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Foundations Of Nursing > Test 2 > Flashcards

Test 2 Flashcards

1
Q

What is the nursing process in order?

A

ADPIE (Assessment, Diagnosis, Planning, Implementing, Evaluating)

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2
Q

The type of knowledge that is based on scientific facts (akin to the knowledge found in a textbook).

A

Theoretical Knowledge

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3
Q

The type of knowledge which involves what to do and how to do tasks and skills safely.

A

Practical Knowledge

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4
Q

The type of knowledge that includes our own preferences or biases that may influence our thinking.

A

Self-Knowledge

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5
Q

Which knowledge is based on HOW to do something.

A

Practical Knowledge

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6
Q

Which knowledge is based on what to do and why to do it?

A

Theoretical Knowledge

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7
Q

What knowledge is based off of experiences?

A

Self-Knowledge

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8
Q

What knowledge helps a person handle situations where there is an element of right and wrong?

A

Ethical knowledge

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9
Q

This type of data comes directly from the patient.

A

Subjective data

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10
Q

This type of data is quantitative data or observable that is easily measured.

A

Objective data

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11
Q

This type of data can be deemed as “factual.”

A

Objective data

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12
Q

This part of the nursing assessment is the data gathering.

A

Assessment

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13
Q

This type of assessment is initiated upon first contact with a patient.

A

Initial assessment

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14
Q

This type of assessment is continuing the plan of care.

A

Ongoing assessment

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15
Q

This type of assessment explores the patient’s single complaint or symptom (often focuses on the primary concern).

A

Focused assessment

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16
Q

This type of assessment includes information about a person’s social and situational status, home support systems, holistic assessment of the patient’s beliefs and spiritual needs, what kind of assistance the patient has, and if the patient needs a discharge.

A

Comprehensive assessment

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17
Q

If information comes from another source than the patient, it is considered a ________ source.

A

Secondary

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18
Q

If the information comes directly from the patient, it is considered a __________ source

A

Primary

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19
Q

The statement of client health status that nurses can identify, prevent, or treat independently.

A

Nursing diagnosis

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20
Q

What is the major difference between nursing and medical diagnoses?

A

Medical is narrow; Nursing is broad. Nursing diagnoses are customizable to the patient’s individual needs.

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21
Q

What are the five types of nursing diagnoses?

A
  1. Actual
  2. Potential
  3. Collaborative
  4. Wellness
  5. Syndrome
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22
Q

What type of diagnoses are a predetermined cluster of nursing diagnoses that occur together? (Chronic Pain Syndrome)

A

Syndrome Diagnoses

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23
Q

What type of diagnoses are not identifying a problem but rather an area for improvement or to support health behaviors that are already happening? (Readiness for enhanced nutrition)

A

Wellness Diagnoses

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24
Q

What type of diagnoses address a problem with the probably cause and observable evidence? (Impaired swallowing related to sore throat)

A

Actual Diagnoses

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25
Q

What type of diagnoses focuses on problems that a patient may not have ye, but are clearly at risk for developing? (Risk for Falls)

A

Potential Diagnoses

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26
Q

What type of diagnoses requires collaboration with a provider to get orders in place?

A

Collaborative Diagnoses

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27
Q

What are the steps of developing a nursing diagnosis?

A

ADPIE

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28
Q

What is a PES statement?

A

Problem-Etiology-Symptoms

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29
Q

How does a PES statement work?

A

Problem (related to) etiology (as evidenced by) symptoms

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30
Q

What is the first part of the nursing diagnosis statement?

A

The NANDA label

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31
Q

What is the second part of the nursing diagnosis statement?

A

The etiology

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32
Q

What is the third part of the nursing diagnosis statement?

A

Evidence supporting your diagnosis or symptoms the patient is manifesting

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33
Q

What is a three part nursing diagnosis statement called?

A

A PES statement

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34
Q

What the five Maslow’s Hierarchy of Needs?

A
  1. Physiological Needs (Most Important)
  2. Safety Needs
  3. Belongingness and Love
  4. Esteem Needs
  5. Self-Actualization (Least Important)
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35
Q

What are the two main ways to prioritize the patient’s needs?

A
  1. ABC’s

2. Maslow’s Hierarchy of Needs

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36
Q

Which is higher priority out of acute vs chronic?

A

Acute

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37
Q

Which is the higher priority out of actual vs potential?

A

Actual

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38
Q

Critical thinking is the process of ______ ______.

A

Problem Solving

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39
Q

Theoretical knowledge is ______ based, whereas practical knowledge is knowing _____ to do a task properly.

A

science; how

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40
Q

________ may not be delegated to an assistive personnel.

A

Assessment

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41
Q

A head-to-toe assessment done during every shift is an example of what kind of assessment?

A

Ongoing

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42
Q

Does a focused assessment always only focus on one body system?

A

No

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43
Q

Which type of assessment evaluates the potential presence of domestic violence?

A

Psychosocial

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44
Q

Vital signs using a Dinamap are an example of what kind of data? Coming from what kind of source?

A

Objective; Secondary

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45
Q

Patient’s blood pressure is elevated, so the nurse checks with the patient to assess for a probable cause is what?

A

Validation

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46
Q

What will help the nurse to make sure that they gather all the necessary information to make an informed decision and draw correct conclusions?

A

Having a questioning attitude

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47
Q

The process of analyzing data, identifying patterns, and drawing conclusions.

A

Diagnostic Reasoning

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48
Q

True or False: There will always be exactly one nursing diagnosis for every medical diagnosis

A

FALSE

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49
Q

Nursing diagnoses are judgments based on ______ made in our nursing assessments.

A

Inferences

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50
Q

How many nursing diagnoses are there?

A

234

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51
Q

What type of nursing diagnosis only uses the NANDA label (problem statement) and an evidence statement?

A

Wellness diagnosis

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52
Q

What type of nursing diagnosis only uses the problem statement and etiology?

A

Potential Diagnosis (Risk For)

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53
Q

When would you include a “secondary to” statement?

A

When we are pointing out that we are address the collateral health manifestation and not the prevailing condition

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54
Q

What is the primary concern in Maslow’s Hierarchy of Needs?

A

Physiological (What is going to kill your patient the fastest?)

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55
Q

Love and belonging is what level of Maslow’s?

A

Third

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56
Q

Nursing diagnosis is always the result of a nursing ___________.

A

Assessment

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57
Q

What are continuous and change over time?

A

Plans

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58
Q

Predictions of changes in a patient’s health status that we expect the patient to achieve.

A

Expected Client Outcome (ECO)

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59
Q

ECO is always written in the terms of _____ ______.

A

Patient activity

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60
Q

In an ECO, what always must be the priority?

A

The Patient

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61
Q

What drives the ECO statement?

A

The NANDA problem and symptoms

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62
Q

What is the SMART mnemonic used for?

A

To narrow in your ECO goal.

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63
Q

What does SMART stand for?

A 
Is the goal:
S: Specific 
M: Measurable 
A: Attainable/Achievable
R: Relevant/Realistic
T: Time Bound
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64
Q

If a nurse delegates a task to an aid or NCP, who is responsible for making sure the task gets completed?

A

The nurse

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65
Q

Short term ECOs usually take place for how long?

A

During the admission of the patient

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66
Q

What type of intervention are those that nurses can put into place without the guidance of a provider? (Ex: ambulating a patient)

A

Independent intervention

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67
Q

What type of intervention involves collaboration with ancillary staff? (Ex: utilizing physical therapy)

A

Interdependent intervention

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68
Q

What type of intervention requires a provider order? (Ex: medications and diagnostics tests)

A

Dependent intervention

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69
Q

Transferring responsibility for the performance of a task while retaining accountability for a safe outcome.

A

Delegation

70
Q

What type of intervention includes monitoring the patient or collecting data to evaluate their status?

A

Assess Intervention

71
Q

What type of intervention is something the patient or the nurse will perform in order to effect a change?

A

Action intervention

72
Q

What type of intervention includes teaching the patient?

A

Education intervention

73
Q

What type of intervention is preventing the potential problem from becoming an actual problem?

A

Prevention intervention

74
Q

Patients plans of care based on selected nursing diagnoses are called _____ ______.

A

Standardized plans

75
Q

A pre-set plan based on standard of care for the predetermined diagnosis.

A

Critical pathways

76
Q

What are the three phases of implementation?

A
  • Doing
  • Delegating
  • Documenting
77
Q

Knowing that patient’s needs and advocating for their care with other providers is considered what?

A

Collaboration

78
Q

Communicating the plan of care to multiple providers.

A

Coordination of Care

79
Q

What are the 5 Rights to Delegation

A
  1. Right Task
  2. Right Circumstance
  3. Right Person
  4. Right Communication
  5. Right Supervision
80
Q

The close the loop communication is what right?

A

Right Communication

81
Q

This type of evaluation is performed while:

  • implementing an intervention
  • immediately after an intervention
  • with each patient contact
A

Ongoing evaluation

82
Q

This type of evaluation is performed at specific times and is conditional.

A

Intermittent evaluation

83
Q

This type of evaluation is the assessment of the progress made towards the goal at the time of discharge.

A

Terminal evaluation

84
Q

What are the three ways to determine if an ECO has been met?

A
  • Met
  • Partially Met
  • Not Met
85
Q

Under what circumstances should a goal be revised?

A

If the outcome is partially met or not met

86
Q

What must you do if a goal is partially met or not met?

A

Revise for a more attainable goal

87
Q

What portions of the plan must be reviewed if a goal is partially met or not met?

A

All steps

  • Diagnosis
  • Assessment
  • Planning Outcomes
  • Planning Interventions
  • Implementation
88
Q

Nurse driven outcomes are an outcome where nurses have a direct, autonomous impact. What is an example of a nurse driven outcome?

A

Hospital Acquired Pressure Injury (HAPI)

89
Q

True or False: It is easier to measure demonstration than it is to measure understanding.

90
Q

A nutrition consult is an example of what type of intervention?

A

Collaborative

91
Q

What type of intervention requires a provider’s order?

92
Q

Vital signs are an example of what kind of intervention?

93
Q

Speaking with a provider to obtain an order for medication is an example of what kind of intervention?

94
Q

“Bridging the Gap” by providing information between 2 separate health care providers in providing care for a patient is an example of what?

A

Coordination of Care

95
Q

A conditional assessment to re-evaluate for improvement after an intervention is what kind of evaluation?

A

Intermittent

96
Q

Reassessments during an evaluation of the ECO is an ______ assessment.

97
Q

If a desired patient response is observed some of the time, but not 100% of the time, the goal is what?

A

Partially met

98
Q

An evaluation is an assessment that occurs ______ an action or intervention.

99
Q

When can you discontinue a care plan, based on your evaluation?

A

After goals have been met

100
Q

Which of the following is the primary nursing diagnosis?
A. Risk For Falls
B. Readiness for Enhanced Resilience
C. Constipation

A

C. Constipation

101
Q

What is the priority nursing diagnosis?
A. Acute Pain
B. Chronic Urine Retention
C. Disturbed Sensory Perception (Visual)

A

A. Acute Pain

102
Q

What is the priority nursing diagnosis?
A. Sleep Deprivation
B. Ineffective Breathing Pattern
C. Dysfunctional GI motility

A

B. Ineffective Breathing Pattern

103
Q

According to Maslow’s, what is the priority nursing diagnosis?
A. Disturbed sensory perception (auditory)
B. Disturbed body image
C. Spiritual Distress

A

A. Disturbed sensory perception (auditory)

104
Q

Using ABCs, what is the priority nursing diagnosis?
A. Ineffective breathing pattern
B. Ineffective airway clearance
C. Deficient fluid volume

A

B. Ineffective airway clearance

105
Q

What is the priority nursing diagnosis?
A. Impaired mobility
B. Risk for Injury
C. Anxiety

A

A. Impaired mobility

106
Q

What is the priority nursing diagnosis?
A. Deficient fluid volume
B. Impaired gas exchange
C. Chronic pain

A

B. Impaired gas exchange

107
Q

What is the priority nursing diagnosis?
A. Risk for infection
B. Acute Confusion
C. Complicated grieving

A

B. Acute Confusion

108
Q

Which lab is the best indicator of nutritional status in a patient?

A

Pre-albumin

109
Q

True or False: Albumin is not the most accurate way of measuring the patient’s nutritional status if they also have a fluid imbalance.

110
Q

Obesity occurs in how many adults in the United States?

A

2/3 of the population

111
Q

What are the interventions for Imbalance: More Than (Name 4)

A
  • Evaluate Endocrine Problems
  • Food Diary
  • Make healthy choices (shop smart)
  • Weekly weigh-ins
  • Calorie Counting/Meal Planning
  • Adequate Sleep
  • Exercise
  • Emotional Support
112
Q

What are the interventions for Imbalance: Less Than (Name 4)

A
  • Supplements (Vitamins, Minerals, Diet-Specific)
  • Food stamps/Community Resources
  • Meals on Wheels
  • Increase community and socialization
  • Assist to feed the patient
  • Increase Appetite
  • Enteral/Parenteral Feedings
113
Q

True or False: Enteral feedings are preferred to parenteral or IV nutrition because they have lower incidence of sepsis or infection.

114
Q

How long can a closed feeding system be run for? (Max)

115
Q

How long can an open feeding system be run for? (Max)

116
Q

What are 2 subjective assessments of a patient’s nutritional status?

A
  • Food diary

- 24 hour recall

117
Q

What are 3 objective measurements of a patient’s nutritional status?

A
  • Abdominal appearance
  • Skin fold measurements
  • Lab Values
118
Q

What developmental stage does the patient need to eat frequently?

119
Q

What developmental stage does the patient tend to have body image issues?

A

Adolescence

120
Q

What development stage does the patient have decreased senses?

A

Older adult

121
Q

What developmental stage does the patient need more calcium, protein, and folic acid?

A

Childbearing

122
Q

What developmental stage does the patient have newfound independence which puts them at a risk of nutritional imbalance?

123
Q

What are the risks of obesity?

A
  • Obstructive Sleep Apnea
  • Stroke
  • HTN
  • Diabetes
  • Gallbladder disease
  • Heart Disease
124
Q

What nutrients are those who follow a vegetarian or vegan diet most likely to experience a deficiency?

A

Protein, Calcium, Vit B12

125
Q

What must be done prior to the first infusion of tube feeding through a nasogastric (NG) tube?

A

A chest xray to check for placement

126
Q

Name 5 interventions done for a patient who is at risk for aspiration

A
  1. Auscultate breath sounds after meals
  2. Keep suction nearby
  3. Keep neck in forward flexion
  4. Avoid straws
  5. Check Mouth for pocketing
127
Q

Name 5 interventions done for a patient with nausea

A
  1. Keep mouth moist
  2. Encourage small meals
  3. Eat bland foods
  4. Remain in upright position after eating for 30-45 min
  5. Limit offense/strong odors
128
Q

How long must a patient be NPO after vomiting?

129
Q

How often is the UDSA guidelines updated?

A

Every 5 years

130
Q

What do the colors stand for in the “Choose My Plate” Guide?

A 
Red- Fruits
Green- Vegetables
Orange- Grains
Purple- Proteins
Blue- Dairy
131
Q

Water, Black coffee, Tea (with no cream), Chicken broth, clear juices (apple juice, grape juice, cranberry juices), popsicles, carbonated beverages, and Jello are examples of what?

A

Clear liquid diet

132
Q

Creamy soups, milk or milkshakes, pudding, custards, cream of wheat hot cereal, yogurt, orange and tomato juice (in addition to clear liquid diet) are examples of what?

A

Full liquid diet

133
Q

A mechanical soft diet is typically low in what?

134
Q

Healing with minimal scarring (usually by surgical incision)

A

Primary intention

135
Q

This type of healing has the largest scarring

A

Secondary intention

136
Q

This healing is a combination of primary and secondary

A

Tertiary intention

137
Q

This type of healing is where the wound is left open

A

Tertiary intention

138
Q

The type of wound that extends beyond the dermis into the subcutaneous layer or even beyond into the muscular layer is called?

A

Full thickness wound

139
Q

This type of wound only includes the top layer or two of skin: the dermis and epidermis

A

Partial thickness wound

140
Q

What kind of wound drainage is yellow?

141
Q

What kind of wound drainage is bright red?

A

Sanguineous

142
Q

How often should a NG tube be flushed?

A

Anytime a feeding cycle is started and stopped and both before and after a medication

143
Q

What kind of wound drainage is pink and watery?

A

Serosanguineous

144
Q

What kind of wound drainage is creamy and yellow (pus)?

A

Purulent exudate

145
Q

What are the two types of wound drainage that are related to pressure injuries?

A
  • Slough

- Eschar

146
Q

What kind of wound drainage is necrotic tissue that’s black?

147
Q

What kind of wound drainage is a thick, stringy, and waxy yellow substance?

148
Q

What are the most vulnerable to increased pressure?

A

Bony prominences

149
Q

What are the four risk factors for pressure injury?

A
  1. Patient is already having problem with decreased blood flow (ex: diabetics)
  2. Prolonged immobility
  3. The presence of pressure from medical devices/tubes
  4. Decreased sensation
150
Q

What are the six categories that the Braden Scale includes?

A
  1. Sensory Perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction & Shear
151
Q

What kind of nursing plan is a Braden Scale assessment?

A

Independent

152
Q

What score on the Braden Scale indicates risk for pressure injury?

A

Anything 18 or less.

153
Q

A wound where it cannot be seen or assessed because of the tissue covering it.

A

Unstageable wound

154
Q

A wound that involves only the epidermis and the skin is nonblanchable.

A

Stage I Pressure Injury

155
Q

A wound that goes beyond the dermis and the subcutaneous layer into the muscular layer, sometimes exposing the bone

A

Stage IV pressure injury

156
Q

A wound that is the breakdown beyond the dermis and extends into the subcutaneous tissue.

A

Stage III pressure injury

157
Q

A wound that has broken into the skin but only affects the superficial dermal layer

A

Stage II pressure injury

158
Q

What stage(s) of a pressure injury involve full thickness loss?

A

Stage III and IV

159
Q

What stage(s) of a pressure injury involve partial thickness loss?

160
Q

Are pressure injuries always preventable?

161
Q

What are the 6 interventions for risk of pressure injuries?

A
  • Prevention
  • Skin Care/Moisture Control
  • Adequate Nutrition
  • Frequent repositioning
  • Therapeutic Mattresses
  • Client/Family Teaching
162
Q

How long can a patient remain NPO before requiring alternative nutrition?

163
Q

What is the criteria to advance a patient’s diet from full liquids to a regular diet?

A

No nausea/vomiting after a meal

164
Q

This type of wound healing consists of the wound healing from the “inside out” or the tissue filling in the wound bed from the bottom up.

A

Secondary intention

165
Q

This type of wound healing involves a delayed surgical closure.

A

Tertiary intention

166
Q

Ischemia from decreased blood flow causes breakdown in the skin which causes what?

A

pressure injury

167
Q

A patient who is incontinent and requiring linen changes 3 times each shift would score what on a Braden scale?

168
Q

What are the 6 things to include when documenting a wound assessment?

A
  1. Size
  2. Location
  3. Appearance
  4. Drainage
  5. Peri-wound areas
  6. Pain
169
Q

How many extra calories does a pregnant woman need a day?

A

300 calories

170
Q

What substance can interfere with the absorption of nutrients in food?

171
Q

Individuals with traumatic injuries need what extra nutrients for wound healing and tissue rebuilding?

A

Proteins and Vitamin C

Foundations Of Nursing (7 decks)

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