question

what constitutes the third step of the nursing process and will require the use of your critical thinking skills, in which decision-making and problem-solving techniques are incorporated?

answer

planing

question

After you have identified your patient's nursing diagnosis what is the next step?

answer

planning appropriate care

question

what involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions?

answer

planing

question

A plan of care is dynamic and will change as your patient's needs change, or as you identify new needs.

answer

Planning requires working closely with patients, their families, and the health care team through communication and ongoing consultation.

question

Establishing Priorities

answer

Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions. Helps nurses anticipate and sequence nursing interventions

question

Classification of priorities

answer

High—Emergent Intermediate Low—Affect patients' future well-being

question

when you will need to rank and deal with individual and aggregate nursing diagnoses so you can recognize those most important problems to organize your day?

answer

to care for one patient and group of patients

question

how you attend to each patient's most important needs and better organize ongoing care activities?

answer

By ranking a patient's nursing diagnoses in order of importance

question

if untreated, result in harm to a patient or others have the highest priority and typically revolve around safety, adequate oxygenation, and circulation.

answer

nursing diagnosis

question

These priorities can be physiological, psychological, or related to other basic human needs.

answer

you must always consider each patient's unique situation

question

A task for an intermediate-priority diagnosis involves

answer

the nonemergent, non-life threatening needs of the patient

question

may not be related to a specific illness or prognosis but may call for an intervention that affects the patient's future well-being. Many of these deal with the patient's long-term health care needs.

answer

The low-priority nursing diagnosis

question

with who you select mutually agreed-on priorities based on the urgency of the problems, the patient's safety and desires, the nature of the treatment indicated, and the relationship among the diagnoses?

answer

together with your patient

question

as a patient's condition changes.

answer

The order of priorities changes

question

when priority setting begins at a holistic level?

answer

when you identify and prioritize a patient's main diagnoses or problems

question

why patient-centered care requires you to know a patient's preferences, values, and expressed needs?

answer

Ethical care is a part of priority setting.

question

when it is important to reorder priorities?

answer

Each time you begin a sequence of care such as at the beginning of a hospital shift or a patient's clinic visit

question

Involve patients in priority setting whenever possible.

answer

You also need to prioritize the specific interventions or strategies that you will use.

question

Always assign priorities on the basis of good nursing judgment.

answer

Consulting with the patient to learn the patient's concerns does not relieve you of the responsibility to act in a patient's best interests.

question

why it is important to have open dialogue with the patient, the family, and other health care providers?

answer

When ethical issues make priorities less clear

question

* assess patient * identify problems * prioritize problems * identify desired outcomes *identify interventions for achieving outcomes * prioritize interventions * deliver patient care * evaluate interventions

answer

-patent acuity -availability of resources -interruptions from care providers -nurse-patient relationship -ward organization -priority-setting strategies and frameworks -philosophies and models of care -experience and expertise of nurse

question

why many factors within the health care environment affect your ability to set priorities?

answer

The same factors that influence your minute-by-minute ability to prioritize nursing actions affect your ability to prioritize nursing diagnoses for groups of patients.

question

The nature of nursing work challenges your ability to cognitively attend to a given patient's priorities when you care for more than one patient.

answer

Always work from your plan of care and use your patients' priorities to organize the order for delivering interventions and documenting care.

question

Fulmala is a first semester nursing student who is assigned to Ms. Nadine Skyfall, a 35 y/o American Indian patient diagnosed with severe anemia secondary to a bleeding peptic ulcer. Ms. Skyfall experiences pain because of the ulcer and weakness and fatigue resulting from the anemia. Fulmala develops Ms. Skyfall's plan of care, which addresses pain, weakness, and fatigue. Fulmala includes nutrition and patient safety as part of the plan of care.Why aren't anemia and peptic ulcer part of the care plan?

answer

nursing care plans do not directly address the medical diagnosis.

question

what is a broad statement that describes the desired change in a patient's condition or behavior? An aim, intent, or end

answer

Goal

question

what is a measurable criteria to evaluate goal achievement?

answer

Expected outcome

question

Once you identify nursing diagnoses for a patient, what you ask yourself?

answer

, "What is the best approach to address and resolve each problem? What do I plan to achieve?"

question

what are specific statements of patient behavior or physiological responses that you set to resolve a nursing diagnosis or collaborative problem?

answer

Goals and expected outcomes

question

when having goals and expected outcomes serves two purposes

answer

It gives a clear direction for selecting and using nursing interventions and for evaluating the effectiveness of the interventions.

question

when you know that a goal has been at least partially achieved?

answer

Once an outcome is met

question

when interventions requires consideration of your previous experience with similar patient problems and any established standards for clinical problem management?

answer

Selection of goals, expected outcomes

question

these are goals and outcomes?

answer

outcomes need to meet established intellectual standards by being relevant to patient needs, specific, singular, observable, measurable, and time limited

question

when you use critical thinking attitudes?

answer

in selecting interventions with the greatest likelihood of success.

question

what is a specific and measurable behavior or response that reflects a patient's highest possible level of wellness and independence in function?

answer

patient-centered gaol

question

what is an objective behavior or response expected within hours to a week?

answer

short-term goal

question

what is an objective behavior or response expected within days, weeks, or months

answer

long-term goal

question

what is realistic and is based on patient needs and resources?

answer

Patient-centered goals, which reflects a patient's highest possible level of wellness and independence in function.

question

what represents predicted resolution of a diagnosis or problem, evidence of progress toward resolution, progress toward improved health status, or continued maintenance of good health or function?

answer

a patient goal

question

why each goal must be time limited?

answer

so that the health care team has a common time frame for problem resolution

question

The time frame depends on what?

answer

the nature of the problem, its causes, the patient's overall condition, and the treatment setting.

question

what is what you expect the patient to achieve in a short period of time?

answer

a short-term goal Because hospital stays are shorter than before, these goals may last several hours to days

question

what are expected to be achieved over a longer period of time?

answer

Long-term goals

question

when setting their individualized goals?

answer

Always partner with patients

question

why they need to be alert and must have some degree of independence in completing activities of daily living, problem solving, and decision making?

answer

For patients to participate in goal setting

question

even though patients are often totally dependent on you as the nurse

answer

Patients need to understand and see the value of nursing therapies

question

it includes the patient and the family (when appropriate) in prioritizing the goals of care and developing a plan of action?

answer

mutual goal setting

question

why patients fail to fully participate in the plan of care?

answer

Unless goals are mutually set and a clear plan of action is decided

question

when the nurse act as an advocate or support for the patient to select nursing interventions that promote his or her return to health or prevent further deterioration when possible?

answer

when setting goals

question

what must be measurable?

answer

outcomes

question

It direct nursing care because they are the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patient's health problem?

answer

expected outcome

question

Expected outcomes should be what?

answer

written in a sequential time frame that give progressive steps in which a patient moves toward recovery and impose an order on nursing interventions and set limits for problem resolution?

question

A patient's _________, ________ reach an expected outcome improves his or her likelihood of achieving it

answer

willingness and capability

question

A list of ___________ expected outcomes gives you practical guidance in planning interventions.

answer

the step-by-step

question

what provide a common nursing language for continuity of care and measuring the success of nursing interventions?

answer

NOC outcomes

question

who published the Nursing Outcomes Classification (NOC) and linked the outcomes to NANDA International nursing diagnoses?

answer

the Iowa Intervention Project

question

it is focused on measuring outcomes to gauge the quality of health care?

answer

attention in the health care environment

question

why it needs to become part of a standardized approach to a patient problem?

answer

If a chosen intervention repeatedly results in desired outcomes that benefit patients

question

Thus it is important to identify and measure patient outcomes that are influenced by nursing care.

answer

Nursing plays an important role in monitoring and managing patient conditions and diagnosing problems that are amenable to nursing intervention.

question

why nurses need to identify and measure patient outcomes influenced by nursing interventions?

answer

For the nursing profession to become a full participant in clinical evaluation research, policy development, and interdisciplinary work,

question

there are multiple NOC-suggested outcomes

answer

For each NANDA International nursing diagnosis

question

changes in the status of patients over time allow nurses to improve patient care quality and add to nursing knowledge.

answer

Efforts to measure outcomes and capture changes

question

what is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions?

answer

A nursing-sensitive patient outcome

question

what is singular, observable, measurable, time limited, mutual, and realistic?

answer

A patient-centered goal

question

Outcomes and goals reflect are?

answer

patient behaviors and responses expected as a result of nursing interventions

question

Write a goal or outcome to reflect a what?

answer

a patient's specific behavior, not to reflect your goals or interventions

question

what must be defined precisely before a patient response to a nursing action can be evaluated?

answer

a specific goal or outcome

question

what addresses only one behavior or response?

answer

each goal or outcome

question

what occur in physiological findings and in the patient's knowledge, perceptions, and behavior?

answer

observable changes

question

Do not use vague terms or qualifiers such as?

answer

"normal," "acceptable," or "stable"

question

use terms that can be evaluated precisely such as?

answer

terms that describe quality, quantity, frequency, length, or weight.

question

Time-limited time frames for each goal and expected outcomes indicate what?

answer

when nurses expect identified responses to occur

question

Time frames enable nurses to do what?

answer

help patients meet goals and make progress at a reasonable rate.

question

Mutual factors combine goals and expected outcomes to ensure what?

answer

the patient and the nurse agree on the direction and time limits of care

question

nurses can increase the patient's motivation and cooperation by what?

answer

By setting mutual goals and expected outcomes

question

why goals and outcomes must be attainable?

answer

For the patient to succeed

question

When setting goals and outcomes, make sure to factor in the patient's physiological, emotional, cognitive, and sociocultural potential, as well as the economic costs and resources required to reach these in a timely manner.

answer

Because lengths of stay are now much shorter, this can be problematic.

question

Seven Guidelines for Writing Goals

answer

1. patient centered 2. singular goal or outcome 3. measurable 4. mutual factors 5. observable 6. time limited 7. realistic

question

A patient is suffering from shortness of breath. The correct goal statement would be written as A. The patient will be comfortable by the morning. B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. The patient will not complain of breathing problems within the next 8 hours. D. The patient will have a respiratory rate of 14 to 18 breaths per minute.

answer

B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. addresses the seven guidelines for writing goals

question

what are treatments or actions based on clinical judgment and knowledge that nurses perform to meet patient outcomes?

answer

nursing interventions

question

what nurses need for nursing intervention?

answer

Know the scientific rationale for the intervention Possess the necessary psychomotor and interpersonal skills Be able to function within a setting to use health care resources effectively

question

Part of the planning process is to select what?

answer

nursing interventions to meet the patient's goals and outcomes

question

when you choose interventions individualized for the patient's situation?

answer

Once nursing diagnoses have been identified and goals and outcomes selected

question

when you select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes.

answer

during planing

question

what occurs during the implementation phase of the nursing process?

answer

actual implementation of these intervention

question

Independent—Actions that a nurse initiates ?

answer

Nurse initiated

question

Dependent—Require an order from a physician or other health care professional?

answer

Physician initiated

question

Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals?

answer

Collaborative

question

what require no order and no supervision or direction from others?

answer

Nurse-initiated interventions are autonomous actions based on scientific rationale.

question

what it is according to the Nurse Practice Acts in a majority of states?

answer

independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling.

question

what provides standardization to help nurses select suitable interventions for patients' problems?

answer

NIC taxonomy

question

identify some independent nursing actions

answer

can include elevating an extremity, providing patient education, showing how to splint

question

what require specific nursing responsibilities and technical nursing knowledge?

answer

physical-initataed interventions are based on the physician's or the health care provider's response to treat or manage a medical diagnosis

question

Each of these interventions requires nursing responsibilities and specific knowledge

answer

Advanced practice nurses who work under collaborative agreements with physicians, or who are licensed independently by state practice acts, are able to write dependent interventions.

question

when you review the necessary interventions and determine whether the collaboration of other health care disciplines is necessary?

answer

when you plan care for a patient

question

which multidisciplinary health care team selects and assigns interdependent nursing interventions?

answer

patient care conference

question

do not automatically implement the therapy, but determine whether it is appropriate for the patient.

answer

When preparing for physician-initiated or collaborative interventions

question

The ability to recognize incorrect therapies is particularly important when?

answer

administering medications or implementing procedures.

question

what protects the patient and members of the health care team. When you carry out an incorrect or inappropriate intervention, it is as much your error as the person's who wrote or transcribed the original order?

answer

Clarifying an order is part of competent nursing practice.

question

Every nurse faces an inappropriate or incorrect order at some time

answer

You are legally responsible for any complications resulting from the error.

question

Fulmala develops Ms. Skyfall's plan of care, including writing the goals and expected outcomes. Fulmala knows that the guidelines for writing goals and expected outcomes include which of the following? (Select all that apply.) A. Measurable B. Time-limited C. Observable D. Diagnostic E. Realistic

answer

Measurable, time-limited, observable, realistic The seven guidelines for writing goals and expected outcomes are patient-centered, singular goals or outcomes; they are observable, measurable, and time-limited with mutual factors, and they are realistic.

question

When selecting interventions

answer

review the patient's needs, priorities, and previous health experiences

question

Correctly written nursing interventions include what?

answer

actions frequency quantity method the person to perform them.

question

when doing selection of intervention what are the six factor to consider?

answer

1. characteristic of nursing diagnosis 2. goals and expected outcomes 3. evidence base for intervention 4. feasibility of the interventions 5. Acceptability to the patient 6. Nurse's competency

question

who developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across health care settings and to compare outcomes?

answer

The Iowa Intervention Project

question

The NIC model includes three levels

answer

domains classes interventions for ease of use.

question

NIC interventions are linked with

answer

NANDA International nursing diagnoses.

question

are the highest level (level 1) of the model, and broad terms are used to organize the more specific classes and interventions

answer

the domains

question

includes 30 classes, which offer useful clinical categories

answer

the second level of the model

question

includes 542 interventions, defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

answer

the third level of model

question

Each intervention includes a variety of nursing activities from

answer

which to choose and which a nurse commonly uses in a plan of care

question

You determine which interventions and activities

answer

best suit your patient's individualized needs and situation

question

Fulmala knows that _________________ interventions require an order from a physician or another health care professional

answer

dependent nursing Dependent nursing interventions are actions that require an order from a physician or other health care professional.

question

Nursing diagnoses, goals and expected outcomes, and nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation

answer

nursing care plan

question

what Systems for Planning Nursing Care do?

answer

Reduces the risk for incomplete, incorrect, or inaccurate care Changes as the patient's problems and status change

question

Contributions from all disciplines involved in patient care

answer

Interdisciplinary care plan

question

nurses are responsible for providing a written nursing plan of care for all patients

answer

In health care settings

question

The plan can take many forms, such as

answer

Kardex, standard care, or computerized plan

question

Increasingly, hospitals are adopting electronic health records (EHRs) and a documentation system that includes

answer

software programs for nursing care plans.

question

can be used for change-of-shift reports

answer

written care plans helps to ensure continuity of care by all nurses.

question

enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care.

answer

A care plan includes a patient's long-term needs.

question

Incorporating the goals of the care plan into

answer

discharge planning is important

question

when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions

answer

a critical time

question

Communicates information from off going to oncoming patient care personnel = "Nurse hand off"

answer

change-of-shift report

question

Focus your reports on

answer

the nursing care, treatments, and expected outcomes documented in the care plans.

question

nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions.

answer

During a nursing handoff

question

you discuss with the next caregivers your patients' plans of care and their overall progress

answer

At the end of a shift

question

In some agencies, the nursing handoff process occurs during walking rounds when nurses exchange information about patients at the bedside

answer

giving patients the opportunity to also ask questions and confirm information.

question

organize information exchanged by nurses in change-of-shift reports

answer

Written care plans

question

Avoid adding personal opinions about the patient because

answer

these are not relevant and could unnecessarily influence the oncoming nurse's perception of him or her as an individual.

question

A student care plan

answer

Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation Is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care

question

Planning care for patients in community-based settings involves

answer

Educating the patient/family about care Guiding them to assume more of the care over time

question

A six-column format includes

answer

(1) assessment data relevant to corresponding diagnosis (2) goals (3) outcomes identified for the patient (4) implementation for the plan of care (5) a scientific rationale (the reason that you chose a specific nursing action, based on supporting evidence) (6) a section to evaluate your care. In the implementation section, you select interventions appropriate for the patient.

question

For care plans in community-based settings, you design a plan to

answer

(1) educate the patient/family about necessary care techniques and precautions (2) teach the patient/family how to integrate care within family activities (3) guide the patient/family on how to assume a greater percentage of care over time

question

the plan includes

answer

nurses' and the patient's/family's evaluation of expected outcomes.

question

what are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially?

answer

Critical pathways

question

The main purpose of critical pathways is to

answer

deliver timely care at each phase of the care process for a specific type of patient.

question

pathways increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another

answer

Care plans and critical pathways

question

clearly defines transition points in patient progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficiently as possible.

answer

a critical pathway

question

pathways improve continuity of care because they clearly define the responsibility of each health care discipline.

answer

a critically pathway

question

Well-developed pathways include

answer

evidence-based interventions and therapies

question

analyze the relationships among the diagnoses

answer

When planning care for each nursing diagnosis

question

Draw dotted lines between nursing diagnoses to

answer

indicate their relationship to one another

question

it is often not realistic to have a written columnar plan developed for each nursing diagnosis.

answer

Because you care for patients who present with multiple health problems and related nursing diagnoses

question

The links need to be accurate, meaningful, and complete so you can explain why nursing diagnoses are related

answer

It is important for you to make meaningful associations between one concept and another

question

What are some examples of independent nursing interventions that Fulmala may develop for Ms. Skyfall? (Select all that apply.) A. Medication administration B. Medication teaching C. Patient positioning D. Family teaching

answer

Medication teaching, patient positioning, family teaching Independent nursing interventions do not require an order from another health care professional. Examples of independent nursing interventions include patient positioning and education. Administering medication requires an order from a physician or other health care professional.

question

When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a A. Critical pathway. B. Nursing care plan. C. Concept map. D. Diagnostic label.

answer

c

question

when you identify a problem that you are unable to solve using personal knowledge, skills, and resources.

answer

consultation occur the process requires good intrapersonal and interprofessional collaboration.

question

Consultation with other care providers increases what

answer

your knowledge about the patient's problems and helps you learn skills and obtain resources.

question

enters a clinical situation and more clearly assesses and identifies the nature of a problem, whether it is patient, personnel, or equipment oriented.

answer

an objective consult

question

Share information from the patient's medical record, conversations with other

answer

other nurses, and the patient's family

question

to help identify and resolve a nursing problem, and biasing or prejudicing them blocks problem resolution.

answer

Consultants are in the clinical setting

question

Avoid bias by

answer

bias by not overloading consultants with subjective and emotional conclusions about the patient and the problem.

question

provide a private, comfortable atmosphere for the consultant and the patient to meet.

answer

When you request a consultation

question

is turning the whole problem over to the consultant

answer

a common mistake

question

is not there to take over the problem but to help you resolve it.

answer

the consultant

question

request the consultation for a time when both you and the consultant are able to discuss the patient's situation with minimal interruptions or distractions.

answer

when possible

question

The success of the advice depends on the implementation of the problem-solving techniques.

answer

Always give the consultant feedback regarding the outcome of the recommendations.

question

when the exact problem remains unclear

answer

Begin with your understanding of the patient's clinical problem.

question

Fumala works with the nutritionist to develop a meal plan for Ms. Skyfall. True or False: Collaborative interventions are therapies that involve multiple health care professionals.

answer

True Rationale: Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

question

Consultation occurs most often during which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation

answer

c

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