (head nodding, hand squeezing)

Physically or Cognitively Impaired Patients

______ must be used in phone calls, faxes, emails, or in Internet transmission of PHI.

Privacy Standards

- is a widely used way of communicating information about a patient to other health care providers quickly and efficiently. - When done correctly, it allows communication to be clear and concise.

SBAR (Situation, Background, Assessment, Recommendation)

The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment: 1. Secured 2. Accessible 3. Confidential 4. Documented

systematic, analytic approach to finding a solution to a problem

Problem Solving

Choosing a solution or answer from among different options; often considered a step in the problem-solving process

Decision Making

- Logical thinking that links thoughts, ideas, and facts together in a meaningful way; used in scientific inquiry and problem solving

Reasoning

The result or decision related to the processes of thinking and reasoning

Judgment

The interaction of these concepts is central to the development of critical thinking: (4)

- Reflection - Evidence - Standards - Attributes or traits

is a way to improve the quality of thought processes through analysis, assessment, and reconstruction.

Critical Thinking

In nursing, _______ includes content learned in prerequisite courses (such as anatomy and nutrition), nursing-specific courses (such as pathophysiology and pharmacology), and specialty information about specific populations (such as pediatrics).

baseline knowledge

The focus of _______ collection is often based on knowledge gaps.

information gathering/data

- is instrumental in providing safe patient care. - guides delegation of tasks. - guides interdisciplinary decisions about discharge planning, end-of-life decisions, and other ethical issues. - guides preoperative plans of care. - guides communication and promotes team-oriented decision making. - supports positive patient outcomes.

Critical Thinking

- The results of deliberate thinking are used to guide further thinking. - The ability to engage in reflection about and during practice and to make changes in practice based on the - is the hallmark of an experienced practitioner. - is an effective tool that enables students and nurses to think about how best to improve their future caregiving in similar situations.

Reflection

- Identification and use of evidence is necessary to guide analysis of situations and decision making. - Nursing practice must be based on _____ gained through research and review of findings.

Evidence

- Critical thinking needs to be assessed and evaluated according to standards to ensure the quality of thinking. - Nursing practice is based on ______ established by the American Nurses Association in areas such as the nursing process, ethics, education, research, communication, leadership, and collaboration.

Standards

- Personal characteristics associated with critical thinking, including fairness, responsibility, and empathy, are examples of _____ that contribute to a nurse’s ability to think critically while providing safe patient care.

Attributes or traits

is characterized by accuracy, self-reflection, clarity, and soundness. Effective critical thinking depends on specific components such as a knowledge base, reasoning, inference, validation, and attitudes that promote learning.

critical thinking

Nursing curricula are filled with content, and there have been suggestions that ________ exists in many nursing programs.

Content saturation

Optimal patient management requires _______ and _______ with all disciplines involved in the patient’s care.

critical thinking and collaboration

is used by the registered nurse to guide decisions related to delegation of assignments and tasks.

Critical thinking

______ and _______ promote team-oriented decision making that supports positive patient outcomes.

communication and collaboration

logical thinking that links thoughts in meaningful ways.

Reasoning

uses specific facts or details to make conclusions and generalizations; it proceeds from specific to general.

inductive reasoning

involves generating facts or details from a major theory, generalization, or premise (i.e., from general to specific).

Deductive reasoning

intellectual acts that involve a conclusion being made on the basis of something else

inferences

The feeling that you know something without specific evidence

intuition

Examination of how information is organized and given meaning Differs from facts and evidence Is based on personal concept, experience, perspective

Interpretation

The process of gathering information to determine whether the information or data collected are factual and true To find support for findings or data Ensuring competence of nurses

Validation

_______ data are often validated with ______ data; for instance, a patient complains of severe itching, and the nurse validates this subjective finding when observing scratch marks and a rash.

subjective | objective

Attitudes Necessary for Critical Thinking: - _________: feeling certain about one’s ability to accomplish a goal - ________: considering a wide range of ideas before coming to a conclusion - _______: avoiding bias or prejudice and dealing with a situation in a just manner - _______: admitting one’s limitations - _______: being willing to try new ideas - ______: following orderly thinking to do what is best - _______: staying determined to work until the goal is achieved - _______: formulating new ideas and alternative approaches - _______: being motivated to achieve and asking why - _______: being honest and willing to adhere to principles in the face of adversity - _______: acting on sound knowledge and acknowledging actions as one’s own

Confidence Thinking Independently Fairness Humility Risk Taking Discipline Perseverance Creativity Integrity Responsibility and Accountability

Nurses use this skill to understand and explain the meaning of data. Drawing on knowledge of theory and application, the nurse uses interpretative skills to consider possible causes and implications of observed data, events, and actions.

interpretation

Investigating plans of action on the basis of examination of subjective and objective data is an example of nursing analysis. Considering the advantages, disadvantages, and consequences of all possibilities, nurses determine appropriate explanations or actions.

Analysis

Relevance is important in the evaluation of new information. Nurses also evaluate when determining whether the desired outcome for an intervention was achieved.

Evaluation

Critical thinkers skilled in inference make accurate conclusions that are based on sound reasoning. Nurses gather relevant baseline data and compare them with other information, such as admitting diagnoses, medical history, and knowledge of disease processes, to make inferences.

inferences

The ability to explain conclusions is an important critical-thinking skill.

explanation

Similar to reflection, ______ requires monitoring of thinking, with specific emphasis on reflecting on the rationale for the conclusion drawn and action taken.

self-regulation

For nurses, the consistent use of the essential skills of critical thinking guides this

clinical decision making

Thinking errors to avoid: (5)

``` Bias = a tendency to favoritism or partiality Illogical thinking Lack of information Closed-mindedness Erroneous assumptions ```

- Asking questions for clarification before implementing patient care is essential to ensuring patient safety and providing patient-centered care! - Actively listening to patients enhances a nurse’s ability to communicate patient needs, values, and preferences to other members of the health care team.

Erroneous assumptions

are available for point-of-care, hand-held devices and in the health care facility electronic health record.

references

``` Discussion with colleagues Audible verbalization of thoughts Literature review Intentional application of knowledge Concept maps Simulation Role playing Written work ```

Methods for improving critical thinking skills

is a teaching–learning strategy that has been linked with improved critical-thinking skills

concept mapping

Defined as-”freedom from danger, harm or risk”.

safety

is a responsibility for all healthcare providers to think/know in relation to caring for the patient and themselves.

safety

Locations where safety is a concern for nurses: (6)

- Hospital - Home - Community - Workplace - Home health care - Long term & short term post hospital care

- Ability to Communicate - Physical Health State - Psychosocial Health State - Developmental age of the person - Lifestyle > Occupation > Social Behavior > Environment - Mobility - Sensory Perception - Knowledge

Factors Affecting Safety

- Fall risk - Choking - Abuse - MVA accidents - Poisoning - Suffocation

Safety Concerns of Infants

- Accidents r/t MVA or other recreational vehicles - Abuse - Suicide - Potential for drug or ETOH abuse/overdose - STD (sexually transmitted disease

Safety Concerns of adolescents

- Occupation hazards - Accidents r/t MVA or recreational vehicles - Environmental hazards - Drug or ETOH abuse or overdose - Suicide

Safety Concerns for Working Adults

- Fall risk - Accidental overdose - Abuse - Suicide - Fire at home

Safety Concerns for Elderly

- Prevent accidents. - Orient person to surroundings (avoid falls). - Maintain vehicle in working order, schedule eye exams, and keep noise at a minimum. - Promote safe environment at home (avoid fires). - Use medication trays (avoid poisoning).

Safety Considerations for Older Adults

- Age >65 - History of falls - Impaired vision or balance - Altered gait or posture, impaired mobility - Medication regimen - Postural hypotension - Slowed reaction time; weakness, frailty - Confusion or disorientation - Unfamiliar environment

Factors that Contribute to Falls

- Terrorism - Bio-Terrorism - Natural disasters - Tornado - Hurricanes - Earthquakes *Educate the community to prevent injuries

Safety in the Community

- determines, develops, and monitors safe practices for each industry. - Ergonomic program - Injury and Illness prevention program - Hazard communication program - Exposure control plan

The Occupational Safety and Health Administration (OSHA)

- Independent, not-for-profit organization - Accredits more than 20,500 health care organizations and programs in the United States. - Accreditation recognized nationwide and reflects an organization’s commitment to meeting excellent performance standards. - The vision: “All people always experience the safest, highest quality, best value health care across all settings” - Scheduled or surprise visits to facilities (on-site surveys at least every 3 years; can be more often if there is any reason for them to re-evaluate)

The Joint Commission (TJC)

- used in hospitals to alert hospital staff of possible emergencies using as few words as possible - color coded-red, blue, yellow, pink, etc.

Codes

used in hospitals to alert hospital staff of possible dangers to that particular patient -color coded- red, yellow, purple, etc.

Armbands

- The systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients - The framework within which nurses provide care to patients in an organized and effective manner

nursing process

Thinking like a nurse is facilitated by nurses using the_____ in the development of individualized patient plans of care.

nursing process

- Can be handwritten or be part of the electronic medical record - Often incorporate aspects of multidisciplinary clinical pathways - Following the steps of the nursing process helps nurses to provide patient care that meets standards required by state boards of nursing and guided by the American Nurses Association’s Nursing: Scope and Standards of Practice.

Care Plans

- Is the data collection thorough and accurate? - Are outcomes specific and realistic for the individual patient? - Have all of the underlying factors contributing to the patient’s response to illness been adequately addressed in the plan of care? - Could any of the nursing interventions have a negative impact on the patient? - Does each intervention provide for patient-centered care and the safety of the patient? - Are there new data that necessitate modification of the existing plan of care?

Critical Thinking in the Nursing Process

Gathered patient care data through observation, interviews, and physical assessment.

Assessment

Analyze, validate, and cluster patient data to identify patient problems

Diagnoses

Prioritize the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes

Planning

Initiate specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes.

Implementation

Determine whether the patient’s goals are met, examine the effectiveness of interventions, and decide whether the plan of care should be discontinued, continued, or revised.

Evaluation

is the organized and ongoing appraisal of a patient’s well-being.

assessment

(NANDA-I) identifies an actual or potential problem or response to a problem.

Nursing diagnosis

(1) The patient’s identified need or (p)roblem (2) The (e)tiology or underlying cause (3) Signs and (s)ymptoms PES

Actual Nursing Diagnosis

(1) The patient’s identified need or problem | (2) Factors indicating vulnerability

Risk Nursing Diagnosis

(1) The nursing diagnostic label | (2) Defining characteristics

Health Promotion Nursing Diagnosis

- the nurse prioritizes a patient’s various nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals. - Goals: Patient-focused Realistic Measurable

Planning

involves listing behaviors or observable items that indicate attainment of a goal.

Outcome identification

step of the nursing process focuses on initiation of appropriate interventions designed to meet the unique needs of each patient.

implementation

Written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician’s order.

protocals

- multidisciplinary resources to guide patient care | - Independent, dependent, direct, and indirect interventions are listed in the critical pathway.

Clinical Pathways

- All health care professionals are required to _____ patient interventions they implement in a traditional or an electronic medical record. - Nurses must _____ the physical treatment and patient education that is provided. - Ethical and legal standards mandate that nurses ______ only the interventions that they themselves implement.

document

focuses on the patient and the patient’s response to nursing interventions and goal or outcome attainment.

evaluation

- One aspect of care leads into and informs the next. - It is crucial that the professional nurse continuously reassess the patient, revise care as needed, and evaluate whether the patient’s goals are being met. - The ongoing process of evaluating and adjusting intervention strategies requires nursing care to be based on current evidence.

Cyclic and Dynamic Natur of the Nursing Process

-Begins with first observation - Includes information and attributes - Data are: > Analyzed > Validated > Organized > Documented

Components of Assessment

All significant ______ should be documented and verified for accuracy during the interview phase of assessment.

observation

- Orientation Phase - Working Phase > Health History > Review of Systems - Termination Phase

Patient Interview

``` - Includes all information that can guide the development of a patient-centered plan of care: > Chief complaint or reason for seeking health care > History of current illness > Allergies > Medications and adverse reactions > Medical history > Family and social history > Health promotion practices ```

Health History

- Nurse collects subjective information. - Questions asked during the review of systems usually are brief and inquire about the normal function of each body system. - Any deviation from normal triggers more directive questions and affects the physical assessment. - After the collection of data, goals for care are established during the working phase in collaboration with the patient.

Review of Systems

Prior to initiating patient ______, the nurse needs to assess a patient’s cognitive ability, reading level, and potential language barriers.

education

Assessment should include collecting information about what the patient ______ about her or his current condition and what additional knowledge is needed.

already knows

Assessment information about the patient’s educational needs should be _____ and should guide aspects of the patient’s individualized plan of care.

documented

- Review diagnostic test results - Ensure privacy and good lighting - Gather equipment and instruments - Perform hand hygiene - Collect objective data by: > Collecting vital signs > Inspection > Palpation > Percussion > Auscultation

Physical Assessment

______ of patients requiring critical care cannot be delegated to unlicensed assistive personnel (UAP).

initial and ongoing assessment

- Thorough interview - Health history - Review of systems - Extensive physical head-to-toe assessment - Often include lab and diagnostic tests > Cranial nerve evaluation > Sensory organ evaluation

Comprehensive Assessment

``` - A brief individualized PE is conducted: > At the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern > When signs indicate a change in a patient’s condition or development of a complication - Vital signs, pain level, pulse oximetry - The nurse examines the head, eyes, ears, nose, throat, neck, thorax, abdomen, and extremities. ```

Focused Assessment

``` Perform when: - Time is a factor. - Treatment must begin immediately. - Priorities for care need to be established in a few seconds or minutes. Patient treatment is based on: - A quick survey of accident or illness onset. - (Followed by) a narrowly focused physical exam of critical injuries or symptoms and signs. ```

Emergency Assessment

a form of emergency assessment

triage

Requires immediate and continuous care

critical

requires care within 30 min

emergent

- requires care within 30-60 min. | - potentially life threatening

urgent

- requires care with 60-120 min. | - stable health condition

non-urgent

- requires care when possible | - less urgent

fast track

Come directly form patient

primary data

- from family member, friends, of health care team | - from patient's chart

Secondary data

is making sure that the data are accurate.

validating data

is a hint or an indication of a potential disease process or disorder.

cue

All ____ need to be interpreted and validated to verify the data’s accuracy.

cues

are conclusions based on the nurse’s personal preferences, past experiences, generalizations, or outdated and inaccurate health care information.

inaccurate inferences

Accurate interpretation of patient data requires that the nurse have a wide breadth of knowledge, including disease processes, vital sign parameters, and normal values and outcomes for laboratory and diagnostic tests.

accurate

After the patient’s data are collected, validated, and interpreted, the nurse organizes the information in a ______ (format) that facilitates access by all members of the health care team.

framework

Focus on the physical aspects of a patient’s condition rather than a more holistic view.

Body systems model

Factual and complete documentation facilitates _____ care that is responsive to patient needs.

comprehensive

is essential to the overall effectiveness of every patient-centered plan of care.

accurate assessment

Nurses must develop excellent ______ skills to accurately aid in appropriate diagnosis and treatment of their patients

assessment

the identification of actual or potential health problems or life processes and responses to a problem, follows assessment in the nursing process.

nursing diagnosis

Identification of correct nursing diagnoses depends on: | 4

- Accurate collection - Accurate validation - Accurate analysis - Accurate clustering of patient data

Use of the ______ maintains focus on the patient; the patient’s needs, potential concerns, and/or response to situations.

nursing process

Proper identification and articulation of nursing diagnoses guide the dynamic ______.

nursing process

______ in patient status and life experiences require the addition, modification, and discontinuation of nursing diagnoses on the basis of nursing judgment and evidence-based research findings.

changes

Identify and label medical illnesses - Physical - Psychological

Medical diagnoses

- Broader in focus - Consider patient’s response > To medical diagnoses > To life situations - Make clinical judgments > Based on medical diagnoses and conditions

Nursing Diagnoses

- First unofficial conference 1973 - Guided by physician’s orders and directed at medical signs and symptoms - Cycle of Revision = Every 2 years > Diagnoses are evaluated according to how well they are: * Developed * Supported by research > Diagnoses are developed through comprehensive research and data collection

NANDA-I

Describe the response of a patient to a current need, problem, or life process

Actual Nursing Diagnosis

Used to identify specific potential problems of individuals vulnerable to developing complications resulting from their current disease state or life experience

Risk nursing diagnosis

Clinical judgments based on the expressed desire of patients, families, or groups for change

Health promotion Nursing Diagnosis

A diagnosis label Related factors Defining characteristics

Actual nursing DX statements

``` A diagnosis label Risk factors (or related factors) ```

Risk nursing DX

A diagnosis label | Defining characteristics

Health promotion nursing DX

is a concise term or phrase that represents a pattern of related, clustered data.

diagnosis label

are the underlying cause or etiology of a patient’s problem.

related factors

are cues or clusters of related assessment data that are signs, symptoms, or indications of an actual or health-promotion nursing diagnosis.

defining characteristics

_____ patient information should be considered as potentially contributing to the identification of diagnostic labels.

All

- Check the diagnostic able against the official NANDA-I list - Write the statement to address the highest priority needs of the patient - Be sure the statements are based on assessment data of the patient

Diagnostic validity

- life span - culture, ethnicity, and religion - disability - morphology

Diversity considerations

_____ nursing diagnostic statements lead to accurate development of individualized plans of care

clear

begins by prioritizing nursing diagnoses.

Planning phase

Complete assessment data and concise nursing diagnoses affect _______.

patient care outcomes

The nurse’s ability to ____________ expressed through nursing diagnosis statements is essential for establishing realistic outcome criteria and interventions to help meet them.

prioritize patient needs

Involving patients in planning helps them to: (3)

(1) Be aware of identified needs, (2) Accept realistic and measurable goals, and (3) Embrace interventions to best achieve the mutually agreed-on goals. Inclusion of patients in the planning process tends to improve goal attainment and patient cooperation with interventions.

Setting _____ is the first step in planning

priorities

The nurse is responsible for the during prioritizing needs: (3)

- Monitoring patient responses - Making decisions culminating in a plan of care - Implementing interventions, including interdisciplinary collaboration and referral, as needed

Use to organize most-urgent to less-urgent needs. | Basic, physiologic needs must be met before higher needs, such as self-esteem.

Maslow's Hierarchy of needs

Nurse–patient collaboration in the goal-setting process can help to alleviate the incidence of _______.

conflicting priorites

achievable in less than 1 week

short term goals

weeks or months to achieve

long term goals

Acceptable to nurse, patient, and family Appropriate in nursing and medical diagnosis and therapy Realistic for patient capabilities Specific, measurable, and understood by patient and other nurses

Effective goals

Consider patient’s conditions and resources | Physical, mental, spiritual, economic

realistic goals

Written for the patient, to reflect patient activities

patient centered

Specific, with concrete methods of judging attainment

measurable goals

Include a time for evaluation

Time-limit goals

standardized vocabulary used for describing patient outcomes

Nursing Outcomes Clissification

“an individual, family, or community state, behavior, or perception that is measured along a continuum in response to nursing interventions.”

outcomes

are criteria by which goal attainment is observed or measured.

Outcome indicators

``` All formats contain areas in which the nurse identifies: Key assessment data Nursing diagnostic statements Goals Interventions for care Evaluation of outcomes ```

care plan development

a comprehensive, research-based, standardized collection of interventions and associated activities.

Nursing interventions classification

The nurse incorporates orders from health care providers into the patient’s overall care plan by associating each with the appropriate nursing diagnosis.

dependent nursing interventions

complement independent nursing interventions to more fully address patient needs.

dependent interventions

Require cooperation among a few or many health care professionals and unlicensed assistive personnel (UAP). Include physical therapy, home health care, personal care, spiritual counseling, medication reconciliation, and palliative or hospice care. Care planning cannot be delegated to a UAP.

Collaborative interventions

Nursing Interventions Classification (NIC) = a comprehensive, research-based, standardized collection of interventions and associated activities. Provides multidisciplinary interventions linked to each NANDA-I nursing diagnosis and a corresponding NOC Includes associated activities that nurses do on behalf of patients, independent and collaborative interventions, and direct and indirect care.

Independent Nursing interventions

Seamless __________ throughout a patient’s care ensures continuity of treatment and improved patient outcomes.

communication

plays an important role in the success of a patient’s transition to the home setting after hospitalization.

discharge planning

Discharge information should include: (4)

Medical information Patient goals Interventions to accelerate recovery Interventions to provide needed care

Inadequate discharge planning may lead to:

An increase in patients returning to the hospital More frequent emergency room encounters Adverse events

consists of performing a task and documentation of each intervention.

implementation

refers to interventions that are carried out by having personal contact with patients. Some must be carried out by the RN; others may be delegated.

direct care

``` nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients. Communication and collaboration Referrals Research Advocacy Delegation Prevention-oriented interventions ```

Indirect care

``` Reassessment Activities of daily living Physical care Informal counseling Teaching ```

Direct Care

Educating patients regarding their role in monitoring _______ by health care workers can increase compliance and reduce hospital-acquired infections.

handwashing

: tasks within the nursing scope of practice that the nurse may undertake without a physician or primary care provider (PCP) order.

Independent nursing interventions

tasks the nurse undertakes that are within the nursing scope of practice but require the order of a PCP to be implemented. - standing orders - medication administration - medical treatment

Dependent Nursing interventions

Must be accurate for communication to other providers. Most often is charted in the patients EHR and flow sheets per agency policy. Should be completed in a timely and professional manner.

documentation

Final step in nursing process Focuses on the patient and the patient’s response to nursing interventions and outcome attainment Use patient outcomes to judge success

evaluation

_______ begins when determining whether patient goals have been met. ________ examines how interventions affected patient outcomes. Ideally _______ will show positive patient outcomes. Often, though, patient’s goals are unmet, requiring a revision of the care plan.

evaluation

occurs with each patient–nurse interaction.

reassesment

As _____ in a patient’s condition occur, the plan of care should be revised.

changes

When a patient ____ is unmet or partially met, the plan of care may need to be revised or adapted.

goal

_____ of a patient goal or outcome may be positive when the patient’s goal is met and the problem resolved.When this happens, the nurse needs to determine whether the patient’s plan of care should be continued to support sustained or greater improvement or should be discontinued.

evaluation

Reasons to discontinue the plan of care: - -

- goal attainment | - changing circumstances

_____ goals sometimes emerge through the reflection process.

high priority

Should be updated regularly after patient evaluations Part of the ongoing, dynamic, cyclic nursing process Adapts to patient’s health status Modified because of changes in patient condition: Deterioration improvement

Care Plan Modification

a formal way to look at patient and treatment outcomes and to determine what can be done differently to affect a situation in a positive way.

Quality Improvement (QI)