WEEK 1 CARE PLANNING

Question 1

What is the term for a written legal document that identifies client health
challenges as either 1) clinical Impressions
or 2) potential or at risk clinical Impressions?

Answer 1

Care plan

Question 2

What are 4 sources of data?

Answer 2

1. Head to toe assessment
2. Chart (MAR, interdisciplinary notes)
3. Client/family
4. Labs/diagnostics

Question 3

What is another term for data?

Answer 3

Assessments

Question 4

Define the abbreviations AEB and MB

Answer 4

As Evidenced By and Manifested By

Question 5

What does RT stand for, and what does it mean?

Answer 5

Related To; it is the medically diagnosed cause of the Clinical Impression

Question 6

What if the patient has no formal diagnosis?

Answer 6

Write “undiagnosed cause,” “probable,” or “possible”

Question 7

What is the difference between expected outcomes and goals of care?

Answer 7

Expected outcomes provide proof that the goal has been met (e.g. normal range parameters)

Question 8

Name the 5 headings of the nursing care plan

Answer 8

1. Data
2. Problem
3. Goal
4. Interventions
5. Evaluation

Question 9

What is the nurse concerned with that provides focus for nursing diagnoses?

Answer 9

Human responses that arise from illness that affect the ability to function satisfactorily

Question 10

Name the 3 parts of a clinical impression

Answer 10

1. Challenge
2. Cause of challenge: “Related to”
3. Defining characteristics (signs and symptoms): “As evidenced by”

Question 11

Name 2 parts of a potential or at-risk clinical impression

Answer 11

1. Possible in-future challenge
2. Cause of (non-existant) challenge: “Related to”

Question 12

What is the focus of nursing care?

Answer 12

Help clients to meet their own needs

Question 13

Name 4 roles of the nurse

Answer 13

Instrumental, teach, counsel, guide

Question 14

What is the purpose of the standardized language used in clinical impression statements?

Answer 14

Communicates what nurses are responsible for and accountable to recognize and treat based on their education, experience, and legal scope

Question 15

What are the 2 parts of a goal statement?

Answer 15

1. Outcome
2. Time frame

Question 16

What are the 3 components of a healing initiatives statement?

Answer 16

1. Action word
2. Clear body (who, what, when, where, how, resources needed)
3. Time frame

Question 17

A healing initiatives statement including the words “as ordered” means what?

Answer 17

The action is delegated by the physician and requires an order

Question 18

The evaluation part of the care plan requires the nurse to know what?

Answer 18

Abnormal and normal data

Question 19

Explain why the following clinical impression statement is incorrect:

“Doesn’t know how to take antihypertensives, manifested by statesments of lack of knowledge on drugs, related to hypertension.”

Answer 19

1. Is not worded as the client’s response to medically diagnosed disease
2. Vague; no specific quoted statements
3. Does not clearly define that hypertension was medically diagnosed by a physician

Question 20

Explain why the following clinical impression statement is incorrect:

“Lab values less than normal range for RBC, HGB, and HCT, related to severe blood loss.”

Answer 20

1. States data as clinical impression.
2. Does not state client’s response to medically diagnosed disease.

Question 21

What are 4 goals of patient teaching?

Answer 21

1. Health maintenance
2. Health promotion and disease/injury prevention
3. Illness management
4. Appropriate selection and use of resources

Question 22

What are 2 kinds of patient teaching, and how are they different?

Answer 22

1. Informal teaching: incidental, questions and answers
2. Formal teaching: Specific learning needs identified, goals and teaching plan developed

Question 23

What are the CAP domains of learning?

Answer 23

Cognitive, Affective, Psychomotor

Question 24

What is the nurse’s role in nurse-facilitated teaching groups?

Answer 24

Keeping the information moving among all members

Question 25

What are two of the nurse's roles in technology based interactive teaching?

Answer 25

1. Preview and ensure accurate, complete, and appropriate for meeting learning outcomes 2. Teaching the client how to access credible websites

Question 26

The nurse should ensure printed learning materials meet what criteria?

Answer 26

1. Accurate, complete, focused on topic 2. Include pictures/diagrams 4. Suit the client's learning needs, have the info the patient wants to know 5. Gender and culturally sensitive

Question 27

What are the goals of conducting a therapeutic interview in the affective teaching domain?

Answer 27

1. Help client feel understood: provide reassurance, support, empathy, and respect 2. Decrease the client's resistance to change; increase confidence in ability to change 3. Facilitate client's exploration of self, including inner motivations and strengths

Question 28

What are two types of one-to-one teaching in the psychomotor domain?

Answer 28

1. Demonstration-return demonstration 2. Teach-back strategy

Question 29

What kind of teaching plans are included in caremaps and clinical pathways?

Answer 29

Standardized (pre-printed) teaching plans

Question 30

Name 5 steps to develop a teaching plan

Answer 30

1. Assess ability, motivation, and readiness to learn 2. Identify teaching needs 3. Develop learning goals with the client 4. Implement teaching 5. Evaluate client's learning

Question 31

Briefly define the cognitive learning domain

Answer 31

What the client knows and needs to know

Question 32

Briefly define the affective learning domain

Answer 32

The client's beliefs, values, and perspectives

Question 33

Briefly define the psychomotor learning domain

Answer 33

The client's abilities

Question 34

Name 7 techniques to evaluate if there has been mastery of knowledge, attitudes, and behavioral changes

Answer 34

1. Direct observation 2. Verbal/nonverbal cues observation 3. Direct questions 4. Written measurement tool 5. Talk to client's family 6. Client self evaluation 7. Teach-back method

Question 35

What is a challenge to patient teaching related to elderly age?

Answer 35

Crystallized intelligence persists but fluid intelligence declines (slower to learn, reduced ability to retain info)

Question 36

When a client uses humour during patient teaching, what may this indicate?

Answer 36

It may be a coping mechanism for anxiety

Question 37

What may indicate that a client is not ready to learn?

Answer 37

High stress, denial, or rationalization

Question 38

How should teaching be adapted when the client is in pain or experiencing nausea/vomiting/fatigue?

Answer 38

Provide brief explanations only, do not teach new information until after symptoms are managed.

Question 39

What should the nurse do when planning experiences with consideration of adult learning principles?

Answer 39

Provide opportunities for the client to learn from other adults with similar experiences

Question 40

What skill is necessary for the nurse in the role of teacher?

Answer 40

Determining when clients are too distressed physically of psychologically to learn

Question 41

When the nurse is feeling stress about the limited time available for client teaching, what strategy would be most beneficial?

Answer 41

Setting realistic goals that have high priority for the client

Question 42

What is the best reason for the nurse to choose to include family members in client teaching?

Answer 42

Clients have been shown to have better outcomes when caregivers are involved

Question 43

What are 2 benefits of role play as a teaching strategy?

Answer 43

1. Increased self efficacy of clients and caregivers 2. Rehearses new behaviors

Question 44

The nurse notes that a patient regularly asks about the purpose and potential adverse effects of each oral medication that they have received during their time in the hospital. How should the nurse best interpret the patient’s questions?

Answer 44

The patient is identifying his learning needs

Question 45

Which 2 actions best demonstrate a nurse’s awareness of learning styles and the role they play in patient and caregiver teaching?

Answer 45

1. Assess patients' learning styles prior to teaching 2. Use materials that appeal to a variety of learning styles

Question 46

What are 4 purposes of home care programs?

Answer 46

1. Promote independence 2. Prevent, delay, or substitute for acute or long-term care 3. Assist with the use of community services 4. Supplement the care and support provided by friends and family.

Question 47

What are 4 categories of home care services?

Answer 47

1. Acute 2. Chronic 3. Palliative 4. Rehabilitative

Question 48

Name 6 roles that may comprise a home health care team

Answer 48

1. Community health nurses 2. Home care or home health nurses 3. Case managers 4. Community health or home support workers 5. Nurse practitioners 6. Clinical nurse specialists.