EXAM 3 (Chapters 4, 24, 9, 10, 13) Flashcards
Final step in a complete assessment
Rationale for developing a RN diagnosis
“A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”
What is the expected outcome of shortness of breath?
Maintain patent airway
How do you validate subjective data?
By asking the patient
Which step in the nursing process is collecting data in?
Nursing assessment
Who is the best source of information for an adult patient?
The patient
Orientation phase of an interview
Phase can last for a few meetings or extend over a longer period. It is the first time the nurse and the patient meet and is the phase in which the nurse conducts the initial interview
Who can develop a NANDA diagnosis?
What is the evaluation process?
Determine if goals met and expected outcomes achieved
Order of nursing process
Assess —> Dx —> Planning —> Implement —> Evaluate
Define SMART
Specific
Measureable
Attainable
Realistic
Timed
Different assessment approaches
- Collection and verification of data from a primary source (the patient) and secondary sources (e.g., family caregiver, friends, health professionals, medical record)
- Interpretation and validation of data to ensure a complete database.
Evaluation measures of a goal of pressure injury
Steps of review and revision during implementation phase
What is a preventative nursing action?
What can be adjusted during the evaluation phase?
What are some nurse-initiated intervention?
Possible outcomes for a patient after abdominal surgery
Examples of physician-initiated interventions
Appropriate outcome statements, what should be included?
Patient-centered care improves….
What type of questions would a nurse want to ask during the interview phase?
Can nurses use medical diagnosis for their nursing diagnosis?
What are the types of nursing diagnosis?
Best way to document an abrupt and rude patient statement
Who would be the best primary source of information for what comforts a child?
Nurses are legally and ethically obligated to keep patient information confidential
What does HIPAA require a provider to provide to a patient?
Incident or occurrence reports when should they be documented?
Top 10 reasons for sentinel events
Fall — 485 reported events
Delay in treatment — 97
Unintended retention of a foreign object — 97
Wrong surgical site — 85
Patient suicide — 79
Assault/rape/sexual assault of a patient — 55
Patient self-harm — 45
Fire — 38
Medication management — 35
Clinical alarm response — 22
Who sets the standards for documentations?
American Nurses Association (ANA), Nurse Practice Act
Be Accurate. Write down information accurately in real-time. …
Avoid Late Entries. …
Prioritize Legibility. …
Use the Right Tools. …
Follow Policy on Abbreviations. …
Document Physician Consultations. …
Chart the Symptom and the Treatment. …
Avoid Opinions and Hearsay.
Characteristics of quality documentation
Good Documentation is Up to Date. …
Good Documentation anticipates failure. …
Good Documentation does not contain specific terms without clear definitions. …
Good Documentation does not use words like “simply”. …
Good Documentation is extensive, and has many examples.
How should a nursing student sign their name when documenting?
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
Concepts included in informatics
Correct nursing actions for a telephone order
What does a problem-oriented medical record include?
What actions require an incident or occurrence report?
What are critical pathways?
A critical Pathway (CP) is a clinical management tool that helps medical care providers coordinate the delivery of patient care for a particular case type or condition.
What is a telephone report?
Interventions for a patient with Alzheimer’s disease
The homeless population has a higher prevalence of what disease?
Mental health
Which intervention should be completed first when working with a member of a vulnerable population?
Language behavior
What does the nurse assess when looking at a community’s social system?
Public health problems are influenced by……
What groups are part of the vulnerable population?
Know the terms for sexuality and self-concept.
What would a nurse ask to assess patient perception of identity?
What is role performance?
Signs and symptoms of physical or sexual abuse
Sadness, crying, anxiousness.
Short attention span.
Change or loss of appetite.
Sleep disturbances, nightmares.
Becoming excessively dependent.
A fear of home or a specific place, excessive fear of men or women, lacks trust in others.
What questions would a nurse ask to determine sexual health of an adolescent?
Which age group is the most vulnerable to identity stressors?
Instructions to discuss birth control with a female patient
Ways in which the media has negative impact on body image
Does cultural background directly influence self-concept?
Does the capacity for sexuality diminish in older adults?
Which behaviors may indicate an altered self-concept?
Manifestations of an altered self-esteem include self-negating verbalizations, reduced social interactions, lack of eye contact during interaction, and verbalization of feelings of guilt.
What does PLISSIT stand for?
Permission
Limited
Information
Specific
Suggestion
Intensive
Therapy
Different sexual orientations
