Fundamentals Exam 3

Question 1

What is a nursing diagnosis?

Answer 1

a statement of client health that a nurse can identify, prevent, and treat independently. has ZERO medical diagnosis in it

Question 2

What is the nursing process?

Answer 2

a systematic problem solving process that guides all nursing actions

Question 3

What is a medical diagnosis?

Answer 3

describes a disease, illness, or injury. only doctors can prescribe and use a medical diagnosis.

Question 4

What is the role of the home health nurse?

What is a goal at the beginning of a visit?

Answer 4

Home health provider, educator, advocate, care coordinator.
Describe changes in clients health status that you hope to achieve. Ensure safety of client and self

Question 5

What is the time frame for a short-term goal?

Answer 5

a few hours or days

Question 6

Name the 4 pioneers of community health nursing and their contribution.

Answer 6

Florence Nightingale- patients benefit from a cleaner environment
Margaret Singer- founder of Planned Parenthood
Lillian Wald- first community health nurse
Clara Barton- founder of Red Cross

Question 7

What is the first stage of the nursing process and what happens in this stage?

Answer 7

assessment. gather data, recognize cues related to the physical, mental, spiritual, cultural, and social economic status

Question 8

PERRLA

Answer 8

Pupil, Equal, Round, Reactive, Light, Accomadation

Question 9

7 Rights of Medication

Answer 9

Right Patient, Right Drug, Right Dosage, Right Time, Right Reason, Right Documentation, Right Route

Question 10

What does ADPIE stand for?

Answer 10

assessment, diagnosis, planning, implementation (interventions and outcome), and evaluation.

Question 11

What is a SMART goal?

Answer 11

specific, measurable, achievable, relevant, and time-bound.

Question 12

What is the time frame for a long-term goal?

Answer 12

a week, month, or more

Question 13

What are the 5 Rights of Delegation?

Answer 13

right task, right circumstances, right person, right direction or communication, right supervision

Question 14

What is subjective data?

What is objective data?

Answer 14

subjective date- what the patient tells you
objective data- facts. vitals signs

Question 15

What is primary data?

What is secondary data?

Answer 15

primary data- from the patient
secondary- Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature

Question 16

What is a comprehensive assessment?

Answer 16

a tool used by nurses to evaluate a patient’s complete health status. This includes the patient’s physical, mental, lifestyle, and socioeconomic condition. The assessment is the first step in developing a plan of care.

Question 17

When do you complete an initial assessment?

When is an ongoing assessment completed?

Answer 17

initial- very first assessment
ongoing assessment- a continuing process of assessment of the patient and the patient’s family as a means of clarifying the status of the patient

Question 18

Name 3 types of special needs assessments.

Answer 18

braden scale assessment, fall assessment, emergency assessment

Question 19

What type of questions are used in an interview? Explain each.

Answer 19

open ended and closed ended. open ended is patient can go further in explaining and closed ended is yes and no questions

Question 20

When do you validate data?

Answer 20

every time.

Question 21

How do you prioritize problems?

Answer 21

order of importance or urgency. Use the ABCs or Maslow’s Hierarchy of Needs

Question 22

Explain Maslow’s Hierarchy of Needs

Answer 22

Maslow’s hierarchy of needs is a theory of motivation which states that five categories of human needs dictate an individual’s behavior. Those needs are physiological needs, safety needs, love and belonging needs, esteem needs, and self-actualization needs.

Question 23

What are characteristics of critical thinking?

Answer 23

felxible, non-judgemental, purposeful, and

Question 24

What information is included in writing a goal or expected outcome?

What is the purpose of an outcome?

Answer 24

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

Question 25

What is the role of the case manager in community health nursing?

Answer 25

Nurse case managers are responsible for planning and providing efficient and high-quality healthcare and being a patient advocate.

Question 26

Why is it important to be a critical thinker?

Answer 26

nurses are faced with complex situations, fast paced, and nurses apply knowledge to provide holistic care

Question 27

What is the difference between community health nursing and public health nursing?

Answer 27

the difference is community health focuses on individuals, families, and groups that affect the community as a whole
public health focuses on the community as a whole and the effects of the communities health status

Question 28

What information is needed in a nursing diagnosis statement?

Answer 28

the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. actual, risk, and wellness.

Question 29

How does a nursing diagnosis differ from a medical diagnosis?

Answer 29

nursing diagnosis doesn’t diagnose the patient

Question 30

Who is responsible for a delegated task?

Answer 30

the person who delegated the task

Question 31

When is evaluation data collected and how is it used?

Answer 31

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the expected outcomes to determine if they were met by the time frames indicated.

Question 32

How does a home health nurse keep himself/herself safe?

Answer 32

prior to the visit the home health nurse must contact the client about safety issues and pets. Assess the area for safety concerns.

Question 33

What are the levels of health prevention?

What occurs at each level?

Answer 33

Three levels.
Primary: healthy eating, exercising, immunizations
Secondary: annual physical exams, diabetes screens
Tertiary: rehab