Nursing Health Saftey

Question 1

The American Nursing Associations defines the nursing process as an ongoing and systematic cycle comprised of the following 6 sequential steps:

Answer 1

Assessments
Diagnosis
Outcomes identification
Planning
Implementation
Evaluation

Question 2

Excelsior college teaches the nursing process as 5 sequential steps. What are they?

Answer 2

Assessment
Analysis
Planning
Implementation
Evaluation

Question 3

Standard 1: Assessment refers to what?

Answer 3

A systematic and ongoing collection of data relevant to a pt’s health or to the situation or ambience influencing a pt’s health.

Question 4

Standard 2: Diagnosis definition (ANA)?

Answer 4

The clinical judgement about the healthcare consumers response to actual or potential health conditions or needs.

Question 5

Standard 3: Outcomes identification (ANA)?

Answer 5

Refers to the identification of expected care outcomes that are individualized according to the pt’s presenting needs or diagnosis to the situation in which the pt. is found.

Question 6

Standard 4: Planning (ANA)?

Answer 6

Developing a plan of care and prescribes strategies designed to achieve the expected outcomes.

Question 7

Standard 5: Implementation (ANA)?

Answer 7

May include any or all of activities such as: providing, monitoring, delegating, coordinating, teaching, and counseling.

Question 8

Standard 6: Evaluation (ANA)?

Answer 8

The process of determining the progress toward attainment of expected outcomes, including the effectiveness of care.

Question 9

What are the 5 components of a nursing diagnosis?

Answer 9

1) diagnostic label
2) definition of the diagnosis
3) defining characteristics of a diagnosis
4) risk factors associated with the diagnosis
5) other factors related to the diagnosis

Question 10

What are the 5 types of nursing diagnosis?

Answer 10

1) actual diagnosis
2) health promotion diagnosis
3) risk diagnosis
4) syndrome diagnosis
5) possible diagnosis

Question 11

What are the NANDA-1 axes identified? There are 7 of them.

Answer 11

1) the diagnostic focus
2) subject of the diagnosis
3) judgment

4) location
5) age
6) time

7) status of the diagnosis

Question 12

What are the 4 main care plan components?

Answer 12

EASE!

E - expected outcomes
A - Actual & potential problems
S - specific interventions
E - Evaluation / Progress notes

Question 13

What are the 5 components of outcome statements?

Answer 13

Subject: Who is the person expected to achieve the outcome (e.g., patient or parent)?

• Verb: What actions must the person take to achieve the outcome?
• Condition: Under what circumstances is the person to perform the actions?
• Performance criteria: How well is the person to perform the actions?
• Target time: By when is the person expected to be able to perform the actions?

Example: “Parents will bathe newborn in room independently by 5/8.”

Question 14

Regarding Standard 5 of the Nursing Process, Implementation, what are the subcategories?

Answer 14

5A) Coordination of care

5B) Health teaching and health promotion

Question 15

Regarding Problem-Oriented Medical Record (POMR), what are the 4 basic components? Describe?

Answer 15

1) database - pt’s info
2) problem list - as described
3) plan of care - care plan
4) progress notes - soap format frequently used, as well as soap-ier (interventions, evaluations, revision)

Question 16

What is the PIE documentation model groups information into three categories?

Answer 16

PIE is an acronym for Problems, Interventions, and Evaluation of nursing care. They can also have numbers added, for instance, problem #5, or intervention #3.

If there is no approved nursing diagnosis for a problem, the nurse develops a problem statement using NANDA’s three-part format: client’s response, contributing or probable causes of the response, and characteristics manifested by the client.

Question 17

What is focused charting?

Answer 17

Focus Charting - Focus charting is intended to make the client and client concerns and strengths the focus of care.

The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR.

Question 18

What is Charting by exception?

Answer 18

Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.
CBE incorporates three key elements: flowsheets, standards of nursing care, & bedside access to chart forms.

Question 19

What does ISBAR stand for regarding handoff communication tools?

Answer 19

I-SBAR: Introduction, Situation, Background, Assessment, Recommendation.

Question 20

List the five functions of the initial comprehensive nursing assessment.

Answer 20

a. Make a judgment about a patient’s health status.
b. Make a judgment about a patient’s ability to manage his/her own healthcare.
c. Make a judgment about a patient’s need for nursing.
d. Refer the patient to a physician or other healthcare professional.
e. Plan & deliver individualized, holistic nursing care that draws on the patient’s strengths

Question 21

Identify eight sources of patient data, & give an example of each.

Answer 21

a. Patient: Most patients are willing to share information when they know it is helpful in planning their care.
b. Support people: Family members, friends, & care-givers are helpful sources of data when a patient is a child or has a limited capacity to share information with the nurse.
c. Patient record: A review of the records prepared by different members of the healthcare team provides information essential to comprehensive nursing care.
d. Medical history, physical examination, & progress notes: Sources that record the findings of physicians as they assess & treat the patient.
e. Reports of laboratory & other diagnostic studies:

These sources (e.g., x-rays & diagnostic tests) can either confirm or conflict with data collected during the nursing history or examination.

210 f. Reports of therapies by other healthcare professionals: Other healthcare professionals record their findings & note progress in specific areas (e.g., nutrition, physical therapy, or speech therapy).

g. Other healthcare professionals: Other nurses, physicians, social workers, etc., can provide information about a patient’s normal health habits & patterns & response to illness.
h. Nursing & other healthcare literature: If a nurse is unfamiliar with a disease, it is important for him/her to read about the clinical manifestations of the disease & its usual progression to know what to look for when assessing the patient

Question 22

Briefly describe why the following characteristics of data are important when collecting & recording patient data.

a. Purposeful: ___________________________________________________________________________
b. Complete: ___________________________________________________________________________
c. Factual & accurate: __________________________________________________________________
d. Relevant: _____________________________________________________________________________

Answer 22

a. Purposeful: the nurse must identify the purpose of the nursing assessment (comprehensive, focused, emergency, time-lapsed) & then gather the appropriate data.
b. Complete: All patient data need to be identified to understand a patient’s health problem & develop a plan of care to maximize health promotion.
c. Factual & accurate: Nurses concerned with accuracy & fact must continually verify what they hear with what they observe using other senses & validate all questionable data.
d. Relevant: Because recording data can become an endless task, nurses must determine what type of data & how much data to collect for each patient.

Question 23

Give an example of three observations nurses should make each time they encounter a patient.

Answer 23

a. What are the patient’s current responses to his/her situation?
b. What is the patient’s current ability to manage his/her care?
c. What is the immediate environment?

Question 24

List three patient goals that should be accomplished by the end of the introduction phase of the patient interview.

Answer 24

a. Patient should know the name of his/her primary nurse & what he/she can expect of nursing.
b. Patient should sense that the nurse is competent & cares about him/her.
c. Patient should know what is expected of him/her in terms of developing the plan of care & participating in its execution.

Question 25

Give two examples of closed questions, open-ended questions, & reflective questions that could be used to elicit information from your patient, a 42-year-old mother of three young children who has recently been diagnosed with diabetes; she is admitted to the hospital overnight for observation.

a. Closed questions: _________________________________________________________________________
b. Open-ended questions: ___________________________________________________________________
c. Reflective questions: ______________________________________________________________________

Answer 25

a. Closed questions:

How long have you been experiencing these symptoms?

How many children do you have at home?

b. Open-ended questions:

How will you modify your diet now that you have been diagnosed with diabetes?

What do you know about insulin injections?

c. Reflective questions:

What effect will diabetes have on your life? How do you feel about using insulin injections to control your diabetes?

Question 26

Explain how the following factors affect assessment priorities when collecting patient data.

a. Patient’s health orientation: _______________________________________________________________
b. Patient’s developmental stage: ____________________________________________________________
c. Patient’s need for nursing: _________________________________________________________________

Answer 26

a. Patient’s health orientation: Patients must identify potential & actual health risks & explore habits, behaviors, beliefs, attitudes, & values that influence levels of health.
b. Patient’s developmental stage: Nursing assessments are modified according to the patient’s develop- mental stage.
c. Patient’s need for nursing: Whether the nurse will interact with the patient for a short or long period & the nature of nursing care needs influence the type of data the nurse collects.

Question 27

Give two examples of when data need to be validated.

a. _____________________________
b. ________________________________________

Answer 27

a. When there are discrepancies (e.g., a patient claims he has no pain but grimaces when you touch his chest)
b. When the data lack objectivity (e.g., when a patient claims to have 20/20 vision but holds his reading material far away from his face).

Question 28

Explain when the immediate communication of data is indicated: _____________________________

Answer 28

Immediate communication of data is indicated whenever assessment findings reveal a critical change in the patient’s health status that necessitates the involvement of other nurses or healthcare professionals.

Question 29

What 3 basic components does a nursing diagnosis generally include?

Answer 29

Actual