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NUR151-Evol-Nursproc

Evolve resources for Nursing Process Ch 15 - 20

QuestionAnswer
When the day shift nurse visits the client to clarify the client's bad experience with surgery, the nurse is exhibiting which aspect of critical thinking? Discipline
Discipline includes completing the task at hand, including assessments (which were not completed on the previous shift).
Integrity includes recognizing when one's opinions conflict with those of others and finding a mutually satisfying solution.
Confidence demonstrated in one's presentation and belief in one's knowledge and abilities.
Perseverance helps the critical thinker to find effective solutions to client care problems, especially when they have been previously unresolved.
Fairness involves analyzing all viewpoints to understand the situation completely before making a decision.
Curiosity gives the critical thinker the motivation to continue to ask questions and learn more.
Risk taking involves trying different ways to solve problems.
Using the same pain scale for all clients and ratings promotes consistency—each nurse has the same measurement scale to compare assessments.
Relevance refers to how applicable the assessment is.
An assessment has depth when it deals with less obvious issues.
Specificity refers to the ability of the assessment to provide information about the particular problem of interest.
Reflection is the process of purposefully thinking back and recalling a situation to discover its purpose or meaning.
Client assessment is the first step in the process of instruction.
At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step.
Complex critical thinkers separate themselves from authorities and analyze and examine choices more independently.
Commitment is the third level of critical thinking in which the person anticipates the need to make choices without assistance from others.
The scientific method is a process of problem solving.
Assessment is the process of observing and collecting data.
Planning is the step in which the diagnosis is analyzed for problem resolution.
Intervention consists of the steps actually taken after planning.
Evaluation measures the effectiveness of the plan.
Experience is acquired through clinical learning situations.
Problem solving is a series of steps to resolve a problem.
Clinical decision making is a process in which critical thinking steps are followed for problem resolution.
The critical thinking component involved in the nurse's review of the literature is knowledge application
Before performing a procedure for the first time at a new agency, the travel nurse Reads about the procedure in the policy and procedure manual
The nurse enters a room during a tense moment between spouse and client, nurse should Ask the client and spouse if they need some time alone right now.
A client is asked and responds she gets up in the middle of the night to void, the nurse should then ask "Why do you get up at night?" – it may be because her husband is up and she may not have nocturia.
Scientifically based clinical judgment The nurse is demonstrating awareness of the effect of insulin. Because the client will be NPO status, no calories will be consumed. Giving the usual injection of insulin could cause the client to experience hypoglycemia.
The pt is a 65-year-old overweight woman with multiple medical diagnoses. What tool should be used to plan her care? concept map is a visual representation of pt problems and interventions that shows their relationships to each other and allows easy synthesis of data about the client.
A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? Pain intensity, Location of pain, Character of pain, Radiation of pain, Meaning of pain to the client
Collection and verification of data Assessment
Information about a client’s needs, health problems, and responses to these problems database
Organized conversation with pt to obtain info Interview
Pt’s perceptions about themselves; for example, feelings of anxiety, pain, or stress Subjective data
Comparison of data with another reliable source to confirm accuracy validation
Categories or groups of related data that offer comprehensive review of health functioning Functional health patterns
Organization of data to classify and focus on the correct problem data clustering
Information that is descriptive, concise, and complete without inferences or interpretive statements assessment data
The purpose of assessment is to establish a database about the pts perceived needs, health problems, & responses to these problems - data also reveal related experiences, health practices, goals, values, and expectations.
Assessments include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client.
The health perception–health management pattern involves the pt's self-report of health & well-being, how the pt manages his health, & knowledge of preventative health practices.
The cognitive-perceptual pattern involves sensory-perceptual patterns, language adequacy, memory, and decision-making abilities.
The coping–stress tolerance pattern involves the client's ability to manage stress, sources of support, and the effectiveness of the patterns in terms of stress tolerance.
The value-belief pattern involves the values, beliefs, and goals that guide the pts choices or decisions.
During data clustering, the nurse organizes cues into patterns that indicate individualized nursing diagnoses and identify collaborative problems.
Known allergies are a part of historical data.
Biographical data include age, address, occupation, work status, marital status, course of health care, and insurance.
The history of the present illness includes when the symptoms began, whether they began suddenly or gradually, whether they come and go, and other information about the illness.
The environmental history includes data about the client's home and working environments.
A review of systems (ROS) is based on information obtained from the client during the interview. This information is an example of ______________ data. subjective
nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes.
The nurse reviews data regarding pt pain symptoms, comparing defining characteristics for Acute pain w/Chronic pain. Nurse selects Acute pain. This is ex of avoiding which type of error? Error in data clustering - occur when data are clustered prematurely, incorrectly, or not at all.
The use of standard formal nursing diagnostic statements provides a precise definition that gives all members of the health care team a common language for understanding the pt needs.
The term readiness indicates a wellness nursing diagnosis.
A potential nursing diagnosis is a risk for diagnosis.
A nurse who is uncertain and asks a colleague to consult is avoiding a data collection error.
"Unhappy and worried about health" is not a scientifically-based nursing diagnosis, and it can lead to error in Diagnostic label
A pt wound is not healing & appears to be worsening w/current treatment. What is the first option nurse should consider? Calling wound care nurse as consultant - notifying physician may be appropriate after nurse decides on plan of action w/wound care nurse.
The defining characteristics for Impaired urinary elimination include nocturia, frequency, and urinary retention – not inadequate urinary output
Expected outcomes and goals are the main components of the planning phase of the nursing process.
The client should be the focus of the planning stage.
Interventions are initially determined by the nurse
A client-centered goal is a specific & measurable behavior or response that reflects pt's highest possible level of wellness & independence in function.
Which of the following is an example of an expected outcome statement in measurable terms? Client will report pain intensity of less than 4 on a scale of 0 to 10.
Providing frequent mouth care and controlling aversive odors and unpleasant visual stimulation that trigger nausea are examples of independent intervention.
Nurse instructs aide to report any coughing during meals in the pt. In this situation the nurse is acting as Delegator
The nurse prepares a pt for a lumbar puncture. Before the start of the procedure the nurse is sure to takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications.
Nurse requests a stimulant laxative for a pt receiving opioid. What is nurse demonstrating? Control of adverse reactions
Ex of instrumental activities of daily living Ability to cook meals, write checks, and take meds.
Recording vital signs is an example of indirect care.
Taking vital signs is an example of a psychomotor skill.
Anticipating complications is a cognitive skill that is an assessment skill.
Which of the following is an example of interpretation? Matching the results of evaluative measures w/expected outcomes to determine the pt’s status
If goals are unmet or partially met, intervention must be continued - goals and expected outcomes, interventions, and priorities may need to be redefined.
Care plans are discontinued after goals are met; they are revised when goals are not met.
Nursing diagnoses should be changed only if a new diagnosis becomes appropriate, not when goals and objectives are not met.
The QI process is concerned with exceeding standard of care, examining ways to be more efficient, improving pt satisfaction, & focusing on service - nursing staff collaborates w/appropriate health care disciplines during QI.
Created by: Ladystorm
 

 



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