Last Nursing Process Test simpler

What do the 6 major ethical principles mean?

Autonomy = client choice; beneficence = do good; nonmaleficence = do no harm; veracity = tell the truth; fidelity = keep promises; justice = fairness.

Can a competent client refuse treatment?

Yes. Respect and advocate for the client's decision.

What are negligence, malpractice, and intentional torts?

Negligence = breach of duty causing injury; malpractice = failure to meet professional standards; intentional torts include assault, battery, defamation, and invasion of privacy.

What professional actions help protect clients?

Follow standards of care, protect confidentiality, document accurately, communicate effectively, and practice safely.

What are reflection, clarification, and focusing?

Reflection explores feelings; clarification checks understanding; focusing helps the client discuss an important topic.

What are common nontherapeutic responses?

Giving advice, false reassurance, criticizing, rejecting, challenging "why" questions, or changing the subject.

What are the 5 steps of the RN nursing process?

Assessment, analysis, planning, implementation, and evaluation.

What is subjective vs. objective data?

Subjective = what the client reports. Objective = what can be observed or measured.

What happens during assessment and analysis?

Assessment collects data; analysis/diagnoses identifies actual or potential client problems.

What happens during planning?

Set priorities, nursing interventions, and SMART client-centered goals.

What happens during implementation and evaluation?

Implementation performs the interventions; evaluation checks whether outcomes were met.

What should happen if an outcome is not met?

Reassess, validate the data, and revise the goals, interventions, or care plan.

What is delegation, and what tasks can commonly be given to AP?

Delegation assigns a task to another qualified person. AP can commonly assist with ADLs, vital signs, height, and weight for stable clients.

What cannot be delegated to AP?

Assessment, clinical judgment, clinical reasoning, and decision-making.

What are the Five Rights of Delegation?

Right task, circumstance, person, directions/communication, and supervision/evaluation.

What do Right Task and Right Circumstance mean?

The task must fit the person's role and policy, and the client's condition/situation must be appropriate and stable.

What do Right Person and Right Directions mean?

The person must be qualified, and instructions must be clear and specific.

What does Right Supervision and Evaluation mean?

The nurse monitors completion of the task and evaluates the client outcome.

What makes interprofessional teamwork effective?

Shared goals, clear roles, mutual respect, communication, and collaboration.

What are SBAR, ISBAR, and closed-loop communication?

SBAR = Situation, Background, Assessment, Recommendation. ISBAR adds Identity. Closed-loop communication verifies that a message was received and understood.

What are the 3 domains of learning?

Cognitive = knowledge; affective = feelings/values; psychomotor = physical skills.

What are teach-back and return demonstration?

Teach-back = client explains information back. Return demonstration = client performs the skill.

How should teaching be adapted for older adults?

Reduce distractions, use a low tone, allow more time, and teach information in smaller pieces.

What should the nurse assess before teaching?

Readiness, literacy, language, cognition, sensory ability, comfort, culture, motivation, and learning barriers.

What does ABCDE stand for?

Airway, Breathing, Circulation, Disability, Exposure.

Why is airway usually the first ABCDE priority?

A blocked airway can quickly become life-threatening.

What do Breathing, Circulation, Disability, and Exposure assess?

Breathing = oxygenation; Circulation = blood flow; Disability = neurologic status; Exposure = other important findings.

What is Maslow's hierarchy from lowest to highest?

Physiological, safety, love/belonging, self-esteem, self-actualization.

Which needs are generally prioritized first?

Physiological needs such as oxygenation, circulation, hydration, nutrition, and elimination.

What does the safety-and-risk framework prioritize?

The problem causing the greatest immediate risk of harm.

Should nursing priorities stay the same all shift?

No. Reassess often and use the least restrictive safe intervention when appropriate.

What is hospice care?

Comfort-focused end-of-life care; these notes associate hospice with a life expectancy of 6 months or less.

What is palliative care?

Comfort and symptom relief during serious illness; it may occur while active treatment continues.

What is the main difference between hospice and palliative care?

Hospice focuses on end-of-life comfort; palliative care may begin earlier and occur with curative treatment.

What is respite care?

Temporary care that gives the primary caregiver a break.

What breathing changes can occur near death?

Dyspnea, retained secretions/death rattle, and Cheyne-Stokes respirations.

What comfort measures may help dyspnea and death-rattle secretions?

Positioning, a fan, relaxation, side positioning, and prescribed symptom-relief or secretion-reducing medications.

What are Cheyne-Stokes respirations and mottling?

Cheyne-Stokes = irregular breaths followed by apnea. Mottling = cool purple, pale, or gray skin from decreased perfusion.

How should the nurse support dignity near death?

Talk calmly even if the client is unresponsive, respect preferences, provide comfort, preserve control, and involve the client in decisions.

What are a stressor, eustress, and distress?

A stressor triggers stress; eustress is positive stress; distress is negative or unhealthy stress.

What is acute vs. chronic stress?

Acute stress is short-term and immediate; chronic stress is long-lasting and can harm health.

What types and sources of stress should you know?

Acute, episodic acute, chronic, traumatic, environmental, psychological, and physiological; sources include work, finances, loss, illness, and family problems.

What happens during fight-or-flight?

Catecholamines increase heart rate, blood pressure, glucose, oxygen intake, alertness, and pupil size.

What does the HPA axis ultimately cause the adrenal glands to release?

Cortisol.

What are the three stages of GAS?

Alarm, resistance, and exhaustion.

What happens during the three GAS stages?

Alarm = fight-or-flight; resistance = continued coping; exhaustion = resources are depleted and illness risk increases.

What are primary appraisal, secondary appraisal, and reappraisal?

Primary = "Is it a threat?" Secondary = "Can I cope?" Reappraisal = reevaluate as the situation changes.

What is problem-focused vs. emotion-focused coping?

Problem-focused tries to change the situation; emotion-focused tries to change the emotional response.

What are adaptive coping and defense mechanisms?

Adaptive coping helps long-term. Defense mechanisms unconsciously reduce anxiety, such as denial, projection, and rationalization.

What should you know about crisis, trauma-informed care, and compassion fatigue?

Assess safety first in crisis; trauma-informed care avoids retraumatization; compassion fatigue is cumulative stress from caring for suffering clients and can be reduced with rest, support, exercise, meditation, and self-care.