role of nurse – quiz 2 nursing process – Flashcards
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purpose is to dx, and treat human responses to actual or potential health problems
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its required to have a nursing plan and nursing dx
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we say what happens as a result of a disease1
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impaired gas exchange ect
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ADPIE
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assessment nursing diagnosis planning: outcomes/interventions implementations evaluation
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Assessment
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subjective/objective data sources of data: primary source: client/family secondary source: physical exam, nursing hx, team members ect. validate info reliability compare to standard norms
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assessment... nursing interview (hx) health assessment - review of systems physical exam is...
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inspection palpation percussion auscultation
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Nursing diagnosis
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how the client is responding to an actual or potential problem that requires nursing intervention -interpret/analyze data -identify client's problems and stregths
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3 parts of nursing diagnosis
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-problem statement -etiology -defining characteristics can remember by "pes" problem, etiology(r/t), and symptoms-defining characteristics
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problem statement
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impaired skin integrity
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etiology
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R/T- imobility secondary to cva
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defining characteristics
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AEB data - stage 3 pressure ulcer
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AMB
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As manifested by
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AEB
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as evidenced by
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types of nursing diagnosis (4)
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actual risk wellness or health promotion syndrome
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collaborative problems
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require both nursing interventions and medical interventions-doctors order
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Smart Outcomes (evaluation)
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Specific Measurable Attainable Realistic Timed
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ABC and maslow prioritize nursing diagnosis
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self actualization esteem social safety phsiological-nutrition is first
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nursing interventions
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assess do teach refer
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3 types of interventions
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independent (nurse initiated) dependent (physician initiated) collaborative (both)
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in order for an actual nursing diagnosis to be valid it must have one or more supporting
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defining characteristics
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The scope of professional identity in nursing includes
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autonomy, knowledge, competence, professionhood, accountability, advocacy, collaborative practice, and commitment
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Generally the most independently functioning nurse. has a master's degree in nursing, advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized area of practice.
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An APRN
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nursing code of ethics
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Defines the principles of right and wrong to provide patient care
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You are participating in a clinical care coordination conference for a patient with terminal cancer. You talk with your colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A nonnursing colleague asks about this code. Which of the following statements best describes this code?
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Defines the principles of right and wrong to provide patient care
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An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, auscultates her lung sounds, listens to her heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed?
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Assessment
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A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed?
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Implementation
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A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with the family. The nurse is acting as the patient's:
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Advocate
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Evidence-based practice is defined as:
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A problem-solving approach that integrates best current evidence with clinical practice
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The examination for registered nurse licensure is exactly the same in every state in the United States. This examination:
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Provides a minimal standard of knowledge for a registered nurse in practice
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Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (Select all that apply.)
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A. Caregiver B. Autonomy and accountability C. Patient advocate D. Health promotion
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Advanced practice registered nurses generally:
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Function independently
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Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform?
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Moving from an acute illness to a health promotion, illness prevention model
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Which of the following nursing roles may have prescriptive authority in their practice? (Select all that apply.)
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Certified clinical nurse specialist and Nurse practitioner
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A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?
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Informatics
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nurse is caring for an older-adult couple in a community-based assisted living facility. During the family assessment he notes that the couple has many expired medications and multiple medications for their respective chronic illnesses. They note that they go to two different health care providers. The nurse begins to work with the couple to determine what they know about their medications and helps them decide on one care provider rather than two. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?
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Safety
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The nurses on an acute care medical floor notice an increase in pressure ulcer formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure ulcer risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career?
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Nurse researcher
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Nurses at a community hospital are in an education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. This is which type of education?
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In-service education
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Nursing responds to the health care needs of society, which are influenced by
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economic, social, and cultural variables of a specific era.
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Nursing standards provide the guidelines for
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implementing and evaluating nursing care.
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A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?
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Health perception-health management pattern
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The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:
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Clinical inference.
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A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe?
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problem-oriented approach
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The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview?
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Working phase
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A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems?
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"You have four children; do you have any concerns about going home and caring for them?
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Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care
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Open-ended
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A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:
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Patient's level of function.
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A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess?
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Self-perception-self-concept pattern
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During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing?
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Tell me what makes your headaches begin.
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Which of the following examples are steps of nursing assessment?
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Collection of information from patient's family members Recognition that further observations are needed to clarify information Comparison of data with another source to determine data accuracy
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When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.)
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An observation of how a patient turns and moves in bed The care recommendations of a physical therapist The results of a diagnostic x-ray film
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The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n):
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Problem-focused nursing diagnosis
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A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of:
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Data cluster.
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A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement?
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Identifying the medical diagnosis instead of the patient's response to the diagnosis.
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A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error?
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Insufficient number of cues
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A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor?
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Mother's deficient knowledge
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A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format?
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Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested
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A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?
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Wrong diagnostic label
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Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
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Impaired Skin Integrity related to physical immobility Nausea related to gastric distention
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A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.)
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Data interpretation. Data collection.
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In which of the following examples are nurses making diagnostic errors? (Select all that apply.)
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The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia
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nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.)
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What do you believe will help you control your blood sugar? What worries you the most about having diabetes? How is your diabetic diet affecting you and your family?
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The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.)
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Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs Helps nurses focus on the scope of nursing practice Builds and expands nursing knowledge
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Which of the following nursing diagnoses is stated correctly? (Select all that apply.)
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Sleep Deprivation related to sustained noisy environment Ineffective Protection related to inadequate nutrition
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A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first?
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Talking with the patient about her concerns and acknowledging her sense of unfairness
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A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient?
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Erythema of skin will be mild to none within 48 hours.
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A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient?
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Enhancing patient knowledge about the effects of diabetes
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The nurse writes an expected outcome statement in measurable terms. An example is:
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Patient will report stool soft and formed with each defecation
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ID: 11401341186 A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention?
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IV fluid administration
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A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort?
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Engage the patient in setting mutual outcomes for distance he is able to walk
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A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first?
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Reconnect the drainage tubing
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A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.)
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Assess condition of skin before making the call Explain the patient's response emotionally to the repeated leaking of stool Describe the type of bag being used and how long it lasts before leaking
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It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.)
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Including the wife in the hand-off discussion Doing prework such as checking laboratory results before giving a report Using a standardized checklist for essential information
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Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.)
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Notion of urgency for nursing action Symptom pattern recognition suggesting a problem Mutually agreed on priorities set with patient
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A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.)
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Maintaining intravenous (IV) infusion at 100 mL/hr Consulting with dietitian on initial foods to offer patient
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Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (Select all that apply.)
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The intervention should be directed at reducing noise. The intervention should be one shown to be effective in promoting sleep on the basis of research The intervention should be one acceptable to the patient
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A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.
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Policy for conducting hourly rounds Staffing level Interruption by staff nurse colleague
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A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.)
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Walked to end of hall No shortness of breath
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The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following?
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Physical care technique
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Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?
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Individualizing how to apply the clinical guideline for a patient
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Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?
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Cognitive
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What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?
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Measures quality of care within hospitals
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A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation?
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Critical thinking
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A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit?
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Patient
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A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? (Select all that apply.)
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The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure.
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A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.)
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Shows competence in how to monitor patients' clinical status and inform the physician of critical changes Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly
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A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.)
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Determining all consequences associated with the patient missing specific medicines Making a judgment of the value of improved adherence for the patient
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The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.)
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The call to the ostomy and wound care specialist is an indirect care measure. The cleansing of the skin is a direct care measure. Correct
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Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.)
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Checks scientific literature or policy and procedure Reassesses the patient's condition Collects all necessary equipment Considers all possible consequences of the procedure
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A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.)
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Makes it quicker and easier for nurses to intervene Sets a level of clinical excellence for practice Delivers evidence-based interventions for stage II pressure ulcer
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A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction?
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Asking patient to identify three low-sodium foods to eat for lunch
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A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation:
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Examining results of clinical data
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A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of:
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Evaluative measures.
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After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following?
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Reflection-on-action
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A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of:
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Comparing outcome criteria with actual response.
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A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which statement is appropriate for evaluating a patient's expectations of care?
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The nurse asks, "Did you believe that you received the information you needed to follow your diet?"
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A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of:
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Expected outcomes.
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Which of the following does a nurse perform when discontinuing a plan of care for a patient?
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Confirms with the patient that expected outcomes and goals have been met
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For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? (Select all that apply.
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Patient describes correct schedule for taking antiarthritic medications. Patient explains situations for using heat application on inflamed joints.
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A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. (Select all that apply.)
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Quality of life Use of clinic services Adherence to use of inhale
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A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? (Select all that apply.)
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Appropriateness of the intervention for the patient Correct application of the intervention for the patient care setting
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A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? (Select all that apply.)
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Checked the IV infusion rate Inspected the condition of the IV dressing at the site
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Purposes of the Nursing Outcomes Classification (NOC) include which of the following? (Select all that apply.
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To identify and label nurse-sensitive patient outcomes To test the classification in clinical settings To define measurement procedures for outcomes
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Which of the following statements correctly describes the evaluation process? (Select all that apply.)
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Evaluation requires the use of assessment skills. Evaluation involves making clinical decisions Evaluation is an ongoing process.
