Exam 1 Review Flashcards
A national organization that sets the practice and ethical standards for nurses is…
American Nurses Association
What does QSEN stand for?
Quality and Safety Education for Nurses
Which nurse theorist focused on the patients needs and is an example of nursing skills? (Needs theory)
Virginia Henderson
Developing professional identity is a process requiring experience, learning, and reflection. According to Benner’s theory “from novice to expert” a nurse who has been in the same clinical position for 2-3 years is considered:
Competent
As a student nurse in the skills labs, which attribute of professional identity are you demonstrating?
Doing
The professional identity attribute of _____ is demonstrated by adopting the attitudes and behaviors that reflect the value of how a professional thinks, feels , and acts.
Being
Nursing is defined as a profession because nurses…
Practice autonomy
The professional nurse is an advocate for..
Themselves and their peers
The profession
The patient
The nurse notices that she has missed giving a scheduled medication. She immediately reports this to the provider for updated orders regarding the medication. According to professional identity this is known as:
Accountability
Autonomy
The authority to make decisions related to nursing practice.
Knowledge
The synthesis of theory, evidence, and practical application.
Competence
The knowledge, skills, and abilities necessary for the practice setting.
Professionhood
The development of professional nursing, preparing for nursing practice.
Accountability
The assuming of responsibility for one’s own nursing practice.
Advocacy
The support and defense of the healthcare participant.
Collaborative Practice
The integration of nursing with other disciplines to provide holistic care.
Commitment
The altruistic dedication to all aspects of the nursing profession.
Florence Nightgale
Environmental theory. it involves the nurse’s initiative to configure environmental settings appropriate for the gradual restoration of the patient’s health.
Benner
Created the stages for nursing proficiency
Humility
When a person demonstrates humility, he or she views the world with equanimity, taking neither an overstated amount of credit nor blame for a particular situation
Courage
(1) to affect change, and (2) “to stand in opposition for moral rightness.” Courage can also be categorized as physical or moral.
Doing
Performing any kind of skill.
Strong focus on external expectations and tasks.
Being
- Personal or psychological view of the professional nurse. Explains what it means to do the right thing even when no one is looking.
- Adopting attitudes and behaviors that reflect the value of how a professional thinks, feels, and acts.
- May incorporate rules and principles, but is beyond the laws, codes, and standards within the discipline or society.
Acting ethically
- Live accordingly your principles
- Being attentive to what is considered right and good from both a societal and professional perspective.
Flourishing
A transformational or human flourishing perspective is necessary for professional identity to move past the initial phases of formation.
Changing identities
Reworking of a person’s identity.
The student nurse graduates and is now an R.N.
Novice
Beginning nursing student or any nurse entering a situation in which there is no previous level of experience.
Advanced Beginner
A nurse who has had some level of experience with the situation. This experience may be only observational in nature, but the nurse is able to identify meaningful aspects or principles of nursing care.
Competent
A nurse who has been in the same clinical position for 2 to 3 years. This nurse understands the organization and specific care required by the type of patients. Is able to anticipate nursing care and establish long-range goals.
Proficient
A nurse with more than 2 to 3 years of experience in the same clinical position. Perceives a patient’s clinical situation as a whole, is able to assess an entire situation, and can readily transfer knowledge gained from multiple previous experiences to a situation. Managing care.
Expert
A nurse with diverse experience who has an intuitive grasp of an existing or potential clinical problem. Is able to zero in on the problem and focus on multiple dimensions of the situation.
Clinical decision making requires the nurse to..
Establish and weigh criteria in deciding the best choice of therapy for a patient.
Critical thinking (is):
involves the application of knowledge and experience to identify problems.
Clinical judgment (is):
A decision or opinion you make after analyzing information.
Clinical reasoning
uses critical thinking, knowledge, & experience to develop solutions to patient problems & make decisions in a clinical setting.
What does ADPIE stand for..
Assessing
Diagnosis
Planning
Implementing
Evaluation
Assessing
The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation.
Diagnosis
The registered nurse analyzes the assessment data to determine the actual or potential diagnoses, problems, and issues.
Identification
The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
Planning
The registered nurse develops a plan encompassing strategies to achieve expected outcomes.
Implementation
The registered nurse coordinates care delivery.
The registered nurse employs strategies to teach and promote health and wellness.
Evaluation
The registered nurse evaluates progress toward attainment of goals and outcomes.
What is SMART goals?
Specific—Outcomes reflect a specific patient behavior or response.
Measurable—You must be able to measure or observe whether a change takes place in a patient’s status.
Attainable—Outcomes are more achievable when you mutually set them with a patient.
Realistic—Set expected outcomes that are realistic and relevant for patients.
Timed—Set a time for each outcome to be met.
Sources of data
Patient, family/ caregiver, health care team, medical records, other records, and nurse experiences.
Subjective data
are your patients’ verbal descriptions of their health problems gathered during interviews (informal and formal). It includes patient feelings, perceptions, and self-reported symptoms.
Objective data
Are the findings resulting from observation of patient behavior and clinical signs as well as direct measurement, including what you see, hear, and touch.
Maslow’s Hierarchy of needs
- Physiological needs—Life-threatening problems (or risk factors) posing a threat to physiological needs (e.g., problems with breathing, circulation, nutrition, hydration, elimination, temperature regulation, physical comfort)
- Safety and security—Problems (or risk factors) posing a threat to safety and security (e.g., environmental hazards, fear)
- Love and belonging—Problems (or risk factors) posing a threat to feeling loved and a part of something (e.g., isolation or loss of a loved one)
- Self-esteem—Problems (or risk factors) posing a threat to self-esteem (e.g., inability to perform normal activities)
- Personal goals—Problems (or risk factors) posing a threat to the ability to achieve personal goals
Steps for Setting Priorities
1.Assign high priority to first-level priority problems (immediate priorities): Remember “ABCs plus V and L” as listed next.
Airway problems
Breathing problems
Cardiac and circulation problems
+
Vital signs concerns (e.g., fever, hypertension, hypotension)
Lab values that are life threatening (e.g., low blood sugar)
2.Attend to second-level priority problems:
•Mental status change (e.g., confusion, decreased alertness)
•Medical problems requiring immediate attention (e.g., a diabetic who hasn’t had insulin)
•Pain
•Urinary elimination problems
3.Address third-level priority problems (later priorities):
•Health problems that don’t fit into the earlier categories (e.g., problems with lack of knowledge, activity, rest, family coping)
The nursing process is an example of this type of problem-solving process.
Scientific problem solving
Critical thinking often involves scientific problem solving, but it also involves intuition, logic, and creative thinking.
True
Assessment is the first step in the nursing process and always involves gathering data.
True
Data can be obtained from the patient, family, or other sources as well as from the physical examination.
True
During the evaluation phase, the nurse reviews the patient’s outcome attainment and determines if outcomes have been meet.
True
Evidence interpretation is more associated with the diagnosing phase.
True
What statement best conveys the role of intuition in nurses’ problem solving?
Intuition can be clinically useful adjunct to logical problem solving.
When the nurse assesses the client’s blood glucose level, what is the term for the type of skill the nurse is using?
Technical
What is critical thinking in nursing?
It is a systematic way of thinking.
A nurse is working on developing higher-level reflection skills. Which activity would the nurse most likely be engaging?
Reevaluating experience in light of ideas
Which action exemplifies the purpose of evaluation in the nursing process?
Decide whether to continue, modify, or terminate client care.
A comprehensive assessment resulting in baseline data used to judge pt ability to care for one’s self.
Initial assessment
Assessment of pertinent history and body regions; may also be used to address the immediate as highest priority.
Focused assessment
Family members can be used as interpreters if a professional one is not available
False
Symptoms and covert data
Subjective data
Signs or overt data
Objective data
Data from patients with limited mental or communication capacity can be relied on as accurate.
False
Nurses are responsible for alerting the health care professional whenever assessment data defer significantly from BL.
True
During the interview component of the assessment, how does the nurse convey that the information is important?
Sitting at eye level with the client
A nurse caring for a patient with acute abdominal pain, formulates the care plan. Which is the priority nursing diagnosis?
Impaired comfort.
A client is admitted reporting SOB, wheezing, and coughing. What is an appropriate nursing diagnosis?
Innefective airway clearance
The nurse is aware that nursing diagnosis are:
Within the nursing scope of practice to develop and client-focused.
Which examples of client care are the responsibility of the nurse?
Tailoring treatment and medication regimens for each individual
Promoting safety and preventing harm; detecting and controlling risks
Monitor for changes in health status
The nurse recognizes that identifying outcomes/goals must include:
Involvement of the client and family
When should the nurse begin discharge planning?
On the client’s admission to the hospital
What is true of nursing responsibilities with regard to a physician-initiated intervention? (Physician’s orders)
Nurses do carry out interventions in response to physician’s order.
Which authoritative statements guide current professional nursing practice?
American Nurses Association Standards of Nursing Practice
The joint commission is conducting an accreditation visit. What is the focus of the evaluation being conducted?
Quality assurance
Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of:
Physical changes
Which organization audits charts regularly?
The joint commission
Which intervention is an example of primary prevention?
Administering a MMR immunization to an infant
Which client has a greater risk for latex allergies?
A woman who is admitted for her 7th surgery
A nurse is developing a nursing diagnosis for a client. Which information should be included?
Factors influencing client’s condition
Based on Maslow’s hierarchy of needs, which nursing diagnosis has the highest priority?
Risk of aspiration
During the assessment phase of the nursing process, the nurse..
Gathers, organizes, and documents data in logical database
Once the nursing plan has been initiated, the nursing care plan will:
Change as the patient’s condition changes
Subjective data includes:
Patient’s feelings, perceptions, and reported symptoms.
The critical thinking skill of evaluation in nursing practice can be best described as:
Reviewing the effectiveness of nursing action.
The nursing student can best develop critical thinking skills by doing what?
Actively participating in all clinical experiences.
The order in which the nursing process is approached is:
Assessment, diagnosis, planning, implementation, evaluation.
To get info about a pt’s home/work surroundings, which method of data collection will be used?
Perform a thorough nursing health history.
When a pt complains of nausea and dizziness, the RN recognizes their complains as ________ data.
Subjective
Which intervention depends almost entirely on the client’s adhering to the therapy?
Following a low-fat, low-calorie diet.
What exemplifies the most basic motivation in Maslow’s hierarchy of needs?
Having adequate housing.
What is an example of active listening behavior?
Leaning toward the patient
What is an example of an open-ended question?
What happens when you have a headache?
What is an example of a problem that nurses can treat independently?
Nausea
A nursing diagnosis:
Identifies a client’s health problem.
Who is the primary decision maker when caring for healthy adult clients?
Client
The nurse performing an admission interview on an elderly person should:
Allow more time for a response to question.
The nurse knows that the difference between a sign and symptom is that a sign:
Can be verified by examination.
The nurse clarifies that nursing orders are also called:
Interventions
What is an important consideration when developing a care plan?
Ensure that the patient is involved in the process
What is an example of objective data?
The patient is short of breath on exertion
What is an example of nursing Diagnosis?
Impaired skin integrity
What is an example of medical diagnosis?
Pneumonia
What is the basis of nursing practice?
Identify physiologic and psychologic needs of the patient.
What is a statement about the patient plan of care?
It’s continually reviewed and evaluated
Which nursing diagnosis would an RN prioritize?
Ineffective airway clearance
Example of nursing order:
Perform deep breathing exercises at 1000 and 1400 each day.
Which statements are included in the characteristics of critical thinking?
Interpretation, analysis, and evaluation.
The purpose of obtaining a nursing history is to:
Identify actual and potential nursing diagnoses.
The primary purpose of nursing implementation is to:
Help the patient achieve optimal levels of health.
The planning step of the nursing process includes:
Setting goals and selecting interventions.
Physiological changes related to aging place an older adult at risk for a nursing diagnosis?
Risk for fall
Secondary sources of information:
Medical record
Physician
Spouse or close relative
For clients to participate in goal setting, they should be:
Alert and have some degree of independence
The nurse writes an expected outcome statement in measurable terms. An example is:
Pt will report pain less than 4 on a scale 0-10.
