Exam 2 Study Guide Review Flashcards
ISBAR - R
Introduction
Situation
Background
Assessment
Recommendation
-Readback
Differences between stool softeners and laxatives
laxative defines any medicine that facilitates a bowel movement which includes a broad range designed to treat varying levels of severity. A stool softener is a mild (OTC) over-the-counter laxative used to soften the stool for easier passage and less strain.
Describe hypoglycemia
Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than the standard range.
Signs related to hypoglycemia
Looking pale (pallor)
Shakiness.
Dizziness or lightheadedness.
Sweating.
Hunger or nausea.
An irregular or fast heartbeat.
Difficulty concentrating.
Feeling weak and having no energy (fatigue)
Describe hyperglycemia
Hyperglycemia is the technical term for high blood glucose (blood sugar). High blood glucose happens when the body has too little insulin or when the body can’t use insulin properly.
Signs related to hyperglycemia
Fruity-smelling breath.
Dry mouth.
Abdominal pain.
Nausea and vomiting.
Shortness of breath.
Confusion.
Loss of consciousness.
A body of law known as statutory law has evolved from accumulated judiciary decisions.
A. True
B. False
B. False
Rationale: A body of law known as common law has evolved from accumulated judiciary decisions. Most law involving malpractice is common law.
The state nurse practice act is the most important law affecting nursing practice.
A. True
B. False
A. True
Rationale: The state nurse practice act is the most important law affecting nursing practice. Each nurse practice act protects the public by broadly defining the legal scope of nursing practice.
What are reasons for revoking or suspending a license?
Drug or alcohol abuse
Fraud
Deceptive practice
Criminal acts
Previous disciplinary actions
Gross or ordinary negligence
Physical or mental impairments, including age
Which is the correct term for this nursing action: A nurse falsely imprisons a patient by an unauthorized use of restraints.
A. Crime
B. Tort
C. Misdemeanor
D. Felony
B. Tort
Rationale: A tort is a wrong committed by a person against another person or that person’s property. False imprisonment is an intentional tort. A crime is a wrong against a person or that person’s property as well as the public. Crimes can be classified as misdemeanors or felonies.
What are intentional torts?
Assault and battery
Defamation of character
Invasion of privacy
False imprisonment
Fraud
What are unintentional torts?
Negligence
Malpractice
In all health care agencies, informed and voluntary consent is needed for admission, for specialized diagnostic procedures or medical–surgical treatment, and for any experimental treatments or procedures.
A. True
B. False
A. True
Rationale: In all health care agencies, informed and voluntary consent is needed for admission, for specialized diagnostic procedures or medical–surgical treatment, and for any experimental treatments or procedures.
What does ANA stand for?
American Nurses Association
A nurse’s personal moral code is to assist all patients to the best of one’s ability. What blended skill would the nurse use when seeking out special services for a homeless patient with a diabetic foot ulcer?
A. Cognitive
B. Technical
C. Interpersonal
D. Ethical/Legal
D. Ethical/Legal
Rationale: Using ethical/legal skills is the best answer as it involves following a moral code and acting professionally. Cognitive skills involve thinking through a situation to achieve outcomes. Technical skills relate to the proper use of equipment. Interpersonal skills are used to develop caring relationships.
What are potential errors in decision making?
Bias
Failure to consider the total situation
Impatience
Five Steps of the Nursing Process
Assessing: collecting, validating, and communicating patient data
Diagnosing: analyzing patient data to identify patient strengths and problems
Planning: specifying patient outcomes and related nursing interventions
Implementing: carrying out the care plan
Evaluating: measuring extent to which patient achieved outcomes
Which step of the nursing process is a nurse using when analyzing patient data to determine a patient’s strengths following a CVA?
A. Assessing
B. Diagnosing
C. Planning
D. Implementing
E. Evaluating
B. Diagnosing
Rationale: The diagnosing step involves analyzing patient data to determine strengths and weaknesses. The assessing step refers to the collection, validation, and communication of patient data. In the planning step, the nurse determines patient outcomes and related nursing interventions, and in the implementing step, the nurse carries out the plan. When evaluating, the nurse measures the extent to which the patient achieved outcomes.
Which of the following characteristics of the nursing process describes the interaction and overlapping of steps within the process itself?
A. Systematic
B. Dynamic
C. Interpersonal
D. Universally Applicable
B. Dynamic
Rationale: The nursing process is dynamic in that there is much interaction and overlapping of the steps. It is systematic since it is an ordered sequence of activities. Interpersonal refers to the human being at the heart of nursing. The nursing process is universally applicable in that it is a framework for all nursing activities
What are the characteristics of the nursing process?
Systematic: part of an ordered sequence of activities
Dynamic: great interaction and overlapping among the five steps
Interpersonal: human being is always at the heart of nursing
Outcome oriented: nurses and patients work together to identify outcomes
Universally applicable: a framework for all nursing activities
What are the steps in concept mapping?
Collect patient problems and concerns on a list.
Connect and analyze the relationships.
Create a diagram.
Keep in mind key concepts: the nursing process, holism, safety, and advocacy
Concept mapping is an instructional strategy that requires learners to identify, graphically display, and link key concepts.
A. True
B. False
A. True
Rationale: Concept mapping is an instructional strategy that requires learners to identify, graphically display, and link key concepts.
Describe Reflection in Action
Happens in the here and now of the activity and is also known as “thinking on your feet.”
Describe Reflection on Action
Occurs after the fact and involves thinking through a situation that has occurred in the past
Describe Reflection for Action
Helps the person to think about how future actions might change as a result of the reflection.
Tanner’s Clinical Judgment Model
Noticing: initial grasp and perceptions of the situation that are impacted by context, the nurse’s practical experience, knowledge of expected versus unexpected data, ethical perspectives, and the nurse–patient relationship
Interpreting: attributing meaning to the data through multiple reasoning patterns
Responding: deciding on an action (or inaction) and monitoring outcomes
Reflecting: in-action and on-action
Lasater Clinical Judgment
Based on Tanner’s model; describes the development of clinical judgment
Effective Noticing
- Focused observation
- Recognizing deviations rom expected patterns
- Information seeking
Effective Interpreting
- Prioritizing data
- Making sense of data
Effective Responding
- Calm, confident manner
Effective Noticing
- Clear communication
- Well-planned intervention/flexibility
- Being skillful
Recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes are steps included in which model?
A. Clinical Judgment Measurement Model
B. Tanner’s Model
C. The Nursing Process
D. Developing Nurses’ Thinking Model
A. Clinical Judgment Measurement Model
Rationale: The six cognitive operations included in layer 3 of the CJMM include recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes.
Which of the following includes four components of moral reasoning and captures the cognitive processes that precede moral action?
A. Information-Processing Model
B. Cognitive Continuum Theory
C. Rest Framework
D. Humanistic - Intuitive Approach
C. Rest Framework
Rationale: The Rest framework includes four components of moral reasoning and captures the cognitive processes that precede moral action. The information-processing model informs decision making and mirrors the way we think of a computer processor. The cognitive continuum theory (CCT) integrates both intuitive and analytical cognitive characteristics. The Humanistic–intuitive approach believes that clinical judgment and decision-making models move from facts and rules to dynamic decision making with clinical experience.
Assessment
Preparing for data collection
Collecting data
identifying cues and making inferences
Validating data
Clustering related data and identifying patterns
Reporting and recording data
Which one of the following assessments would be performed on a patient to gather data about their previously diagnosed liver cancer?
A. Initial comprehensive assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment
B. Focused assessment
Rationale: In a focused assessment, the nurse gathers data about a condition that has already been diagnosed
A nursing assessment duplicates a medical assessment by focusing on the patient’s responses to the health problem.
A. True
B. False
B. False
Rationale: A nursing assessment does not duplicate a medical assessment, rather it focuses on the patient’s responses to the health problem.
Medical vs. Nursing Assessments
Medical-rule out-tests, assessments-based on results- narrow down pathology- focus on the illness and treatment
Nsg- care of the person behind the illness. Focus on the person, physiological and psychological response to the illness. able to meet basic human needs? perform ADL’s
Actual or potential health problems
A patient rates his pain as a “7” on a pain rating scale. This rating is considered to be objective data.
A. True
B. False
B. False
Rationale: A patient rating his pain on a pain rating scale is considered to be subjective data.
Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.
A. True
B. False
A. True
Rationale: Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.
Clinical Reasoning
Analyzing
Synthesizing
Reflecting
Making Judgments
Drawing Conclusions
Describe OLD CARTS
Onset: “When did your symptom(s) begin”?.
Location: “Where is the symptom”?.
Duration: “Is it episodic or constant?” or “How long does it last”?. Characteristics: “How would you describe it?.”
Alleviating and Aggravating factors: “What makes it better or worse?.” Relieving factors: “What makes it better?.”
Treatments: “Have you tried anything to make it better?.”
Severity: “On a scale of 1–10, with 1 being the lower number, how serious is the symptom?.”
Diagnosing
Creating a list of suspected problems/diagnoses
Ruling out similar problems/diagnoses
Naming actual and potential problems/diagnoses and clarifying what’s causing or contributing to them
Determining risk factors that must be managed
Identifying resources, strengths, and areas for health promotion
Nursing Concerns and Responsibilities
Recognizing safety and infection-transmission risks and addressing these immediately.
Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients’ lives—and promoting optimum function, independence, and quality of life.
Anticipating possible complications and taking steps to prevent them.
Initiating urgent interventions. You should not wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment.
A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most likely be determined?
A. Recognizing significant data
B. Recognizing patterns or clusters
C. Identifying strengths and problems
D. Reaching conclusions
D. Reaching conclusions
Rationale: A possible problem, such as high blood pressure, is diagnosed as a conclusion of data interpretation.
Recognizing significant data refers to the comparison of data to a standard or norm (e.g. normal blood pressure values).
A data cluster is a grouping of patient data or cues that points to the existence of a problem (e.g. a series of readings).
The nurse must then identify strengths and problems to determine if the patient is motivated to address them.
A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on their symptoms and a series of test results. Which of the following is the etiology in this scenario?
A. Lung cancer
B. Test results
C. Smoking cigarettes
D. The subjective and objective data
C. Smoking cigarettes
Rationale: The etiology is the factor that maintains the unhealthy condition (smoking cigarettes).
Lung cancer is the problem, and the remaining factors are the distinguishing characteristics.
Formulation of Nursing Diagnoses
Problem—identifies what is unhealthy about patient
Etiology—identifies factors maintaining the unhealthy state
Defining characteristics—identify the subjective and objective data that signal the existence of a problem
The nursing diagnosis risk for impaired skin integrity is an example of a correctly written risk problem.
A. True
B. False
B. True.
Rationale: The nursing diagnosis risk for impaired skin integrity is an example of a risk diagnosis.
A nursing diagnosis may be used to seek reimbursement for nursing services.
A. True
B. False
A. True
Rationale: A nursing diagnosis may be used to seek reimbursement for nursing services.
Which of the following nursing diagnoses is written correctly?
A. Child Abuse related to maternal hostility
B. Breast Cancer related to family history
C. Deficient Knowledge related to alteration in diet
D. Imbalanced Nutrition related to insufficient funds in meal budget
D. Imbalanced Nutrition related to insufficient funds in meal budget
Rationale: Answer A makes legally inadvisable statements, answer B is a medical diagnosis, and answer C reverses the clauses in the statement.
Outcome Identification and Planning
Establish priorities
identify expected patient outcomes
Select evidence-based nursing intervention
Communicate the plan of care
overall treatment plan
nursing standards
Which nursing action would most likely occur during the ongoing planning stage of the comprehensive care plan?
A. The nurse collects new data and uses them to update the plan and resolve health problems.
B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home.
C. The nurse who performs the admission nursing history develops a patient care plan.
D. The nurse consults standardized care plans to identify nursing diagnoses, outcomes, and interventions.
A. The nurse collects new data and uses them to update the plan and resolve health problems.
Rationale: In the ongoing planning stage, any nurse who interacts with the patient updates the plan to facilitate the resolution of health problems, manage risk factors, and promote function.
Teaching and counseling are the key to discharge planning.
The nurse performing the admission nursing history consults standardized care plans during initial planning to formulate the initial care plan.
1st part of the nursing diagnosis
“problem statement”
identifies the unhealthy response
indicates what should change
suggest patient goals/outcomes (expectations for change)
2nd part of the nursing diagnosis
Etiology
identifies factors causing or contributing to the undesired response and preventing desired change
suggests nursing interventions
Which nursing diagnosis would most likely be considered a high priority?
A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance
Answer: B. Impaired gas exchange
Rationale: Impaired gas exchange poses a threat to the patient’s well-being.
Disturbed personal identity and risk for powerlessness are non–life-threatening and are ranked as medium priorities.
Activity intolerance, if not specifically related to the current health problem, is a low priority.
Maslow’s Hierarchy of Human Needs
Physiologic needs
Safety needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
IOM’s Six Aims to be Met by Health Care Systems Regarding Quality of Care
Safe: avoiding injury
Effective: avoiding overuse and underuse
Patient-centered: responding to patient preferences, needs, and values
Timely: reducing waits and delays
Efficient: avoiding waste
Equitable: providing care that does not vary in quality to all recipients
Categories of Outcomes
Cognitive: describes increases in patient knowledge or intellectual behaviors
Psychomotor: describes patient’s achievement of new skills
Affective: describes changes in patient values, beliefs, and attitudes
Which outcome is an affective outcome?
A. By 6/09/19, the patient will correctly demonstrate the procedure for washing her newborn baby.
B. By 6/09/19, the patient will list three benefits of eating a healthy diet.
C. By 6/09/19, the patient will use a walker to ambulate the hallway.
D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking.
Answer: D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking.
Rationale: An affective outcome describes changes in patient values, beliefs, and attitudes. Answers A and C are psychomotor outcomes (learning a new skill) and Answer B is a cognitive outcome (increase in patient knowledge).
A collaborative intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician’s order.
A. True
B. False
Answer: B. False
Rationale: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis, but carried out by a nurse in response to a physician’s order.
Types of Nursing Interventions
Nurse-initiated: actions performed by a nurse without a physician’s order
Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders
Collaborative: treatments initiated by other providers and carried out by a nurse
A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort.
A. True
B. False
Answer: A. True
Rationale: A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort.
