NURS 352: Fundamentals of Nursing Exam #1

How would a nurse validate findings?

To validate findings, an interview with the patient as well as an actual assessment can be done to confirm the nurses findings. Such as running tests to confirm findings.

How would a nurse validate subjective data?

It would have to be derived from the client self report or from a family member. Always recored with " " to indicate a client was speaking. However, subjective data must be confirmed, it is not fact.

Definition of etiology

The cause, set of causes, or causation of a disease or condition.

A nurse as just assessed a patient with a high bp and high pulse rate. What step of the nursing process would be next?

analyzing

What is an independent nursing intervention?

nursing actions that are initiated by the nurse and do not require a privileged provider's order to be initiated

What is an example of an independent nursing intervention?

Repositioning, vital signs, ambulating, etc

What is a dependent nursing intervention?

action that requires an order from the physician or input from another discipline

What is an example of a dependent nursing intervention?

Medication administration, oxygen, and any scans

What composes planned considerations?

This is when a nurse develops evidence based goals and desired outcomes. The goals need to be client specific and care plans provide a client centered road map

What acronym is associated with planed considerations?

SMART goals

What are related factors?

underlying cause or etiology of a patient's problem

Maslow's Hierarchy of Needs

physiological, safety, love/belonging, esteem, self-actualization

What does the CURE acronym stand for?

Critical, Urgent, Routine, & Extra

Ways of evaluating care?

evaluating care comprises of looking back on the patients progress from your implementation and goal you set. From here you can reassess if goal is not met.

For client needs what priority frameworks will you use?

Maslows Needs, and CURE

Examples of critical need

intervention from the nurse to prevent the client from deteriorating. Chest pain, respiratory difficulty, & neurological status

Example of an urgent need?

Whenever a client could suffer mild harm or discomfort. Postoperative pain

Example of routine care?

tasks such as administering medication, vital signs, and daily assessment

Example of extra care?

needs that are not essential to a patient but provide comfort such as providing a blanket & combing the clients hair

What does the ABCDE acronym stand for?

Airway, Breathing, Circulation, Disability, and Exposure

What are the prioritization categories of triage?

Emergent (red), Urgent or delayed (yellow), non-urgent (green), expectant (black)

When is triage used?

in events of mass causality

What priority setting frameworks would you use in client problems?

ABCDE and triage

In priority setting frameworks what is the priority goal?

establish main priority goal for patient

What are the levels or prevention?

primary, secondary, tertiary

Primary preventions

focuses on decreasing the risk for development of medical conditions by changing behaviors or minimizing exposures

examples of primary preventions

vaccination, counseling clients about health info, and changing risky behaviors

Secondary preventions

Actions that lessen, eliminate, or contain problems after they appear.

examples of secondary preventions

screenings such as blood tests, papanicolaou tests, &routine colonoscopies

Short term goal

a goal that you can reach in a short period of time (7 days or less)

long term goal

a goal that you plan that will take longer than 7 days, extended period of time.

What are some causes of diagnostic errors?

data clustering, inaccurate data, not identifying the right cause, focusing on more than one thing at a time, and bad communication

data clustering

occurs when the nurse has not completed a thorough review of patient assessment info

Types of diagnoses a nurse can give?

problem focused, comprehensive, risk, health promotion

acute disease

symptoms develop rapidly but the disease lasts only a short time (less than 6 months)

chronic disease

an ongoing condition or illness that last longer than 6 months

example of acute disease

influenza & asthma attack

example of chronic disease

tuberculosis, arthritis, asthma

Examples of therapeutic responses

silence, rephrasing, summarizing, open ending questions, reflection

strategies to relieve stress

using an empathetic tone when talking to a patient about their diagnoses, address culture, language barriers, reduce distractions, and make comfortable. (therapeutic communication)

example of medical diagnosis

pneumonia, congestive heart failure, & stroke

Methods of Assessment

obtain clients health history, physical assessment, review clients medical record, obtain sub and obj info, observation, auscultation, & palpation

Health promotion

the process of enabling people to increase control over, and to improve, their health

Wellness

positive state of health

health outcomes

result of health promotion and disease prevention measures

culture

learned patterns of perceptions, values, and behaviors shared by a group of people

direct care interventions

something that you preform at bedside, directly affects the patients, insertion of cath, & giving meds

primary information

information that is collected from the client

secondary information

any information that is not collected from the patient themselves

indirect care interventions

Treatments performed away from the patient but on behalf of the patient or group of patients. Ex. charting, change of shift report, & collaboration with team

Safety and risk reduction

assigns priority to whatever finding poses the greatest of immediate risk of clients well being

least restrictive/least invasive

Priority goes to interventions that are least restrictive and least invasive to a client

Make sure it won't put the client at risk for harm or injury

Urgent (urgent vs non urgent)

factors or situations that have considerable probability of causing harm or discomfort

non urgent (urgent vs non urgent)

low risk factors that do not require immediate interventions

example of urgent situations

answering bed alarm

example of non urgent situations

Musculoskeletal conditions, non-allergic itching, & reports of pain with urination

uses of nonverbal communication

use of hands, eye contact, facial expressions, posture, overall appearance, touch, & voice inflection

OARS

Open-ended questions,

Affirmations,

recap,

Summaries

After you evaluate and you have to revise plan of care what step do you go back to?

planning

social determinants of health

economic stability, education, social and community context, health and health care, neighborhood and built environment

dynamic

the continuation of the client care plan over time, slight changes and progress.

Adaptability

being able to change very drastically in terms of the clients care plan

if a client is quiet, crying, or upset what is something you should never do?

ask why or how and give false hope

What are the 5 roles of the nurse

Care provider, educator, advocate, leader, and delegator

What are the step a practical nurse can partake in?

Data collection, planning, implementation, evaluation

The Joint Commission

a not-for-profit organization that evaluates and accredits different types of healthcare facilities. Consists of documentation, policy review, and interviews with staff to ensure a safe environment for client care.

How long does accreditation last from TJC?

3 years

Magnet Status of a Hospital

a program that recognizes acute care facilities that demonstrate excellence in nursing based on meeting standards in five categories.

How long does magnet recognition last?

4 years

Five categories of magnet practice?

-structural empowerment

-new knowledge innovations and improvements

-exemplary professional practice

-transformational leadership

-empirical outcomes

What are the 5 rights of delegation?

1. Right task- can it be delegated

2. Right Circumstance- Should it be delegated

3. Right person- can this person do the task

4. Right direction/ communication- is the task being conveyed in a clear manner

5. Right supervision- is the task being followed up on once complete.

What cannot be delegated?

-assessments

-planning

-evaluating

-nurse reasoning

-judgment

example of validation (therapeutic response)

Did I understand you correctly that...

example of summarizing (therapeutic response)

There are three things you are upset about: your family being too busy, your diet, and being in the hospital too long

example of clarification (therapeutic response)

what do you mean by your last statement?

example of reflecting (therapeutic response)

You seem excited about going home today

example of open ended question (therapeutic response)

What are some of your biggest concerns

example of offering self (therapeutic response)

I'll sit with you for awhile