Exam 2 Flashcards
What is the purpose of the assessment phase in clinical judgement?
Obtain data which will help identify patient’s strengths and weaknesses
During the critical thinking skill of evaluation what action will the nurse take?
Review the effectiveness of nursing actions.
A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the nurses best response?
Conduct a root cause analysis.
The quality and safety education of nurses (QSEN) specifies knowledge, skills, attitudes as goals for students. What attitudes are important?
Respect for others, scope of practice, integrity, and accountability.
Controlling pain is important to promoting wellness. What PHYSIOLOGICAL effect is associated with un-relieved pain?
Prolonged stress response.
A nurse is assessing a patient who states their experiencing awful abdominal pain and rates their pain a 9/10. What would be PHYSIOLOGICAL signs that support this?
Increased BP, Tachycardia, and sweating.
Self-reports of chronic pain are considered to be what?
The GOLD STANDARD
A 4-year-old is demonstrating signs of pain, The best technique to deal with the pain is to what?
Use the FACES scale.
What statement demonstrates that a patient understands the gate control theory of pain?
Medication controls pain by blocking pain impulses from coming through the gate.
If your helping a patient to the bathroom and they begin to fall 5 feet from the bed, what is your best next action?
Gently lower the patient to the floor.
A nurse is assessing a student who is performing a c peripheral assessment, at what point would a nurse intervene?
Assessing Homer’s sign of bilateral extremities.
What is the best method for a chair transfer
The best method is to position the chair at the head of the bed, facing the patients strong leg, close to the bed.
When administering a oral antibiotic to a patient who stepped on something sharp at his home what should the nurse ask before administering the medication?
D you have any allergies to medication?
Nurse is perparing to lift a patient from a bed to a mobile stretcher, what is the best technique to reduce the risk of injury?
Have the patient help as much as possible, raise the bed to the level of the nurse, use friction reducing sheets, and use a lifting device to help lift and move the patient.
Nurse completes an assessment and notices a patient has right sided weakness, slurred speech, and dysphasia. What is the priority in a plan of care.
Aspiration should be the nurses first plan of care.
Action to prevent aspiration?
Elevate the head of the bed to 45 degrees.
Therapist determined that dysphagia precautions are needed and writes a prescription for a pureed diet + honey thickened liquids. What instruction should the nurse provide to the UAP is to..
Bathe the patient first and then place the patient in the high flowers position.
A nurse is assessing the patients functional ability related to nutrition. What is the best way to assess functional ability.
See if the patient can feed herself with her left hand.
To ensure the patient is receiving adequate nutrition the nurse should?
Obtain and record weekly weight.
A patient is 110 pounds and is 170 cm/tall and eats 700 calories a day. What can the nurse conclude about the patients calorie consumption?
The patients calorie consumption is inefficient and will result in weight loss.
What is a good way to fuck up during this exam?
Rush through it
If a family member says the patient enjoys applesauce what is your best response as a nurse?
Offer apple sauce since the patient likes it along with other high calorie snacks
A woman visits the pain clinic and complains of back pain radiating as a 6/10 on the pain scale. She also states that the pain is bad that she can’t take care of her two children. What is the best question to assess the quality of the women’s pain?
How would you describe your pain?
After completing a pain assessment what is the next step by the nurse before implementing any interventions?
Discuss the plan of care with the patient and seek out client input.
What could a nurse suggest as a common NSAID?
Ibuprofen
When a nurse is guiding a patient with a guided imagery exercise, what shoiuld the nurse implement to make the exercise the most effective?
Include as many sensory images as possible
A patient has continued urinary incontinence and has an order placed for an external catheter. What intervention is most appropriate for the nurse to include?
Assess the patient genitals for signs of skin breakdown.
A patient is experiencing restlessness, pain, and has not urinated since the foley catheter has been inserted. What is the next assessment the nurse should make?
Evaluate the urinary drainage tube.
After removing the foley catheter the morning before the patient is discharged, what would warrant intervention?
If the patient has not urinated in 8 hours or less after removal of the catheter.
Is it the nurses responsibility to report any missing narcotics that go missing in the patient care area.
YES
A patient reports to the nurse that shes afraid to speak up regarding a desire to end care for her fear of ethics upsetting her spouse. What principle ensures the nurse will promote the patient needs.
Advocacy
The nurse believes in autonomy above all other principles. What would be an assignment that the nurse would find most difficult to accept?
A family elder who is making decisions for a young family member.
A nurse posts a picture of a patient’s injury on social media without the patients permission. What did the nurse violate?
The nurse violated the ANA code of ethics by not practicing with respect for the inherent dignity and worth of their patient.
Why is it when nurses work together on an ethical dilemma, they should both examine their own beliefs?
So that all perspectives are respected
What is a major attribute of health care law?
It defines the expected behavior of people in the business of healthcare.
What is the definition of durable power of attorney in health care?
A patient signs a document that designates another person to make legally binding healthcare decisions if the client is unable to do so.
What information is most important to include when teaching about the Nursing practice acts (NPAs)
That NPAs protect public saftey and welfare by regulating the scope of the nursing practice
A nurse volunteering giving immunizations caused injury to a patient arm and is now being sued. What will the nurse’s malpractice insurance cover?
Malpractice insurance will only cover the nurse while working at the hospital, not while volunteering.
What doe the A in the nursing process stand for?
Assessment
What does the assessment part in the nursing process include?
Getting comprehensive data about the patients’ health status, both objective and subjective data.
What does the D stand for in the nursing process?
Diagnoses
What does the diagnoses part of the nursing process include?
Based off the information, the nurse identifies the patients actual or potential health problems as a nursing diagnosis.
What does the P stand for in the nursing Process
Planning
What does the planning part of the nursing process include?
The nurse develops a plan of care that outlines specific, measurable, time bound and realistic goals to address the nursing diagnoses.
What does the Intervention look like in the nursing process?
When the nurse puts the plan of care into action to help the patient achieve their goal.
What does the E stand for in the nursing process?
Evaluation
What does the evaluation part of the nursing process look like?
Assess (Not monitor) the effectiveness and making necessary changes based on the patients progress and response.
What are some common care activities related to patient handling?
• Lifting with extended arms
• Lifting when near the floor
• Lifting with one hand
• Lifting when sitting or kneeling
• Lifting in a restricted space
• Pushing/pulling during care
How are patient handling techniques determined?
They are standardized based on individual patient characteristics and conditions to ensure safe handling, movement, and mobilization.
What are common chronic health conditions among young and older adults?
• Arthritis
• Depression
• Cancer
• Chronic kidney disease
• Chronic lung disease
• Heart disease
• Dementia
• Hypertension
• Diabetes
• Stroke
What factors influence a patient’s activity and exercise levels?
• Developmental changes
• Patient behavior
• Lifestyle
• Cultural background
What does this question best assess? How much do you normally exercise?
This question helps assess the patient’s regular physical activity levels.
How do you feel after exercising?
What does this question best assess?
This helps evaluate the patient’s endurance, fatigue levels, and any discomfort experienced after activity.
What do you believe about how exercise affects your health?
What does this question best assess?
This question assesses the patient’s perception of exercise and its impact on their well-being.
Tell me how exercise affects your body.
What does this question best assess?
Helps determine the patient’s understanding of physical activity’s benefits and any experienced physical changes.
Do you have any discomfort while exercising?
What does this question best assess?
This identifies any pain, shortness of breath, dizziness, or other symptoms during physical activity.
How long does it take to resume normal activity after exercising?
What does this question best assess?
Helps assess recovery time and potential limitations in endurance.
How soon after exercise do you feel pain or discomfort?
What does this question best assess?
Assists in identifying the severity and timing of exercise-induced symptoms.
What prevents you from exercising each day?
What does this question best assess?
Identifies obstacles such as pain, lack of time, motivation, or physical limitations.
Why is observing ROM important in nursing assessment?
ROM observation helps determine joint limitations, injuries, inflammation, arthritis, altered nerve supply, or contractures.
What does gait assessment evaluate?
Gait describes a person’s walking style and evaluates coordination, muscle strength, proprioception, balance, and central nervous system function.
What are the characteristics of a cane?
• A lightweight, easily movable device approximately waist-high
• Made of wood or metal
• Provides support and balance for patients with mild balance or strength impairments
How should a cane be measured for proper fit?
• The patient should stand upright with arms relaxed at the sides
• The cane handle should be positioned close to the patient’s wrist crease
• The elbow should have a slight bend when holding the cane
What are crutches, and how do they help patients?
• A wooden or metal staff that rests between the arm and the upper side of the chest under the armpit
• Provides upper-body support when walking
When are crutches typically used?
• Usually for temporary support, such as after tearing a knee ligament or recovering from an injury
How should crutches be measured for proper fit?
• Consider the patient’s height, the angle of elbow flexion, and the distance between the crutch pad and the axilla
• Handgrip height must be adjusted so the patient’s elbows are slightly bent
What are the characteristics of a walker?
• A mobility aid with a wide base of support
• Provides stability and security while walking
• Extremely useful for patients with significant balance or strength impairments
What steps can nurses take to prevent medication errors?
- Follow the 7 Rights of medication administration
- Prepare medications for one patient at a time
- Read the label at least 3 times (from storage, before taking to the room, before administration)
- Use at least two patient identifiers
- Do not allow interruptions during medication administration
- Question unusually high or low dosages
- Clarify unclear orders with the doctor
What are the 7 Rights of medication administration?
Right Medication
2. Right Dose
3. Right Patient
4. Right Route
5. Right Time
6. Right Documentation
7. Right Indication
What is the first priority when a medication error occurs?
The patient’s safety and well-being are the top priority.
What should you do first after a medication error?
Assess and examine the patient’s condition and notify the provider immediately.
What should be done after the patient is stable?
Report the incident to the appropriate person in the agency (such as a supervisor or manager).
What is the nurse’s responsibility regarding documentation of an error?
The nurse must file a report as soon as possible after the error occurs.
What is clinical judgment?
Clinical judgment refers to interpretations and inferences that influence actions in a clinical practice setting.
What is clinical reasoning?
Clinical reasoning involves cognitive and metacognitive processes used to analyze knowledge relative to a clinical situation or specific patient.
Dumbed down- Clinical reasoning is basically how healthcare providers think through a patient’s problem. It means they use both basic thinking and careful reflection on their own thought process to decide what’s going on and what to do next.
What is critical thinking in nursing?
• A cognitive process used to analyze issues or problems
• Knowledge- and logic-based, but not exclusive to nursing or healthcare
• Not situation-dependent
What is evidence-based practice (EBP)?
A problem-solving approach to clinical decision-making that combines:
1. Best available scientific evidence
2. Best available patient & practitioner experience
3. Optimal healthcare outcomes
What do standard-based approaches in nursing provide?
Provide clear guidance or rules
Help standardize patient care within an institution
What are the steps of the nursing process?
- Assessment
- Nursing Diagnosis
- Outcome Identification
- Planning
- Implementation
- Evaluation
What are key strategies for developing clinical judgment?
- Recognize patterns
- Apply concepts to nursing practice
- Use skillful responding
- Engage in reflective practice
How does the International Association for the Study of Pain define pain?
Pain is an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage.
Why is pain considered a universal experience?
Everyone experiences pain, but in different ways
• Pain can influence every aspect of life, including physical, psychological, emotional, social, and spiritual well-being
• Pain varies in location, quality, intensity, frequency, and duration
What is the most reliable indicator of pain?
The patient’s report is the most reliable indicator of pain because pain is a subjective experience, and no two people experience it the same way.
How can pain impact a person’s life?
Pain can:
1. Disrupt sleep, leading to fatigue
2. Reduce coping ability
3. Impair mobility and decrease ability to perform daily activities
4. Affect work duties and social activities
5. Potentially cause loss of independence
6. Impact mood and emotional well-being
Why is a precise and systematic assessment important in pain management?
A precise and systematic pain assessment is essential to:
• Identify areas affected by pain
• Determine likely contributing factors
• Develop the most effective treatment plan
What factors should be included in a patient’s pain history?
Past medical history, including surgeries and injuries
• Psychiatric history (e.g., depression, anxiety)
• History of chemical dependence
• Family history of pain
• Previous pain treatment outcomes
What does a standard pain examination include?
Neurologic assessment
• Musculoskeletal assessment
• Tailored examination focused on the affected areas
What is the gold standard for assessing pain?
The patient’s subjective report of their pain experience
How should you assess the location of a patient’s pain?
Ask the patient to point to the areas of pain on their body.
What are two common scales used to assess pain intensity?
Numeric Rating Scale (NRS) – A 1-10 scale with word anchors:
• No pain (0), Moderate pain, Worst possible pain (10)
2. Faces Pain Scale (FPS) – A visual scale with six faces:
• Uses 0, 2, 4, 6, 8, and 10 to match numeric pain ratings
Why is asking about pain quality important?
Descriptions like burning or shooting may indicate neurological pain, helping to determine the underlying cause.
What questions should you ask about the onset and duration of pain?
When did the pain start?”
How long does the pain last?”
Why is it important to ask about what makes pain better or worse?
It helps determine which pain medications and non-pharmacologic interventions are effective and which are not.
Why is it important to ask about what makes pain better or worse?
It helps determine which pain medications and non-pharmacologic interventions are effective and which are not.
What should you ask to assess the impact of pain on function?
Ask about:
• Medication side effects (e.g., constipation, nausea, sedation)
• Sleep disturbances
• Changes in eating habits
What is the purpose of discussing a comfort-function goal with the patient?
It helps establish realistic expectations for functional goal achievement based on pain management.
What is breakthrough pain, and what is it also called?
Breakthrough pain (also called pain flare) is a temporary exacerbation of pain in a patient with relatively stable baseline pain.
Why is pain reassessment important?
Pain is reassessed regularly to evaluate treatment effectiveness, and the frequency of reassessment depends on:
• Pain severity
• Institutional policies
What are some challenges in assessing pain?
Some patients cannot self-report their pain due to:
• Cognitive impairment
• Being too young to use standard pain assessment tools
What imaging tests can help identify the cause of pain?
X-rays
• CT scans
• MRI
• Ultrasound
Note: These tests should not delay pain treatment.
Why is a thorough assessment important for patients with prolonged nausea/vomiting?
Helps identify high-risk patients
• Determines precipitating factors
• Describes emesis characteristics
What does partially digested food in vomit hours after eating indicate?
Gastric outlet obstruction or delayed gastric emptying
What does fecal odor and bile in vomit after prolonged vomiting suggest?
Intestinal obstruction below the pylorus
What health history factors should be assessed in patients with nausea and vomiting?
GI issues: chronic indigestion, food allergies, infection
• Recent travel
• Pregnancy
• Eating disorders
• Cancer
: What functional health patterns are assessed in nausea and vomiting?
Nutritional-metabolic: amount, frequency, color of vomit
• Activity level: fatigue, weakness
• Cognitive-perceptual: tenderness or pain
• Coping/stress: fear, anxiety
What are key objective findings in nausea and vomiting?
General: lethargy, sunken eyes
• GI: amount, frequency, quality, and color of vomit
• Skin: dry mucous membranes, poor skin turgor
• Urinary: decreased output, concentrated urine
What are the major clinical problems associated with nausea/vomiting?
Fluid imbalance
• Electrolyte imbalance
• Nutritional compromise
• Impaired GI function
What are the expected outcomes for a patient with nausea/vomiting?
Normal electrolyte levels
Ability to maintain adequate fluid/nutrient intake
What are the five steps of the nursing process
Assessment, Diagnosis, Planning, Implementation, Evaluation.
List some therapeutic communication techniques.
Active listening, sharing observations, empathy, hope, humor, and feelings; using touch and silence; providing information; clarifying; focusing; paraphrasing; validation; asking relevant questions; summarizing; self-disclosure; confrontation.
How should a walker be measured for proper fit?
• The top of the walker should align with the crease of the wrist when the arms are down
• The elbows should be flexed about 15-30 degrees when standing inside the walker
