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Nursing Skills > Exam 3; fundamentals of nursing > Flashcards

Exam 3; fundamentals of nursing Flashcards

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1
Q

What is a community?

A

a group of like-minded people

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2
Q

Who is Florence Nightingale

A

she discovered a clean environment prevents infection and she came up with the idea of nursing the whole person (assessing everything not just one problem)

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3
Q

Who is Lilian Wald

A

first community health nurse

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4
Q

Who is Clara Barton

A

founder of American Red Cross

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5
Q

Who is Margaret Sanger

A

founded planned parenthood

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6
Q

What are the 5 roles of community nurses

A
  1. client advocate
  2. educator
  3. collaborator- establish partnerships (ex. special pharmacy)
  4. Counselor (for patient or family)
  5. case manager- make referrals or collaborate with other health and social agencies
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7
Q

What is the primary community nursing intervention

A

to promote health and prevent a disease (ex. educating, collaborating, advocating)

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8
Q

What is the secondary community nursing intervention

A

reduce disease impact; provide early detection and treatment (screenings)

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9
Q

What is the tertiary community nursing intervention

A

halt disease progression/ restore health

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10
Q

What is parish nursing

A

integrates faith with health

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11
Q

What are the three types of assessments in public health?

A

windshield survey (observing the community without being involved with the community)

database utilization: birth records, marriage licenses, news websites, criminal activity

client perceptions: what the patient views on their own community

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12
Q

Is a home healthcare environment a controlled environment?

A

no, do know how clean, what recourses, any accessible food

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13
Q

A patient who is receiving palliative care would not be eligible to have this care provided by a home health agency.

A

false; palliative is managing symptoms such as physical therapy

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14
Q

The nurse knows that the family of the patient receiving home healthcare needs further education about what service when the family requests the RN to :
a. teach the patient how to administer his own insulin
b. change the patient’s PICC line dressing
c. take the patient shopping to buy high protein foods
d. call the social worker to obtain information about medicare

A

C

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15
Q

what is the length/gauge needed needle for an intradermal injection

A

1/4-5/8 in.
25-29 gauge

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16
Q

what is the syringe size of an intradermal needle
what angle is needed

A

1mL
5-15 degree

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17
Q

what is the needed length/gauge for a SubQ injection

A

3/8in., 1/2in., 5/8in.
25-29 gauge

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18
Q

what is the syringe size of an SubQ needle
what angle is needed

A

1 mL, 3mL, insulin
45-90 degree

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19
Q

common injection sites of SubQ

A

abdomen, upper arm, anterior thigh

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20
Q

what is the length/gauge needed needle for an intramuscular injection

A

1-1 1/2in.
20-22 gauge

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21
Q

syringe size of intramuscular
angle needed

A

1mL or 3mL
90 degree

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22
Q

what is the overall effectiveness of a community

A

process

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23
Q

sponsored jointly by government and states

A

medacaid

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24
Q

what is a general characteristic of a community

A

structure

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25
Q

what focuses on patient care on patients who are dying

A

hospice

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26
Q

group of people with at least one shared characteristic

A

aggregate

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27
Q

group of people of a particular class

A

population

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28
Q

provides relief for family caregivers

A

respate

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29
Q

type of survey performed while physically present in the area

A

windshield

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30
Q

the primary goal to promote health

A

community nursing

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31
Q

nursing process

A

a systematic problem-solving process that guides all nursing actions

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32
Q

what is the purpose of a nursing process

A

to help the nurse provide goal-directed, client-centered care

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33
Q

5 characteristics of the nursing processs

A

ADPIE
assessment
diagnosis
planning (outcome & interventions)
implementations
evaluation

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34
Q

what occurs in the assessment phase of the nursing process

A

gather data, recognize cues, collect and record data

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35
Q

nursing diagnosis

A

a statement of client health status that nurses can identify, prevent, or treat independentaly

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36
Q

3 parts of a nursing diagnosis statement

A

actual
risk
wellness

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37
Q

what cannot be used in a nursing diagnosis

A

PES
problem, etiology, symptom format

38
Q

what is the purpose of a client goal

A

patient education so they are able to take care of themselves at home. Or a goal for a patient to make before they can be discharged.

39
Q

5 components of an outcome statement/client goal

A

subject, action, performance criteria, special conditions, target time

40
Q

The purpose of nursing interventions

A

to achieve client outcomes

41
Q

3 components of nursing interventions

A

independent, dependent, interdependent

42
Q

what occurs during the implementation phase of the nursing process

A

doing, delegation, recording

43
Q

what happens during the evaluation phase of the nursing process

A

outcomes, care plan, nursing care

44
Q

ADPIE

A

Assessment- gather data through observation, interview, or examination/evaluation.

Diagnosis- identify the client’s health needs.

Planning (outcomes/interventions)- decide on goals you want to achieve and what interventions will help the client achieve improved health outcomes.

Implementation- carry out or delegate actions.

Evaluation- judge whether your actions have treated or prevented the client’s health problem.

45
Q

subjective vs objective

A

subjective- information from patient
objective- concrete information

46
Q

medical diagnosis vs nursing diagnosis

A

medical- disease, illness, injury
nursing- statement of client health status stated in terms of human responses

47
Q

SMART outcomes

A

specific, measurable, achievable, realistic, timed

48
Q

EBP interventions with rationales

A

rationale explain why the intervention will benefit the health of the paitent

49
Q

What does nursing involve?

A

thinking, caring, doing

50
Q

What is theoretical nursing knowledge?

A

it is the basic principles of science

51
Q

what is practical nursing knowledge

A

it is what to do and how to do it

52
Q

what is self nursing knowledge

A

this is critically thinking and the nurses and/ or selfs own views

53
Q

what is ethical nursing knowledge

A

moral principles and moral decisions (right vs. wrong legally)

54
Q

Which type of nursing knowledge requires an understanding of the pathophysiology of the disease process, medical treatment, and client and family factors?

A

theoretical knowledge

55
Q

What is the processing of noticing?
A. developing an impression of the client situation based on the nurse’s expectation, knowledge, and past experiences
b. the course of action taken by the nurse
c. the process of examining the actions implemented
d. the reasoning process nurses use to make sense of the initial clinical situation

A

A

56
Q

Definition of critical thinking:
A. a problem- solving process that enables one to show others they are wrong
B. an examination of one’s own beliefs in order to defend them intelligently
C. purposeful, analytical thinking that results in a reasoned decision
D. rational thinking that results in obtaining the one correct answer

A

C

57
Q

A nurse who is newly employed at a hospital questions standard of patient care that does not seem to follow evidence based practice. Which critical thinking attitude is the nurse demonstrating?
A. independent thinking
B. intellectual humility
C. Intellectual courage
D. fair- mindness

A

A

58
Q

What are the two main components of thinking

A

critical thinking
theoretical knowledge`

59
Q

What are the two main components of doing

A

practical knowledge
nursing process

60
Q

What are the two main components of caring

A

self- knowledge
ethical knowledge

61
Q

What are the two main components of patient situation

A

patient data
patient preferences, context

62
Q

T or F: college courses, such as microbiology and human growth and development, present content that is considered part of theoretical nursing knowledge

A

true

63
Q

What are the phases of the nursing processes
and what is the mnemonic to remember it?

A

ADPIE
Assessment
Diagnosis
Planning- interventions and outcomes
Implementation
Evaluation

64
Q

What are the four components of assessment

A

collecting, validating, organizing, and recording data

65
Q

What is primary data

A

information coming directly from the patient, or the primary care taker of a patient if patient is unable to do so (ex. child or dementia patient) most reliable source of information

66
Q

what is secondary data

A

information about the patient that comes from everything but the patient
charts, history, other providers, family members

67
Q

What is subjective data

A

anything the patient says

68
Q

what is objective data

A

concrete facts
labs, physical assessments

69
Q

What is medical diagnosis

A

a disease, illness, or injury

70
Q

What is nursing diagnosis

A

a statement of client health status that nurses can identify, prevent, or treat independently

71
Q

what is collaborative problems

A

more than one team member working together for interventions to help reach the expected outcome for the patient

72
Q

What are the three types of nursing diagnosis

A
  1. actual: something that exists
  2. risk: something that may be developed
  3. wellness: something that is health promotion
73
Q

When prioritizing problems: what is the best way to eliminate answers

A

Maslow’s hierarchy of needs

74
Q

What is the formula of writing diagnostic statments

A

problem + etiology

75
Q

What does a problem suggest

A

goal/ outcome

76
Q

what does etiology suggest

A

interventions

77
Q

What is a long term goal

A

to be achieved over a week or longer

78
Q

what is a short term goal

A

to be achieved within a few days

79
Q

Example of an outcome statement
A client will walk to the doorway with assistance from one person by 1400 on 9/8/18
what is the subject, action, performance criteria, special conditions, target time

A

subject: client
Action: will walk
Performance criteria: to the doorway
Special conditions: with assistance from one person
Target time: 1400 on 9/8/18

80
Q

SMART

A

specific
measurable
achievable
realistic
timed

81
Q

What are independent interventions

A

one that RNs can prescribe, perform, or delegate based on their knowledge and skills

82
Q

What are dependent interventions

A

one that is prescribed by a healthcare provider but carried out by the bedside nurse

83
Q

What are interdependent interventions

A

one that is carried out in collaboration with other health care teams

84
Q

What are the 3 components of interventions

A
  1. subject “nurse will..”
  2. Action verb: assist, assess, auscultate, bathe, change, demonstrate
  3. times and limits: frequency, limits
85
Q

What are the five rights of delegation

A

right task
right circumstance
right person
right direction/ communication
right supervision

86
Q

the client’s activity level has decreased post hip replacement surgery. She has been receiving opioid analgesia and has decreased fluid intake. The nurse chooses:
A. a medical diagnosis
B. a risk nursing diagnosis
C. an actual nursing diagnosis
D. a wellness nursing diagnosis

A

B- the patient is at risk for constipation and impaired mobility due to decreased fluid intake and not moving

87
Q

Identify the priority nursing diagnosis:
A. impaired verbal communication related to altered central nervous system
B. Fluid volume excess related to compromised regulatory mechanism
C. impaired physical mobility related to discomfort
D. activity intolerance related to generalized weakness

A

B- can cause respiratory problems due to excess fluid building up in lungs/ respiratory

88
Q

The client has reddened skin and an open abrasion on his elbow from prolonged bedrest. in examining the components of the nursing diagnosis “impaired skin integrity,” the reddened skin and open abrasion would be
A. the defining characteristic
B. the diagnostic label
C. The related factors
D. the risk factors

A

A

89
Q

Identify the client outcome that is written correctly
A. the client’s pneumonia will be resolved as evidenced by clear breath sounds bilaterally by discharge
B. the client will ambulate 20 feet in the hallway using his walker by evening shift tomorrow
C. the client will drink more fluids than he did yesterday by 7:00pm today
D. the client’s urine output will be adequate by the end of the shift

A

B

can’t be A because can’t use a medical diagnosis in it
Can’t be C because you do not compare patient to yesterday, in order to move forward today
can’t be D because adequate is not a specific amount

90
Q

The nurse teaches the client how to change his ostomy appliance. This is an example of what type of interventions?
A. indirect care
B. dependent
C. collaborative
D. independent

A

independent

91
Q

It is a very busy day on the nursing unit. The RN asks the nursing assistive personnel to complete the following tasks. Which tasks are appropriate delegations? (select all that apply)
A. make sure the client takes his pills after his meals
B. ambulate the postsurgical client to the bathroom
C. feed the client with severe visual impairment
D. bathe the client who is listed as a fall risk
E.complete a physical assessment

A

B
C
D

92
Q

The nurse has determined that the goal for a particular nursing diagnosis on the client’s plan of care has not been met. It will be most important for the nurse to:
A. revise the plan of care
B. report this finding to the provider
C. note this finding in the client’s record
D. remove the nursing diagnosis from the plan

A

A

Nursing Skills (16 decks)

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