Exam 3; fundamentals of nursing Flashcards
What is a community?
a group of like-minded people
Who is Florence Nightingale
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)
Who is Lilian Wald
first community health nurse
Who is Clara Barton
founder of American Red Cross
Who is Margaret Sanger
founded planned parenthood
What are the 5 roles of community nurses
- client advocate
- educator
- collaborator- establish partnerships (ex. special pharmacy)
- Counselor (for patient or family)
- case manager- make referrals or collaborate with other health and social agencies
What is the primary community nursing intervention
to promote health and prevent a disease (ex. educating, collaborating, advocating)
What is the secondary community nursing intervention
reduce disease impact; provide early detection and treatment (screenings)
What is the tertiary community nursing intervention
halt disease progression/ restore health
What is parish nursing
integrates faith with health
What are the three types of assessments in public health?
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
Is a home healthcare environment a controlled environment?
no, do know how clean, what recourses, any accessible food
A patient who is receiving palliative care would not be eligible to have this care provided by a home health agency.
false; palliative is managing symptoms such as physical therapy
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
C
what is the length/gauge needed needle for an intradermal injection
1/4-5/8 in.
25-29 gauge
what is the syringe size of an intradermal needle
what angle is needed
1mL
5-15 degree
what is the needed length/gauge for a SubQ injection
3/8in., 1/2in., 5/8in.
25-29 gauge
what is the syringe size of an SubQ needle
what angle is needed
1 mL, 3mL, insulin
45-90 degree
common injection sites of SubQ
abdomen, upper arm, anterior thigh
what is the length/gauge needed needle for an intramuscular injection
1-1 1/2in.
20-22 gauge
syringe size of intramuscular
angle needed
1mL or 3mL
90 degree
what is the overall effectiveness of a community
process
sponsored jointly by government and states
medacaid
what is a general characteristic of a community
structure
what focuses on patient care on patients who are dying
hospice
group of people with at least one shared characteristic
aggregate
group of people of a particular class
population
provides relief for family caregivers
respate
type of survey performed while physically present in the area
windshield
the primary goal to promote health
community nursing
nursing process
a systematic problem-solving process that guides all nursing actions
what is the purpose of a nursing process
to help the nurse provide goal-directed, client-centered care
5 characteristics of the nursing processs
ADPIE
assessment
diagnosis
planning (outcome & interventions)
implementations
evaluation
what occurs in the assessment phase of the nursing process
gather data, recognize cues, collect and record data
nursing diagnosis
a statement of client health status that nurses can identify, prevent, or treat independentaly
3 parts of a nursing diagnosis statement
actual
risk
wellness
what cannot be used in a nursing diagnosis
PES
problem, etiology, symptom format
what is the purpose of a client goal
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.
5 components of an outcome statement/client goal
subject, action, performance criteria, special conditions, target time
The purpose of nursing interventions
to achieve client outcomes
3 components of nursing interventions
independent, dependent, interdependent
what occurs during the implementation phase of the nursing process
doing, delegation, recording
what happens during the evaluation phase of the nursing process
outcomes, care plan, nursing care
ADPIE
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.
subjective vs objective
subjective- information from patient
objective- concrete information
medical diagnosis vs nursing diagnosis
medical- disease, illness, injury
nursing- statement of client health status stated in terms of human responses
SMART outcomes
specific, measurable, achievable, realistic, timed
EBP interventions with rationales
rationale explain why the intervention will benefit the health of the paitent
What does nursing involve?
thinking, caring, doing
What is theoretical nursing knowledge?
it is the basic principles of science
what is practical nursing knowledge
it is what to do and how to do it
what is self nursing knowledge
this is critically thinking and the nurses and/ or selfs own views
what is ethical nursing knowledge
moral principles and moral decisions (right vs. wrong legally)
Which type of nursing knowledge requires an understanding of the pathophysiology of the disease process, medical treatment, and client and family factors?
theoretical knowledge
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
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
C
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
What are the two main components of thinking
critical thinking
theoretical knowledge`
What are the two main components of doing
practical knowledge
nursing process
What are the two main components of caring
self- knowledge
ethical knowledge
What are the two main components of patient situation
patient data
patient preferences, context
T or F: college courses, such as microbiology and human growth and development, present content that is considered part of theoretical nursing knowledge
true
What are the phases of the nursing processes
and what is the mnemonic to remember it?
ADPIE
Assessment
Diagnosis
Planning- interventions and outcomes
Implementation
Evaluation
What are the four components of assessment
collecting, validating, organizing, and recording data
What is primary data
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
what is secondary data
information about the patient that comes from everything but the patient
charts, history, other providers, family members
What is subjective data
anything the patient says
what is objective data
concrete facts
labs, physical assessments
What is medical diagnosis
a disease, illness, or injury
What is nursing diagnosis
a statement of client health status that nurses can identify, prevent, or treat independently
what is collaborative problems
more than one team member working together for interventions to help reach the expected outcome for the patient
What are the three types of nursing diagnosis
- actual: something that exists
- risk: something that may be developed
- wellness: something that is health promotion
When prioritizing problems: what is the best way to eliminate answers
Maslow’s hierarchy of needs
What is the formula of writing diagnostic statments
problem + etiology
What does a problem suggest
goal/ outcome
what does etiology suggest
interventions
What is a long term goal
to be achieved over a week or longer
what is a short term goal
to be achieved within a few days
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
subject: client
Action: will walk
Performance criteria: to the doorway
Special conditions: with assistance from one person
Target time: 1400 on 9/8/18
SMART
specific
measurable
achievable
realistic
timed
What are independent interventions
one that RNs can prescribe, perform, or delegate based on their knowledge and skills
What are dependent interventions
one that is prescribed by a healthcare provider but carried out by the bedside nurse
What are interdependent interventions
one that is carried out in collaboration with other health care teams
What are the 3 components of interventions
- subject “nurse will..”
- Action verb: assist, assess, auscultate, bathe, change, demonstrate
- times and limits: frequency, limits
What are the five rights of delegation
right task
right circumstance
right person
right direction/ communication
right supervision
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
B- the patient is at risk for constipation and impaired mobility due to decreased fluid intake and not moving
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
B- can cause respiratory problems due to excess fluid building up in lungs/ respiratory
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
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
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
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
independent
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
B
C
D
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
