Final Exam Flashcards
Supporting patients right to make healthcare decisions when they are unable to voice their opinions and protecting patients from harm when they are unable to make decisions.
patient’s advocate
Changed the way society thought about nurses. Opened up a nursing school and promoted that hand washing is important.
Florence Nightingale
3 elements of “Full Spectrum Nursing”
- clinical judgement
- critical thinking, reflective thinking
- problem solving
Define Nursing as defined by ANA (American Nursing Association):
protection, promotion, and optimization of health abilities - prevention of illness and injury
Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
safety
How can nursing improve its recognition as a profession?
- Standardizing educational requirements
- Uniform continuing education requirements
- Increased participation of nurses in professional organizations
- Educating the public about the true nature of nursing practice
6 things QSEN represents (students should poses all 6 of these things by graduation)
- patient center care
- evidence bases practice
- teamwork & collaboration
- safety
- informatics
- quality improvement
Authoritative statements of the duties that all RN regardless of role, specialty or population are expected to perform competently.
Nursing Standard of Practice
Laws that regulate nursing practice
- State Boards of nursing
- Licensure
- Guide for Professional standards
Nurse Practice Acts
When nurses work on behalf of an individual, group, family, or community to improve their health status
Indirect care
all people able to receive health insurance/no one without health insurance
Affordable care act
Observing, comparing, contrasting, and evaluating the clients condition.
Clinical judgement
Involves collecting and analyzing information and carefully considering options for action.
Critical thinking, reflective thinking
Considering issues and attempting to find a satisfactory solution.
Problem solving
Wound care, IV antibiotics, educating pts. with diabetes.
Skilled Nursing
Which organization is directly responsible for regulating the practice of nursing in each state?
The State Board of Nursing
Each person has a role, clear understanding of tasks assigned. Compartmental care.
Functional Nursing
Diagnosis and treatment of illness, disease or injury. health restoration.
Secondary care
Purposeful, analytical thinking that results in a reasoned decision.
critical thinking
A nurse who is newly employed at a hospital questions a standard of patient care that does not seem to follow evidence-based practice. The critical thinking attitude she is exhibiting is termed:
independent thinking
Phases of the Nursing Process
- Assessment
- Diagnosis
- Planning Outcomes
- Interventions
- Evaluation
How is the Nursing Process Related to Critical Thinking?
Nurses use critical thinking skills to solve the problem by using the nursing process.
A unique blend of thinking, doing, and caring for the purpose of effecting good outcome from a patient situation.
Full-Spectrum Nursing
What are the model concepts of Full-Spectrum Nursing?
- Thinking
- Doing
- Caring
- Patient situation
What are the components of a theory?
phenomena, assumptions, concepts, definitions, and statements/prepositions
worldview or ideology?
Paradigm
Symbolic representation of a framework or concepts?
Model
The nurse notes that his patient has pitting pedal edema, crackles, and an elevated blood pressure. He concludes that the pt. has fluid volume excess. This is an example of:
Theoretical reasoning
Essential concepts of a Nursing Theory
person, environment, health, nursing
The nurse that incorporates Hispanic beliefs about “hot and cold” into her plan of care for her client. This nurse is providing care based on the nursing theory of:
Madeleine Leininger
Steps of the Nurse Research Process
- Identify & state the problem
- Clarify the purpose of the study
- Perform a Literature Review
Systematic collection of data to determine a client’s current and past health status and function status and to determine the client’s present and past coping patterns.
Assessment
Assess overall health status: Observation, Physical assessment, and nursing interview
Comprehensive Assessment
Name 3 requirements Joint Commission uses regarding patient assessment
ALL PATIENTS ASSESSED FOR PAIN, assessments are written, and agency policies are in place related to reassessment and assessment distribution
Perception/feeling of patient, what the patient states.
Subjective data
Observable and measurable can be seen, heard, or felt by another. ex: vital signs, inspection of a wound, description of an observed behavior.
Objective Data
A clinical judgement about individual, family or community responses to actual or potential health problems and or life processes that the nurse is licensed and competent to treat.
Nursing Diagnosis
An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status
collaborative problem
What is 3 part Actual Dx. Process
Diagnostic Label related to contributing factors as evidenced y defining characteristics.
Data that influence your conclusions about the client’s health status. Should alert you to look for other ____ that might be related to it. Usually an unhealthy response.
cues (significant data)
A broad statement that describes the desired change in a patients condition or behavior.
Goal
Individualized to the patient’s needs, developed with the patient, significant other and nurse (mutually determined), documented and shared with health care team to promote continuity.
Interventions
Knowing how, when, and why to perform an activity makes the action _________
autonomous (independent)
Your decisions and actions with regard to nursing diagnoses and independent interventions.
accountable (answering)
One that is prescribed by the physician or advanced practice nurse but carried out by the bedside nurse.
Dependent intervention
A clinicians specific orders for a type/group of patients.
Standing Orders
Strategies/measures/activities/action that influence patient response
outcomes
Focuses on the setting which care is provided
structure evaluation
Is done at a specified time. Ex: Pt. will lose 1 pound per week until weight of 180 pounds is achieved.
Intermittent evaluation
When does the evaluation process with a patient begin?
Whenever contact with patient occurs
Pathology affecting an organ or body system. Experiences are unique to each individual.
Illness
What is the goal of using client history assessment tool to gather data about nutrition, exercise, leisure activities, spirituality, and home environment?
To increase the client’s awareness of lifestyle choices and his or her role in wellness
5 Stages of Illness Behavior
- Experiencing symptoms
- sick role behavior
- seeking professional care
- dependence on others
- recovery
Created a health grid that plots a person status on health-illness continuum against environmental conditions.
Dunn’s Health Grid
Focus on resolving an issue, making a decision.
Task groups
Focuses on a patient achieving optimal personal growth to achieve goals. Consists of a specific time frame, goal directed and high expectation of confidentiality.
Therapeutic communication
Recommends skills, and attitudes to promote safety.
Quality and Safety Education for Nurses (QSEN)
Prevalent in those older than 65 years old; slippery floors, stairs, tubs; low toilet seat, high bed
Falls (Risk For Fall)
Death or serious injury happening in a hospital.
Sentinel Events
Most frequent assessment you will do as a nurse.
Vital Signs
The nurse would monitor the body temperature most closely/frequently in the care of the client with
a. ) an infection
b. ) an infant
c. ) who has experienced a heat stroke
d. ) with a head injury
D. head injry
What are the common pulse points
apical, carotid, brachial, radial, femoral, popliteal, temporal, and pedal
The quantity of blood pumped out by each contraction of the left ventricle
Stroke volume
The nurse is assessing the dorsalis pedis pulses on an 88 year old client. She notes the feet to be cool and assesses weak, thready pulses. The nurses next action would be to:
Assess the popliteal and femoral pulses
Respiration’s that are regular but abnormally deep and increased in rate
Kussmaul’s Respirations
Gradual increase in depth of respiration, followed by gradual decrease and then a period of apnea.
Cheyne-Stokes Respirations
High pitched continuous musical sounds, usually heard on expiration
wheezes
Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds
crackles
A piercing, high-pitched sound heard primarily during inspiration.
Stridor
What should the nurse do if there pt has abnormal respiration’s.
check pulse ox
The nurse performs a physical examination to:
Establish baseline data, identify nursing diagnoses, collaborative problems or wellness diagnosis.
Four major skills used in physical assessment in orders
- ) Inspection
- ) Auscultation
- ) Percussion
- ) Palpation
Identifies nursing responsibilities for administration and client monitoring
Nurse practice act
Defined as what happens to the drug in the body
Pharmacokinetics
Defined as how the drug affects the body
Pharmacodynamics
4 processes of pharmacokinetics
Absorption, Distribution, Metabolism, Excretion
The client has been on a low-protein diet. This will most likely affect which pharmacokinetic process?
Distribution
Concentration of a drug in the blood serum that produces the desired effect without toxicity
Therapeutic Level
Occurs when the drug is at its highest concentration
Peak Level
Occurs when the drug is at its lowest concentration, right before the next dose is due.
Trough level
One drug interferes with the actions of another and decreases the resultant drug effect, the combined effect is less than that of one drug given alone.
Antagonisitc drug reaction
What are the 6 rights?
Patient, Drug, time, dose, route, documentation
Powerful vasodilator that triggers release of inflammatory chemicals that cause the injured area to become red, swollen, and tender.
Bradykinin
Number 1 thing to stop transmission
hand washing
Infections acquired in the hospital. Leading cause of hospital complications.
Nosocomial
Factors the support host defenses
adequate nutrition, balanced hygiene, rest/exercise, reducing stress, immunization
Hair loss, can be very stressful and affect self-image. An autoimmune disorder, hormonal imbalance, thyroid disease, stress, fever, certain medications or chemotherapy.
Alopecia
Affected by light, temperature, social activities, and work routines.
Circadian rhythms
What part of sleep cycle accounts for about 50% or more?
NII
Sudden muscle weakness during intense emotions such as anger, sadness, or laughter; it can occur at anytime during the day.
Cataplexy
Most common sleep disorder; have chronic difficulty falling asleep, frequent awakenings from sleep.
Insomnia
During rounds on the night shift, you note that a patient stops breathing for 20-30 seconds, along with loud snoring and snorting sounds, several times during the shift. This condition is known as:
sleep apnea
a 4 year old pediatric pt. resists going to sleep. To assist this patient, the best action to take would be:
Maintaining the child’s home sleep routine
Sense of awareness of position and movement without seeing it
Kinesthetic
What is arousal mediated by?
Reticular activating system (RAS)
The client who has had a stroke states to the nurse, “You know, I can’t even tell where my left leg is.” This reflects lack of response to stimuli by the:
Proprioceptors
highest priority w/ impaired tactile perception:
Risk for injury
Immobility of this system effects the endocrine, calcium, resorption, and GI function
Metabolic
You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with: A. Atelectasis B. Hypertension C. Orthostatic hypotension D. Thrombus formation
A. Atelectasis
Pacemaker of the heart
SA node
Regulates cardiac function and blood pressure
Brain stem centers
What decreases heart rate due to stress?
catacholines
What lab test shows that there is inflammation in the body?
C-reactive protein
What exchanges Co2 for O2?
alveoli
What is the first thing you should do if patient is lying down and not breathing well?
Sit patient upright to help open up the airways
What is an early sign of hypoxia
- irritability and then confusion
Why is hydration important in oxygenation?
To keep hydrated and make secretions thinner
What is the primary regulator of fluid volume?
Sodium
Movement of ions against osmotic pressure to an area of higher pressure; requires energy
Active transport
Movement of fluid across a membrane, under pressure, from higher to lower pressure
Filtration
What is the most important indicator of fluid imbalance?
Daily weight
Arises from alveolar hypoventilation, lungs unable to excrete enough Co2, excess carbonic acid in the blood decreases pH
Respiratory acidosis
What is the functional unit of the kidney. Responsible for filtration and absorption.
Nephron
Condition where they don’t know when they have to urinate.
hypereflexia
What should your lab value be for specific gravity in urine samples?
No higher than 0.03
After a colostomy what are you looking for?
1st stool
What are the 4 phases of full thickness wound repair?
Hemostatis (stop bleeding)
Inflammatory
proliferative
Maturation (heal by scar formation)
Partial or total separation of wound layers?
Dehiscence
6 major risk factors of pressure ulcers
sensory perception, moisture, activity, nutrition, friction & shear
removal of nonviable, necrotic tissue so as to provide a clean area for viable cells/fibroblasts to migrate as needed for healing
Debridement
What is the most important things you should tell your patients when involving there care?
Speak up if you have any questions or concerns.
Includes memorization, discussion, lecture, question and answer session, role play, discovery, independent project, field experience.
Cognitive learning
Includes receiving and responding to new ideas, demonstrating commitment to or preference for new ideas. Ex: role play, discussion
Affective learning
A person’s perceived ability to successfully complete a task
Self-efficacy
cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.
Health literacy
Charting only significant findings or exceptions to norms. Inadvertent omissions are the biggest problem.
Charting by Exception
For resident assessment and care screening must be completed within 14 days of admission
Minimum data set (MDS)
What do you have to repeat back in order to confirm accuracy of telephone order?
Date, time, med, there name and title, your name and title.
What is a primary benefit of Computer Physician order Entry (CPOE) is:
reduced medication errors
How current does your nursing article have to be?
Within the last 5 years unless based on theory
Identification of an unethical or illegal situation, can involve one person or an entire organization.
Whistleblowing
The act is considered right or wrong regardless of consequences, based on moral or religious rules.
Deontology
Concern for the welfare and well-being of other.
Altruism
Lacks respect for the patients autonomy, when you think you know best and try to coerce someone to act in a way that you think is best
Paternalism
Twofold duty to do no harm and to prevent harm.
nonmaleficence
Ask the patient whether he/she has a living will or durable power of attorney for healthcare
Patient Self-Determination Act
Standards that define what a reasonable and prudent nurse would do in a practice environment.
ANA Standards of Care
Any disturbance in a person’s normal balanced state. Can be harmful or motivating.
Stress
Stress associated with life stages (ex: going to college, college graduation)
Developmental stress
The student nurse has earned “As” in all of her prerequisite courses. For the first exam in a nursing course, she earns a “D” and now feels that she may not be smart enough to become a nurse. What type of “loss” is the student experiencing?
Perceived loss
Mourning and adjustment time following a loss
Bereavement
Who created the phases of grief involving shock, numbness, yearning, searching, disorganization, despair, and reorganization?
John Bowlby
Occurs when the person is grieving, but expressing the grief through other types of behavior.
Masked Grief
A young woman’s fiancé died in a car accident one month prior to their wedding day. Since his death, she has become promiscuous. What type of grief if any, is this woman displaying?
Masked
Loss that is not socially supported or acknowledge by usual rites or ceremonies.
Disenfranchised
Who created the five psychological stages of dying?
Kubler-Ross
What are the 5 stages of dying and grief
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
What is the main priority for a dying patient?
Administer pain medication to keep the patient comfortable
An interconnectedness between God or a higher power and other people
Spiritual well-being
Associated with a specific system of practice associated with denomination, sect, or form of worship
Religion
Gives an individual a motivation and the resources to achieve
Hope
Provides a highly reliable means of declaring death for respirator-maintained bodies- loss of brainstem function
Uniform Determination of Death Act
One who does not believe in the existence of God. Search for meaning in life through their work and their relationships with others.
Atheist
The belief that a force outside of and greater than the person exists beyond the material world.
Transcendence
Helping people identify meaning and purpose in life, look beyond the present, and maintain personal relations and perhaps a relationship with a higher being or life force.
Spiritual care
When caring for patients, the nurse must understand the difference between religion and spirituality. Religious care helps individuals…….
Maintain their belief systems and worship practices.
To assess, evaluate, and support a patient’s spirituality, the best action a nurse can take is to….
Determine the patient’s perceptions and belief system.
Patients that has written wishes and to be followed after death is called?
Advance Directive
Good stress (ex: passionate kiss)
Eustress
Affect body: structure/function (ex: diseases, mobility problems)
Physiological
Arise from life events (ex: work pressure, family arguments)
Psychological
The hospitalized client states, “I need to know when I’m going to be discharged. I’m so upset and worried that I’m missing work.” the nurse knows….
This is an example of distress and could affect the client’s health status.
What are the 3 general approaches for coping, depending on the situation, what are they?
Alter the stressor, adapt to the stressor, avoid the stressor
Ability to adapt depends on:
intensity of stressor
effectiveness of coping
personal factors
Selye’s theoretical model of physiological responses to stress. Nonspecific bodily responses shared by all people. Response to distress as well as eustress
General Adaptation Syndrome (GAS)
What are the Stage of GAS
- Alarm Stage (Fight or Flight)
- Resistance Stage/Exhaustion (goal: maintenance of homeostasis)
- Recovery
Response to stress involving specific body part, tissue, or organ. Short-term attempt to restore homeostasis.
Local Adaptation Syndrome
Local reaction to cell injury, either by pathogens or by physical, chemical, or other agents. 1st is Vascular Response to control bleeding. 2nd Cellular response and then healing.
Inflammatory Response
Continual stress, repeated CNS stimulation, elevation of certain hormones. Will result in long-term changes in body systems.
Stress-Induced Organic
Conditions characterized by the presence of physical symptoms with no known organic cause. Believed to result from unconscious denial, repression, and displacement of anxiety.
Somatoform Disorders
A crisis, burnout, or ptsd patient.
Stress-Induced Psychological Responses
After assessing the crisis intervention situation what is the first thing you should ensure?
Ensure the patient and nurses safety
A patient becomes angry and states “I hate this hospital, nobody knows what they are doing. I should be home by now!” What is a good response by the nurse?
You seem angry; what is going on that makes you say you hate this place/
Who regulates pastoral care within the hospital system?
Joint comission
Uses synthetic dressings over the wound to allow slough to be self-digested by the action of enzymes that are naturally present in wound fluids
Autolytic
Devitalized tissue, whitish-yellow, tan, stringy, loose but attached to bed. (Needs debridment)
Slough
