Nursing Exam 2

What part of ADPIE is this?

Systemically gathering information about patients physiological, psychosocial, sociocultural, developmental, and spiritual status

EX. The nurse enters a room and notices a patient grimacing, holding their abdomen, and rating their pain as 8/10.

Assessment

What part of ADPIE is this?

Using your critical thinking skills to analyze the assessment data. Nurses identify patterns in the data and draw conclusions, including strengths, problems, and contributing factors.

EX.A nurse determines that a patient’s frequent incontinence is leading to skin breakdown and states: “Impaired skin integrity related to urinary incontinence.”

Diagnosis

What part of ADPIE is this?

The nurse makes a plan of care specific for that patient, focusing on their individual needs; should set goals specifically for the priorities of that paitient.

EX.The nurse writes the following goal: “Patient will ambulate 100 feet with a walker by the end of the shift.”

Plan

What part of ADPIE is this?

Nurses put into action what was planned for their patient; involves doing, giving fluids, walking patient, changing wound dressing, electrolyte replacements.

EX.The nurse teaches a patient with new diabetes how to self-administer insulin and observes while the patient practices.

Implementation

What part of ADPIE is this?

Looking at what has been done to see if you met the desired outcome.

EX.After teaching insulin administration, the nurse asks the patient to demonstrate the skill. The nurse notes the patient performs each step correctly.

Evaluation

What type of data is this?

Data that is directly obtained from the client/patient; either what they say or what you observe

Primary data

What type of data is this?

Data that is from family or from medical data; obtained second hand

Secondary data

What type of data is this?

Recieved from the patient, family, or community, may be used to verify objective data; what patient says like their head hurts

Subjective data

What type of data is this?

Data obtained from a physical assessment

Ex. Seeing that the patient has a red knot on their head

Objective data

When should a nurse validate data?

If the patient has a abnormal complication that they usually never have like having high BP

Is a standardized framework used to develop, teach, and evaluate nurses ability to make sound decisions in complex patient situations.

The clinical judgement model

What part of the clinical judgement measurement model is this?

Assessment

Recognize cues

What part of the clinical judgement measurement model is this?

Analysis/Diagnosis

Analyze cues and Prioritize hypotheses

What part of the clinical judgement measurement model is this?

plan

Generate solutions

What part of the clinical judgement measurement model is this?

Implementation

Take action

What part of the clinical judgement measurement model is this?

Evaluation

Evaluate outcomes

Which of Maslow’s Hierarchy of needs is this?

Mortality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

EX. A patient whose chronic illness is well-managed expresses a desire to write a book about their experiences to inspire others. Which level of Maslow’s hierarchy does this represent?

Self-actualization

Which of Maslow’s Hierarchy of Needs is this?

Self-esteem, confidence, achievement, respect of others, respect by others.

EX. A patient with a new prosthetic leg begins physical therapy and states, “I’m proud I can walk again.” This statement reflects which need in Maslow’s hierarchy?

Esteem

Which of Maslow’s Hierarchy of Needs is this?

Friendship, family, sexual intimacy

During hospitalization, a patient expresses loneliness and asks if their spouse can stay overnight. Which need is the patient trying to meet?

Love, Belonging

Which of Maslow’s Hierarchy of Needs is this?

Security of body , of employment of resources, of morality, of the family, of health, of property

EX.A patient tells the nurse, “I don’t feel safe going home because I live alone and I’m worried I’ll fall again.” This concern relates to which level of Maslow’s hierarchy?

Safety

Which of Maslow’s Hierarchy of Needs is this?

Breathing, food, water, sex, sleep, homeostasis, excretion

Main priorities

EX.A nurse is caring for a patient who is experiencing severe shortness of breath and oxygen saturation of 80%. According to Maslow’s hierarchy of needs, which category of needs should the nurse address first?

Physiological

Nurses should never delegate things they can…

Evaluate, Assess, Teach (EAT)

Is influenced by things such as educational background , culture, language, age, gender identification, and past experiences.

Verbal communication

What level of communication is this?

Conscious internal dialogue, self-talk, can be a positive or negative

Intrapersonal communication

What level of communication is this?

Face-to-face conversation between two people, is the most frequent form of interpersonal communication. Nurses use this type of communication to gather info during assessment.

Interpersonal communication

What level of communication is this?

Interaction that occurs among several people.

Group communication

What level of communication is this?

Unique form of group communication

Public Speaking

What process of communication is this?

Begins the conversation to deliver a message to another person. Initiates content delivery. Sometimes called the source or encoder.

Sender

What process of communication is this?

Refers to the process of selecting the words, gestures, tone of voice, signs, and symbols used to transmit the message

Encoding

What process of communication is this?

Is the verbal and nonverbal information the sender communicates. It might be a conversation, a speech, gesture, or letter. Mus be appropriate for the situation and for the developmental level of the person to receive it.

Message

What process of communication is this?

Is the medium used to send the message. Face-to-face communication is commonly used one. Other types are pamphlets, audiovisual aids, recordings, telephone, internet, and text messages.

Channel

What process of communication is this?

Is the observer, listener, and interpreter of the message. Interpretation

Receiver

What process of communication is this?

Refers to relating the message to your past experiences to determine the sender’s meaning. Uses visual, auditory, and tactile senses. Interpretation of the message by the receiver.

Decoding

What process of communication is this?

Validates that the receiver received the message and understood it as the sender intended, Feedback may be verbal, nonverbal, or both. Verifying avoids confussion.

Feedback

The unconscious use of body language when sending a message

Nonverbal Communication

What communication style is this?

Those who adopt this approach fail to communicate needs, feelings, or opinions. These people avoid conflict and allow others to take the lead. Tend to be submissive, indecisive, or whining. Often apologize for opinions

Passive

What communication style is this?

Avoids direct confrontation but subtly achieves goal through manipulation. May appear cooperative or passive on the surface; yet they undermine or sabotage the efforts of others.

Passive Aggressive

What communication style is this?

Try to dominate others, using intimidation and humiliations to control others. They often find blame or criticism of others, events, or situations. They are poor listeners, tend to be impulsive, and have a low tolerance for frustration.

Aggressive

What communication style is this?

This style of communication is direct, open, honest, spontaneous, responsible, and nonjudgmental. It allows you to take responsibility for your own thoughts and actions without encouraging feedback and enables you to find satisfying solutions to conflict by confronting people constructively.

Assertive

Which phase of the therapeutic relationship is this?

Stage 1

Gathering information prior to meeting client

Anticipate concerns

Plan time and setting for interview; this is before you meet the patient.

Pre-interaction phase

Which phase of the therapeutic relationship is this?

Stage 2

Meeting the client; introductions; establishing rapport and trust

Orient to unit, data collection/patient needs/ history

Prioritize problems and goals

contract developed

Orientation phase

Which phase of the therapeutic relationship is this?

Stage 3

Use of techniques germane to therapeutic communication

Active part of relationship

Usually longest phase

Client clarifies feelings and concerns through verbal and nonverbal communication; nurse serves as a teacher, conselor

Working phase

Which phase of the therapeutic relationship is this?

stage 4

conclusion of relationship

Relinquish responsibility of care

smooth transition to other care givers as needed

Evaluate goal attainment with patient

Termination phase

What communication is the key for patients with impaired speech?

Nonverbal Communication

What Developmental theory is this?

Blieved human development is maintained by instinctual drivers, such a libido, aggression, and survivial. Different drives predominate depending on age of the individual. Consisted of the id, ego, and superego- different parts at different life stages.

Freuds Psychoanalytic Theory

What Developmental theory is this?

Believed cognitive development requires three core competencies; adaption, assimilation, and accommodation. This development occurs from brith through adolescence is a sequence of four stages; sensorimotor, preoperational though, concrete operations, and formal operations.

Piaget Cognitive development theory

Which of Eirkson’s Psychosocial Developmental theory is this?

Birth to about 18 months; stage 1

Trust vs mistrust

Which of Eirkson’s Psychosocial Developmental theory is this?

About 18 months - 3 years; stage 2

Autonomy vs shame and doubt

Which of Eirkson’s Psychosocial Developmental theory is this?

3-5 years; time in there lives they try and become more independent; stage 3

initiative vs guilt

Which of Eirkson’s Psychosocial Developmental theory is this?

6-11 years devloping new ways of thinking, coming in contact with new people; stage 4

Industry vs inferiority

Which of Eirkson’s Psychosocial Developmental theory is this?

11-21 years; developing their self, figuring out who they are; stage 5

identity vs role confusion

Which of Eirkson’s Psychosocial Developmental theory is this?

21-40 years; trying to find a person to spend your life with; married; spending time with friends; stage 6

Intimacy vs isolation

Which of Eirkson’s Psychosocial Developmental theory is this?

40-65 years; become stagnant if they do not change something in their life; stage 7

Generativity vs stagnation

Which of Eirkson’s Psychosocial Developmental theory is this?

over 65 years; people who are doing something new in life; reflection of life and going over any life long regrets; stage 8

Ego integrity vs despair

What is the leading cause of accidental death in toddlers?

Drowning

What are the physicals and hormonals changes in the adolescent years for females?

Undergo a growth spurt between 9-14

Height increases 2-8 inch; weight gain; 15-55 lbs

First menstruation occurs 2 years after puberty with average age of 12

What are the physicals and hormonals changes in the adolescent years for males?

Undergo growth spurt between 10-16

height increases 4-12 inch; weight gain 16-65 lbs

Puberty occurs between 9-12

Which age development has the healthiest stages in life with mature body systems, peak bone density, and child bearing age?

Young adults 19-40

What is the average age for menopause in women?

52 years old

When will perimenopause symptoms occur?

when there is a decline in estrogen levels. 5-7 years before menopause

Is characterized by a decrease in testosterone production, lower sperm count, and a need for more time to achieve an erection. Doe not result in an inability to reproduce but does limit reproductivity.

Andopause

What are the common health problems in middle age individuals?

Obesity. alcoholism, anxiety, depression, early-onset dementia

What is the health promotion for middle aged adults?

Immunizations, health screenings (eye exam, colonoscopy, BP, etc) nutrition, and injury prevention

What stage of development for old age is this?

Physical and psychological adaptations to retirement are paramount in this age group. face barriers to health ages 65 to 74 years old.

Young old

What stage of development for old age is this?

The developmental challenge of this is an increasingly solitary, sedentary lifestyle; ages 75-84 years

Middle old

What stage of development for old age is this?

The developmental challenges of this are sensory impairments, oral health, inadequate nutritional intake, and functional limitations; ages 85 years or above.

oldest old

A syndrome or a set of characteristics that describes a heightened state of vulnerability for developing adverse health outcomes. A multisystem reduction in the persons physiological capacity. Older people tend to fragile.

Frailty

Is it normal for older adults to become confused simply due to normal aging changes?

No

Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of ability to calculate and poor judgment are a normal part of aging process? TRUE OR FALSE

False

What happens to cognitive development as aging happens?

Memory declines; intelligence does not

Is an irreversible progressive decline in mental abilities that affects about 1 in 5 of adults older than age 70. Involves both memory impairments and disturbance in at least on other are of cognition.

Dementia

The loss of ability to communicate

Aphasia

The loss of ability to carry out purposeful movements

Apraxia

The impaired ability to recognize or identify objects. Can lead to the ability to not recognize family members or ones reflections

Agnosia

The undesired change or removal of a valued object, person, or situation

Loss

The physical, psychological, and spiritual responses to loss

grief

Consists of the actions of associated with grief (crying, wearing black, etc.)

Mourning

The period of mourning and adjustment after a loss

Bereavement

What type of loss is this?

Loss of loved one, destruction, natural disaster. Visible and recognized by others

Actual loss

What type of loss is this?

Identified only by the person experiencing it; internal

Perceived loss

What type of loss is this?

Injuries, removal of an organ, loss of function

Physical loss

What type of loss is this?

Perceived loss challenge what we believe, such things as sexuality, control, fairness, meaning and trust

Psychological loss

What type of grief is this?

Uncomplicated (sadness, guilt, yearning, anger, regret, headache, difficulty sleeping)

Overtime loss is felt to be normal part of living

acceptance

normal grief

What type of grief is this?

Grief experienced before the loss of someone or something

Anticipatory grief

What type of grief is this?

Grief lasting longer than 12 months (unable to accept the death of a loved one) inability to join normal life

Prolonged grief disorder

What type of grief is this?

Grief that is not accepted by society (loss of pet, extramarital affair, foster kids removed from a home, abortion) A loss that can’t be publicly shared. Can’t grieve in public

Disenfranchised grief

What type of grief is this?

Poor coping, grieving but expressing grief through other types of behavior (drinking, sex, arguing)

Masked grief

What stage of grief from Kubler-Ross model is this?

The client has difficulty believing in an expected or actual loss. (avoidance, confusion, shock, fear)

Denial

What stage of grief from Kubler-Ross model is this?

The client directs anger toward self, other, a deity, objects, or the current circumstance. (Frustration, irritation, anxiety)

Anger

What stage of grief from Kubler-Ross model is this?

The client negotiates for more time or a cure. (Struggling to find meaning, reaching out to others, telling ones story)

Bargaining

What stage of grief from Kubler-Ross model is this?

The client is overwhelmingly saddened by the inability to change the situation. (Overwhelmed, Helpless, Hostility, Fight)

Depression

What stage of grief from Kubler-Ross model is this?

The client acknowledges what is happening and makes plans for the future. (Exploring options, new plan in place, moving on)

Acceptance

What type of care is this?

Long term and can give meds/life saving measures

Will not treat or cure disease or prevent the client from dying but will treat in uncomfortable symptoms

Palliative care

What type of care is this?

Focuses on the care of the dying, likely to die in 6 months

Terminal

Hospice care

What medication is this?

Administered for pain and dyspnea; opioid

Morphine

What medication is this?

Administered to minimizes wet secretion and promote the ease of breathing- used for death rattle; antiemetic

Scopolamine

What medication is this?

Administered for fluid overload; loop diuretic

Furosemide

What medication is this?

Administered for anxiety; benzodiazepine

Lorazepam

What medication is this?

Administered for nausea and vomiting; antimetic

Ondansetron