Quiz 2

Question 1

Distinguishing relevant from irrelevant

Determining important information

Managing potential complications

Falls under Recognizing Cues

Answer 1

Interpreting (Tanners)

Question 2

Gathering information through senses

Consider cues in context of client Hx & situation

Distinguishing relevant from irrelevant / expected vs not expected

Whats more concerning

Answer 2

Analyzing cues

Question 3

What is the goal of interpreting data?

Answer 3

Analyzing & prioritizing data

Question 4

Organizing data w/ common theme
* Theme is releated to situations; pick system related to systems/objective/subjective data

Based on what RN notices

Clustered infor needed for RN Dx

Ex of theme:
* Pain: Rating, PQRST, & pain meds
* FVO: Abnorm lung sounds, edema, weight gain, increased BP, SOB
* Infection: Increased temp, increased WBC, drainage, odor, swelling, cultures

Answer 4

Clustering Related Information

Question 5

Determining that the data apperas to lead to opposing conclusions & more infor needed

What is unlike, dissimilar, & deveates from what is expected

Answer 5

Recognizing consistencies

Question 6

Determining if & how data nees to be confirmed before being acted upon

Pt safety at risk when errors aren’t met

Recheck when questioning data

Look at vitals

Answer 6

Checking accuracy & reliability

Question 7

S: Sleep problems
P: Problems eating
I: Incontinence
C: Confusion
E: Evidence of falls
S: Skin breakdown

Answer 7

SPICES tool

Question 8

The identification of a disease condition based on a specific assessment of physical S/s, medical Hx, & test/lab results

Language of HCP
* physicians
* advanced practice nurses (midwife/NP)

Ex:
* DM
* pneumonia

Answer 8

Medical Dx

Question 9

Clinical judgement made by RN to describe the pts response or vulnerability to health conditions or life events that the nurse is licensed & competent to treat

Diagnostic label that classifies an individuals/families/communities response to illness

Ex:
* impaired respiratory system - impaired gas exchange
* impaired tissue integrity
* impaired swallowing

Answer 9

Nursing Dx

Question 10

Nurse educators recognized that assessment data need to be analyzed & clustered into patterns & interpreted before RNs could make accurate RN DXs

Answer 10

NANDA International (NANDA-I)

Question 11

Which type of data helps a nuse to think less about individual data points & instead focus on pattern recognition?

A) Subjective data
B) Data Clusters
C) Objective data

Answer 11

B) Data Clusters

Question 12

Involves placing lables on your data patterrn or cluster to clealy identify a pts response to a health problem

Answer 12

Data interpretation

Question 13

Errors occur if you cluster data prematurely, incorrectly, or not at all

Occurs when you make a nursing Dx before grouping all patient data

Answer 13

Errors in Data Clustering

Question 14

T/F: RNs can treat medical Dx

Answer 14

False - A RN cannot treat medical Dx; instead, they treat patients responses to the medical health condition

Question 15

Involves analyzing data gathered about a patient for pattern recognition & validation of avalible cues
* Requires making clinical judgement decisions

Answer 15

Nursing Diagnostic Reasoning

Question 16

What is the diference between a problem-focused nursing Dx (Negative Dx) & a risk nursing Dx?

Answer 16

Problem-focused (Negative Dx): Identifies actual undesirable human response to existing health problems

Risk nursing Dx: Identifies when there is an increasedpotential or volnerability for a patient to develope a problem or complication

Question 17

What should a nursing Dx be gathered from?

Answer 17

A cluster of assessment findings

Question 18

Problem-focused / negative Dx take priority over what other Dxs?

Answer 18

Wellness Dx

At-risk Dx

Health-promotion Dx

Question 19

_ pts normally take priority over _ pts.

A) Short-term acute ; Long-term chronic
B) Long-term chronic ; Short-term acute

Answer 19

A) Short-term acute ; Long-term chronic

Question 20

Measurable pt, family, or community behavior or perception that is measured in response to nursing interventions

Valid & reliable means to support nursing care quality & performance measurement in health care setting

Answer 20

Nurse-sensative patient outcome

Question 21

What do the letters stand for in SMART?

Answer 21

S: Specific
* Outcomes reflect a specific patient behavior or response
* Ex: For pt w/ impaired mobility an outcome statement is “ Pt ambulates hall 3x/day by 4/22” ; Common error is to write “Pt ambulates hallway

M: Measurable
* Be able to measure or observe whether a change takes place in a pts status
* Ex: Body temp will remain below 37 degrees C (98.6F)” ;Don not use vage words (Normal, acceptable, stable)

A: Attainable
* Outcomes are more achievable when mutually set w/ pt
* always consider pts desire to recover & their physical / psychlogical condition

R: Realistic
* Set expected outcomes that are realistic & relavent for pts
* Ex: Are the pts cultural beliefs reflected in outcomes you set? ; “Pt will wash hands & face in 72hrs”

T: Timed
* Set time for each outcome to be met in order to help solve pt problems
* Help determine pt progress

Question 22

Complex process involving 2 or more people from various professional fields to acheive common outcomes for a pt

Involves all health care providers working together

Answer 22

Interprofessional collaboration