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NUR1010 EXAM 1

With regard to research... What is the difference informed consent & full disclosure? Pg 46 - with regard to research, informed consent requires the researcher to provide FULL disclosure meaning complete information re: the nature of the study, subject's rights to refuse participation and likely benefits & risks that may be incurred.
What is the goal of primary care? Know examples. Table 4-5 pg. 63 - Decrease the risk to a client (ind., family, community) for disease or dysfunction. Basically health promotion, protection against specific illnesses. Ex:lifestyle modification, teaching, immunizations
What is the goal of secondary care? Know examples. Early intervention to alleviate disease & prevent further disability. Basically early detection & intervention. Ex:screenings, diagnosis, surgery, acute care
What is the goal of tertiary care? Know examples. Minimize effects of & perm disability due to chronic or irreversible condition. Basically restorative & rehabilitative activities to obtain optimal functioning. Ex:education & retraining, environmental modications
What are the steps in the nursing process? Pg. 79-85 - Assessment, Diagnosis, Planning (Outcome Identification & Planning), Implementation, Evaluation
What does A.D.P.I.E. stand for? Pg. 79 - Assessment, Diagnosis, Planning (Outcome Identification & Planning), Implementation, Evaluation
What is the purpose of the nursing process? Pg. 79 - To provide care that is individualized, holistic, effective and efficient.
What is included in the assessment step of the nursing process? Pg. 79 - Collecting data from a variety of sources, validating data, organizing data, categorizing or identifying patterns in data, making inferences or impressions, recording/reporting data.
What is the difference between primary sources & secondary sources? Pg. 80 - Primary - data from client Secondary - data from family, other providers & medical records.
Explain the 2nd step of the nursing process, diagnosis. Pg. 81 - this step involves breaking down data and synthesizing it by using critical thinking & decision making skills
Name the 5 types of nursing diagnoses. Table 5-4 pg 82 - Actual diagnosis, risk diagnosis, possible diagnosis, wellness diagnosis, and collaborative diagnosis.
What is the difference between subjective data and objective data? Know examples of each. Pg. 80 - Subjective is the client's feelings, perceptions, and concerns about the symptoms or condition. Objective data is observable & measurable data obtained by physical exam and diagnostic tests.
What are the components of critical thinking? Pg. 76 - mental operations (decision-making and reasoning to create meaning), knowledge (declarative i.e. specific facts and information & operative i.e. the nature of the knowledge), and attitudes (sense of curiosity to question assumptions)
What is the role of critical thinking the "planning" phase of the nursing process? Pg. 126 - Nurses have to be able to use critical thinking skills to identify a diagnosis in order to resolve the client's need with greater proficiency. Helps with prioritization in the planning process and make adjustments throughout.
Name the 3 phases of the "planning" step in the nursing process? Pg. 126-127 - Initial planning, Ongoing planning, Discharge planning
What happens during the initial planning phase? Pg. 126 - development of the initial care based on admissions assessment data
What happens during the ongoing planning phase? Pg. 126 - continuous updating of the client's plan of care, new info is gathered and evaluated thus revisions of the plan are made as necessary.
What happens during the discharge planning phase? Pg. 126 - anticipation and planning for the needs after client is discharged, usually involves long-term goal setting and a multidisciplinary approach
What are the 4 critical steps of "planning" in the nursing process? Pg. 126 - establish priorities, set goals & expected outcomes, plan interventions, documentation
What is the difference between a goal & expected outcome? Pg. 128 - one is an aim, intent or end (broad or global statement), the other is detailed, specific statements that include the methods that will be used to obtain a goal.
When constructing an "expected outcome," what 3 attributes should you keep in mind? Pg. 129 - this element of planning should be realistic, mutually desired by client & nurse, attained within a defined time period
What are the 5 components of a well-constructed goal and expected outcome? Describe each. Pg. 129 - Subject, Task statement, Criteria, Conditions & Time Frame. Examples in green boxes.
What is a nursing intervention? Pg. 132 - An action that is based on scientific principles and knowledge from nursing behavioral, and physical sciences that is performed by a nurse to help the client achieve his/her goal and expected outcomes.
What are some things to keep in mind when selecting an appropriate nursing intervention?What is Nursing Checklist Pg. 132
Name the 3 categories of nursing interventions. Pg. 132 - Independent, interdependent & dependent.
Describe independent nursing intervention. Pg. 133 - nursing actions that do NOT require an order from another healthcare provider.
Describe interdependent nursing intervention. Pg. 133 - nursing actions implemented in collaboration with other healthcare professionals. i.e. consultation with a dietician re: nutritional restriction.
Describe dependent nursing intervention. Pg. 133 - nursing actions that do require an order from another healthcare provider, i.e. medication administration.
Name & describe the final step in the nursing process. Pg. 134 - Evaluation - the determination of the client's progress toward achievement of expected outcomes.
What is Maslow's hierarchy? Pg. 98 - Needs model that proposes an individual's basic physiological needs that progresses from a basic to highest need at the top.
What are the 5 levels of need according to Maslow? (name & describe from most basic need at the bottom to the highest need at the top) ***hint level 1 - 3*** Pg. 98 - 1st (Physiological needs - survival needs i.e. food, water, oxygen), 2nd (Safety & Security - both physical and psychological), 3rd (Need for Love & Belonging - humans have an innate need to be part of a group & to be accepted),
What are the 5 levels of need according to Maslow? (name & describe from most basic need at the bottom to the highest need at the top) ***hint level 4 & 5*** 4th (Self-esteem - need to feel worthwhile), 5th (Self-Actualization - Need to function at one's own optimal level & be personally fulfilled)
Define: Actual diagnosis Pg. 116 - problems already in existence
Define: Risk diagnosis Pg. 116 - identified when there is a recognized vulnerability to the client to exhibit a problem but has not manifested the problem yet
Define: Health promotion diagnosis Pg. 116 - identifies behaviors that indicate desire to increase well-being
Define: Wellness diagnosis Pg. 116 - identifies the client's condition or state of health that may be enhanced by deliberate health promoting activities.
What is the difference between a "standing order" & a "protocol"? Pg. 144-145 - one is a standardized intervention written, approved & signed by a prescribing practitioner and kept on file w/in a facility, the other is a series of standing orders of procedures that should be followed under certain conditions.
What is the difference between assault and battery? Pg. 191-192 - one is a stated intent to touch a in an offensive, insulting, or physically intimidating manner / the other is touching another person without consent.
What is malpractice? Pg. 190 - a professional person's wrongful conduct, improper discharge of professional duties, or failure to meet the standards of acceptable care that results in harm to another person.
What is negligence? Pg. 190 - breach of duty (failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstances.
Define: Informed consent Pg. 191 - type of consent form signed by the client indicating he/she understands the reason for the proposed intervention, and its benefits and risks, and agrees to the treatment by signing the consent
What types of procedures require informed consent? Pg. 191 - All invasive procedures.
In order to give informed consent, a client must be: Pg. 191 - must be mentally competent, possess an understanding of the procedure and it's risks and benefits, understand that he/she has the right to refuse to undergo treatment.
What is the nurse's role in obtaining informed consent? Pg. 191 - The nurse has the responsibility to make sure informed consent has been obtained and sign as a witness.
When can informed consent be waived? Pg. 191 - In the case of emergency, situations where the consent of a minor is sufficient, court order or other legal authorization
Define: False imprisonment Give example Pg. 193 - when a client is led to believe they cannot leave. Ex: misuse of chemical or physical restraints
What is HIPAA? Health Insurance Portability and Accountability Act of 1996
An act that ensures the privacy of individual health care information by requiring written confirmation that clients have been informed about their privacy rights. HIPAA
What are some precautions are nurses now taking to protect their client's privacy? Names cannot be posted outside rooms or called in the waiting room, med charts must be stored in a secure area, and discussion of a clients health care info must take place in a private area.
What is Fraud? Give examples of fraud. Pg. 194 - Results from a deliberate deception intended to produce unlawful gain, i.e. overcharging for services, obtaining and using false credentials.
Give examples how nurses can deter fraud. Document facts accurately. Report illegal activity. Educate peers & the public as to what constitutes fraud.
Give examples of unprofessional conduct. i.e. breach client confidentiality; failure to use sufficient knowledge, skills or nursing judgment when practicing nursing; physically or verbally abusing clients; assuming duties w/o sufficient preparation; failure to maintain accurate records
Define: impaired nurse ______________ is habitually intemperate or is addicted to the use of alcohol or habit-forming drugs
Give some indicators of substance abuse. social isolation, changes in appearance, excessive work-related tardiness or absences, increased accidents, excuses of unavailability while on duty, defensiveness, failure to meet deadlines, inaccurate or sloppy documentation
Biggest legal issue safety i.e. failure to monitor client status, medication errors, falls, use of restraints.
Define: Understaffing _______________ is the failure of the facility to provide sufficient # of professional staff to meet client needs
Define: Reassignment _______________ is common method of resolving staffing shortages
What are the pitfalls to reassignment? Pg. 196 - Nurses need to be sure that the area in which they have some orientation to the area they are floating prior to the reassignment, if not knowledgeable in that area being assigned the nurse should indicate such to mgmt & acquire skills needed.
What type of information is required in an accident report? Pg. 196 - Nurses should only state the facts (no opinions or conclusions).
What is done with the incident report upon completion? Pg. 196 - This report goes to mgmt and NOT in the client's chart. Matter of fact, no reference to such report can be make in client's chart.
True/False: Nurses can refuse executing a prescribed order. Pg. 195 - Nurses are obligated to follow orders of a licensed prescribing practitioner, unless the orders would result in client harm.
Define: Nonmaleficence ____________ is the duty to cause no harm to other. Can be in many shapes i.e. physiological, psychological, social and spiritual.
Created by: shaston001