240 old quizzes final exam study

question

Which of the following outcomes is correctly written?
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On discharge, patient will be able to list five symptoms of infection.
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What is the primary purpose of the outcome identification and planning step of the nursing process?
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to design a plan of care for and with the patient
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A plan of care for a patient with a low potassium level includes providing information about the effect of medications and dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan?
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laboratory data
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A nurse is collecting information from Mr. Koeppe, a patient with dementia. The patient’s daughter, Sarah, accompanies the patient. Which of the following statements by the nurse would recognize the patient’s value as an individual?
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“Mr. Koeppe, tell me what you do to take care of yourself.”
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A nurse is formulating a nursing diagnosis for a patient with a respiratory disease. Which of the following would be correct?
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“ineffective airway clearance related to thick mucus”
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A nurse has developed a plan of care with nursing interventions designed to meet specific patient outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?
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Make recommendations for revising the plan of care.
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Which of the following group of terms best defines assessing in the nursing process?
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collection, validation, communication of patient data
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A nurse is collecting data from a home care patient. In addition to information about the patient’s health status, what is another observation the nurse should make?
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safety of the immediate environment
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A student takes an adult patient’s pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?
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Ask the instructor or a staff nurse to take the pulse.
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A nurse is teaching a patient how to administer insulin, with the expected outcome that the patient will be able to self-administer the insulin injection. How would this outcome be evaluated?
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asking the pt to preform the injection in front of you
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Patient lost 2 of the 5 pound/month goal. How should the nurse alter the plan of care in response to this new data?
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The nurse should modify the time criteria.
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What is the primary purpose of validation as a part of assessment?
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to plan appropriate nursing care
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A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next?
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Collect data about patient responses.
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On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?
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the response of the patient to the illness
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Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?
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The nursing diagnosis is based on patient response to the medical diagnosis.
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A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?
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“Do you take anything to help your constipation?”
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A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself?
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sitting at a 45-degree angle to the bed
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A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
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possible problem
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A nurse writes the following nursing diagnosis for a patient with Alzheimer’s: Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?
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disturbed thought processes
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Nurses evaluate many aspects of the healthcare delivery system. Which of the following is always the primary concern when performing the evaluating step of the nursing process?
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the patient
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What is the primary focus of communication during the nurse-patient relationship?
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patient and patient needs
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Which of the following are examples of breaches of patient confidentiality? Select all that apply.
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A nurse discusses a patient with a coworker in the elevator. A head nurse accesses the medical records of a nurse on her shift to check her condition. A nurse shares her computer password with a relative of a patient. A nurse updates the employer of a patient regarding the patient’s return to work.
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A nurse asks a multidisciplinary team to collaborate to develop the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the blended skills essential to nursing practice is the nurse using?
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interpersonal skills
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Why is communication important to the assessing step of the nursing process?
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gather information during assessment
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According to Freud, what is the name given to the part of the mind that represents one’s conscience?
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superego
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An experienced ICU nurse is mentoring a student. The nurse tells the student, “I think something is going wrong with your patient.” What type of clinical decision making is the experienced nurse demonstrating?
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intuitive thinking
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A nurse is documenting the intensity of a patient’s pain. What would be the most accurate entry?
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“Patient states pain is a 9 on a scale of 1 to 10.”
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A nurse is teaching a 7-year old diabetic child who is in Piaget’s concrete operational stage about insulin injections. Based on Piaget’s theory, what would be the nurse’s best method of preparation for this child?
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Demonstrate the procedure on a Teddy bear
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As a beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection?
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Practice giving injections in the learning lab until you feel comfortable
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Which of the following statements is true of factors that influence communication?
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Culture and lifestyle influence the communication process.
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What characteristic is used to describe racial categories?
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skin color
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What is one way in which nurses can develop cultural self-awareness?
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Objectively examine own beliefs, values, and practices.
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A school-aged child always follows the rules and obeys traffic lights when crossing the street. Based on Kohlberg’s theory, what type of development is being demonstrated?
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moral
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Based on Havighurst’s theory, which of the following is one of the developmental tasks of middle adulthood?
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adjusting to physical changes
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Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply.
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A. It is based on principles of nursing process, problem solving, and the scientific method. B. It is guided by standards, policies and procedures, ethics codes, and laws. C. It calls for strategies that make the most of human potential. E. It carefully identifies the key problems, issues, and risks involved.
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What is the nurse’s best defense if a patient alleges nursing negligence?
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patients records
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The nurse is providing home care for a patient who traditionally drinks herbal tea to treat an illness. How should the nurse respond to a request for the herbal tea?
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“Let me check with the doctor to make sure that is okay with your other medications”
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What is a systematic way to form and shape one’s thinking?
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critical thinking
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A student caring for an unconscious patient knows that communication is important even if the patient does not respond. Which nonverbal action by the student would communicate caring?
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holding the patients hand while talking
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A patient tells the nurse that he is very worried about his surgery. Which of the following responses by the nurse is a cliché?
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“Don’t worry, everything will be fine”
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A home health nurse reviews the nursing care with the patient and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?
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planning
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A nurse is providing patient care in a hospital setting. Who has full legal responsibility and accountability for the nurse’s actions?
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The nurse
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Based on an established plan of care, a nurse turns a patient every 2 hours. What part of the nursing process is the nurse using?
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implementing
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Which of the following phrases best describes hospitals today?
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focus on acute care needs
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A student nurse is working in the library on her plan of care for a clinical assignment. The patient’s name is written at the top of her plan. What ethical responsibility is the student violating?
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confidentiality
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A nurse using the principle-based approach to patient care seeks to avoid causing harm to patients in all situations. This principle is known as:
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non-maleficence
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Legally speaking, how would the nurse ensure that care was not negligent?
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documenting the nursing actions in the patients records
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Which of the following are ANA standards of clinical nursing practice? Select all that apply.
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The nurse seeks available resources to help formulate ethical decisions and use them in practice. The nurse maintains patient confidentiality within legal and regulatory parameters. The nurse delivers care in a nonjudgmental manner that is sensitive to patient diversity
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A nurse in a women’s health clinic values abstinence as the best method of birth control. However, she offers compassionate care to unmarried pregnant adolescents. What is the nurse demonstrating?
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nonjudgmental “value neutral” care
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Which of the following is a characteristic of primary healthcare? Select all that apply.
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It brings healthcare as close as possible to where people live and work. It is essential healthcare based on sound methods and technology. It is made universally accessible to individuals and families in the community.
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While at lunch, a nurse heard other nurses at a nearby table talking about a patient they did not like. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating?
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basic respect for human dignity
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Which component of nursing care is central to the care-based approach to bioethics?
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nurse-patient relationship
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A patient, unsure of the need for surgery, asks the nurse, “What should I do?” What answer by the nurse is based on advocacy?
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“Tell me more about what makes you think you don’t want surgery”
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What document was developed to improve workplaces and ensure nurses’ ability to provide safe, quality patient care?
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Bill of Rights for Registered Nurses
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Which of the following is the most frequent reason for revocation or suspension of a nurse’s license?
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alcohol or drug abuse
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A patient nearing the end of life requests that he be given no food or fluids. The physician orders the insertion of a nasogastric tube to feed the patient. What situation does this create for the nurse providing care?
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an ethical dilemma about inconsistent courses of action
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What type of law regulates the practice of nursing?
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civil law
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What is the legal source of rules of conduct for nurses?
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nurse practice acts
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What is the primary focus of communication during the nurse-patient relationship?
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patient and patient needs
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A 4-year-old child has leukemia but is now in remission. What does it mean to be in remission when one has a chronic illness?
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The disease is present, but symptoms are not experienced.
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What is the nurse’s primary role in promoting health?
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LOOK UP ANSWERS (NOT educating others about health promotion activities)
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Which of the following accurately describes Florence Nightingale’s influence on nursing knowledge?
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hand-washing, cultural and spiritual influences promote healing
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Which age group in the population is expanding most rapidly, resulting in changes in the delivery of healthcare?
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older adults
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A nurse observes that certain patients have less pain after procedures than do others, and forms a theory of why this happens. What is a theory?
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a statement of an occurrence based on observed facts
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Why are nursing organizations important for the continued development and improvement of nursing as a whole?
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to set standards for nursing education and practice
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Which of the following is a criteria that defines nursing as profession?
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a strong service orientation
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What phrase best describes health?
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individually defined by each person
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Who was the first nurse to develop a nursing theory?
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Florence Nightengale
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Which of the following nursing pioneers established the Red Cross in the United States in 1882?
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Clara Barton
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Who is considered to be the founder of professional nursing?
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Florence Nightengale
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There are four concepts common in all nursing theories. Which one of the four concepts is the focus of nursing?
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person
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A staff nurse asks a student, “Why in the world are you studying nursing theory?” How would the student best respond?
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“It explains how nursing is difference from medicine”
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In what time period did nursing care as we now know it begin?
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18th to 19th century
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A rapid onset of symptoms that last a relatively short time indicates what health problem?
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an acute illness
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Which of the following factors constitute the environment component of the agent-host-environment model of health and illness (Leavell and Clark, 1965)? Select all that apply.
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Biological and Cultural Factors
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Which of the following is an example of the sociocultural dimension influencing a person’s health-illness status?
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A single mother of two applies for food stamps in order to feed her family
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Breaking the healthcare community into separate entities (such as the medical community, the nursing staff, management, support staff) and analyzing how they work as a whole together is an example of which nursing theory?
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general systems theory
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Which of the following individuals provided community-based care and founded public health nursing?
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Lillian Wald
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What phrase best describes the science of nursing?
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Body of nursing knowledge
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What is a concept?
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abstract images (ideas) that are formed as impressions from the environment and organized into symbols of reality
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What is a Theory?
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a statement based on observed facts that explains or characterizes a process, and occurrence, or an event, but cannot be proved directly as a fact
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What are the four concepts within the metaparadigm of nursing? How would you define these concepts?
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Person Development Health Nursing
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What are levels of prevention? List and provide an example of each.
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Primary- general health promotion, risk factor reduction, and other health protective measures. These strategies include health education and health promotion programs designed to foster healthier lifestyles and environmental health programs designed to improve environmental quality. Secondary-early detection and swift treatment of disease. Its purpose is to cure disease, slow its progression, or reduce its impact on individuals or communities. A common approach to secondary prevention is screening for disease Tertiary- both therapeutic and rehabilitative measures once disease is firmly established. Examples include treatment of diabetics to prevent complication of the disease and the ongoing management of chronic heart disease patients with medication, diet, exercise, and periodic examination.
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Name a Nursing theorist and how it applies to clinical practice by providing an example
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Virginia Henderson- Developed patient centered care. Nurses should keep patients fully informed and put their needs first
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Define Evidence Based Practice (EBP) and discuss why it is important in nursing
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Problem solving approach to making clinical decisions using the best evidence available Blends both science and art of nursing so that the best patient outcomes are achieved . Based on a patient as an individual not a population whole.
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List the steps in the implementation of EBP including the most common format of PICO
answer

Step 1- Ask question about clinical area of interest or an intervention (PICO) Step 2- Collect the most relevant and best evidence Step 3-Critically appraise the evidence Step 4- Integrate the evidence with clinical expertise, patient preferences, and values in making a decision to change Step 5- Evaluate the practice decision or change PICO: P-Patient, population or problem or interest I- Intervention of interest C- Comparison of interest O-Outcome of interest
question

List and describe a minimum of 2 ANA Standards of Practice. Why is the ANA Standards of Practice important to nursing?the diagnoses
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Assessment- Nurse collects comprehensive data pertinent to the patients health or situation Diagnosis- The nurse analyzes the assessment data to determine the diagnoses or issue. Protect the public by defining the legal scope of practice, excluding untrained or unlicensed people.
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What purpose does the Code of Ethics for Nurses serve?
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Nursing bylaws/ethics. Protects and educates nurses on their expected roles. Statements of ethical obligations and duties of nurses Non-negotiable ethical standards expression of nursing’s own understanding of its commitment to society
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What is a Nurse Practice Act? Does Michigan have this? Discuss
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Each state has its own laws that fall under this category, that protects the public by defining the legal scope of nursing practice. Each nurse is expected to care for patients within defined practice limits, failure to do so leaves the nurse vulnerable to charges. Michigans Nursing Practice Act: Michigan has an act that regulates the practice of nursing, along with 25 other health occupations. Michigan does not have a stand-alone act called the Nurse Practice Act because in Michigan, we have a consolidated practice act that covers 25 health occupations and is formally titled the Occupational Regulation Sections of the Michigan Public Health Code, PA 368 of 1978.
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What is a competent practice in nursing and list legal safegaurds
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Each nurse is responsible for making sure that his/her educational background and clinical experience are adequate to fulfill nursing responsibilities. Safe guards: Respecting legal boundaries of practice Following institution procedures and policies Owning personal strengths and weaknesses and seeking means of growth and education Evaluating proposed assignments: refuse if unprepared Keeping current Respecting pt rights Keeping careful documentation Working within an agency to develop and support management policies
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What is the nurses’s responsibility in order to become culturally competent? Why is it important for nurses to examine their own beliefs, values, and family experiences?
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When nurses know values that motivate the decisions and behaviors of pts, they can implement the use of these when teaching and counseling patients.
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Be familiar with one developmental theorist, provide an overview of the theory, and list one developmental task for early childhood, adulthood, and later adulthood.
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Theory of Psychoanalytic Development (Freud)- Emphasizes the effect of instinctual human drives on behavior. Sexual. Libido: Pleasure seeking instincts Components: The unconscious mind- Contains memories, motives, fantasies, and fears The id- Concerned with self-gratification. The ego- Conscious mind, serves as mediator between desires of id and the constraints of reality. The superego- Conscience. Developed at one year old. Praise vs Punishment Early Childhood- Oral: uses mouth as source of gratification and exploration. Conflict in wheening Adulthood- Latency: Transition to genital stage. Increasing self-role id with parents of same sex. Later Adulthood- Genital: Sexual interest expressed in overt sexual relationships
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What is SBAR? Explain the acronym and provide an example of use
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Situation, Background, Assessment, Recommendation standardized way of communicating. It promotes patient safety because it helps individuals communicate with each other with a shared set of expectations. Used to communicate between nurses and physicians. Helps transfer caregivers have a quick overview of what to expect from patient. ex: Situation: Mrs. Smith is having increasing dyspnea and is complaining of chest pain. Background: The supporting background information is that she had a total knee replacement two days ago. About two hours ago she began complaining of chest pain. Her pulse is 120 and her blood pressure is 128/54. She is restless and short of breath. Assessment: My assessment of the situation is that she may be having a cardiac event or a pulmonary embolism. Recommendation: I recommend that you see her immediately and that we start her on 02 stat.
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How would you cite in proper APA format the textbook in our course? Provide an in text example and how you would cite on the reference page
answer

Taylor, C., Lillis, C., Lemone, P., & Lynn, P. (2011). “Fundamentals of nursing: the art and science of nursing care, seventh edition” (7th ed.). Philadelphia, Pa.: Lippincott Williams & Wilkins. In-text citation- (Taylor,.et al, 2011, p.40)
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Nursing documentation guidelines: Is this a legal document? What should the nurse consider regarding documentation? (P 326)
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Content- Must be complete, accurate, concise, current and factual, order sequential Timing- Timely matter, modify if needed Format-Correct charting/form. Accountability- Sign with first initial and last name by title of each entry, if error must print “error” next to, id each pg with pt name and id number Confidentiality- HIPPA This is legal document. When charting, consider avoidance of ambiguous words such as “good, average” or “normal”. Avoid generalizations “seems comfortable today” Chart specifics and details. Use quotes when using wording from pt mouth. Keep everything in order and chart in timely manner. Never have chart in the view of others ie: log off/put chart away in correct placement
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What is QSEN? What does the acronym stand for and what is the purpose for this organization?
answer

Quality and Safety Education for Nurses Purpose: defined quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency. Provide workshops, seminars are additional resources to provide and ensure proper knowledge on Quality and Safety for Nurses
question

What is nursing informatics?
answer

a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.
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What is patient centered care?
answer

Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
question

Provide an overview of the nursing process. List each compenent, describe and discuss each purpose
answer

ASSESSING, DIAGNOSING, PLANNING, IMPLEMENTING, EVALUATING Assessing-Collecting, organizing, validating, and documenting client data Purpose- establish a database about the client’s response to health concerns or illness and the ability to manage health care needs Establish a database: Obtain a nursing health history Review client records Review nursing literature Consult support persons Consult health professionals Update data as needed Organize data Validate data Communicate/document data Diagnosing- Analyzing and synthesizing data Purpose- To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. To develop a list of nursing diagnoses and collaborative problems. Interpret and analyze data: Compare data against standards Cluster or group data (generate tentative hypotheses) Identify gaps and inconsistencies Determine client’s strengths, risks, and problems Formulate nursing diagnoses and collaborative problem statements Planning- Determining how to prevent, reduce, or resolve the identified client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner To develop and individualized care plan that specifies client goals/desired outcomes and related nursing interventions. Set priorities and goals/outcomes in collaboration with client Write goals/desired outcomes Select nursing strategies/interventions Consult with other health professionals Write nursing orders and nursing care plan Communicate care plan to relevant healthcare providers Implementing- Carrying out the planned nursing interventions To assist the client to meet desired goals/outcomes; promote wellness and disease; restore health; and facilitate coping with altered functioning. Reassess the client to update the database Determine need for nursing assistance Perform or delegate planned nursing interventions Communicate what nursing actions were implemented: Document care and client responses to care Give verbal reports as necessary Evaluating- Measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement To determine whether to continue, modify, or terminate the plan of care. Collaborate with client and collect data related to desired outcomes Judge whether goals/outcomes have been achieved Relate nursing actions to client outcomes Make decisions about problem status Review and modify the care plan as indicated or terminate nursing care
question

What is NANDA, NIC and NOC? What do these acronyms stand for? Explain the purpose of each. (P 194)
answer

NANDA: FOCUS ON DIAGNOSIS– North American Nursing Diagnosis Association- Increase visibility of nursing contribution to patient care by contributing to develop, refine, and classify phenomena of concern to nurses NIC: FOCUC ON INTERVENTION– Nursing Interventions Classification- Identify, label, validate,and classify actions nurses perform including direct and indirect care interventions. directly:interventions done with patients – ex: teaching indirectly ex: obtaining lab studies NOC:FOCUS ON CLASSIFICATION– Nursing-sensitive Outcomes Classification- Identify, label, validate,and classify nursing-sensitive patient outcomes and indicators to evaluate the validity and usefulness of the classification and define and test measurement procedures for outcomes
question

Discuss the difference between Therapeutic communication and Non-therapeutic communication
answer

Therapeutic communication shows acceptance and understanding using many verbal and non-verbal communication techniques Non-Therapeutic communication shows judgement, false reassurance, invalidation and giving advice in the “if I were you…” formatting.
question

What is empathy? Why is it important to nursing?
answer

The intellectual identification with or experiencing of the feelings, thoughts, or attitudes of another; A nurse must be sincere and really care about what happens to others. nurses must express our own feelings and needs without sacrificing the integrity of our position and remaining honest.

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