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Foundations Nursing
Foundations Nursing set 1
| Question | Answer |
|---|---|
| A _____________ is the most abstract level of knowledge. It refers to a set of concepts that describe nursing. These concepts are person, environment, health, and nursing. | metaparadigm |
| ___________, the next level of knowledge, describes the beliefs and values of nursing in relation to something more specific such as health. A philosophy provides guidance in practice. | Philosophy |
| The third level of knowledge is a nursing conceptual framework, or ________. A ________ is a set of concepts that provides direction for nursing practice, research, and education. | model |
| The fourth level of nursing knowledge is a __________. Theories come from conceptual models and can be tested in nursing practice. | nursing theory |
| A _________ uses a broad perspective of nursing practice and provides ways of looking at nursing phenomena from a distinct nursing perspective. | grand theory |
| A ________ is moderately abstract and has a limited number of variables. Middle-range theories have a more narrow focus on a specific condition or population. | middle-range theory |
| Florence Nightingale’s (1860) | Adaption to the environment allows for healing |
| Hildegard Peplau (1952) | Theory of Interpersonal Relations |
| Virginia Henderson (1966) | Humane and holistic care for patients |
| Martha Rogers (1970) | Science of Unitary Human Beings Model |
| Sister Callista Roy’s | (1970) Adaptation Model was based on the human being as an adaptive open system. The person adapts by meeting physiological-physical needs, developing a positive self-concept and group identity, performing social role functions, and balancing dependence a |
| Dorothea Orem | A self-care deficit exists when patients cannot meet their own needs. |
| Imogene M. King (1971) | developed a general systems framework that incorporated three levels of systems: (1) individual or personal, (2) group or interpersonal, and (3) society or social. Her theory of goal attainment discussed the importance of interaction, perception, communic |
| Betty Neuman | Systems Model |
| Rosemarie Rizzo (1981) | Human Becoming Theory |
| Jean Watson’s (1988) | Clinical caring processes include sensitivity and mindfulness |
| concept of a nursing discipline? | specific field of study or learning |
| Middle-range theories have which characteristics? | Focus on a specific condition or population Narrow focus with a limited number of variables Can be tested through direct application |
| Maslow’s | Hierarchy of Needs |
| Erikson’s | Psychosocial Theory |
| Lewin’s | Change Theory |
| Paul’s | Critical Thinking Theory |
| Rosenstock’s | Health Belief Model |
| Lewin’s Change Theory | The first step is unfreezing The second step, moving or change The third step is refreezing |
| The nurse is teaching a recently diagnosed diabetic patient to administer insulin injections. Whose theory was the nurse demonstrating? | Dorothea Orem |
| According to Maslow's Hierarchy of Needs, a patient who is unable to show affection toward his wife or accept her reassurances must have which needs met before love and belonging needs can be addressed? (All that apply) | B. Physiologic needs D. Safety and security |
| Based on Lewin's change theory, when a new mother accepts responsibility for the care of her infant and reports comfort with her role, which change step occurred? | D. Refreezing |
| The nurse and patient worked together to facilitate communication when the patient was unable to communicate verbally. Whose theory did the nurse exhibit when caring for this patient? | Imogene King : In Imogene King's General Systems Framework, the nurse and patient work together to achieve desired patient goals |
| The nurse explained the need for, and advantage of, receiving pain medication before ambulating to a patient who is first day post-operative from abdominal surgery. Whose theory did the nurse exhibit with this patient? | Virginia Henderson |
| The nurse facilitated extended visiting hours and offered additional support to the family of a dying patient. Whose theory did the nurse exhibit when caring for this family? | Jean Watson |
| The nurse implemented strict infection control procedures for an immunocompromised patient. Whose theory did the nurse exhibit when caring for this patient? | Florence Nightingale |
| The nurse is implementing concepts from which theory when facilitating a group discussion that involves problem-solving and interpersonal processes? | Hildegard Peplau |
| The nurse is teaching a recently diagnosed diabetic patient to administer insulin injections. Whose theory was the nurse demonstrating? | Dorothea Orem |
| The nurse recognizes that the patient seems disinterested when discussing needed dietary changes. Based on Lewin's Change Theory, which stage does the patient's disinterest represent? | Unfreezing |
| The nurse reflects which theory when helping the patient become as independent as possible before discharge from the hospital? | Virginia Henderson |
| A patient who is physically stable and healing is withdrawn and refusing treatment following an auto accident in which he suffered an amputated limb. Which theory would be beneficial if applied to this patient's care? | Rosenstock |
| Which nursing theory is the nurse exhibiting when teaching the diabetic patient the correct procedure for blood glucose monitoring? | Dorothea Orem |
| Which of Paul's critical thinking skills will the nurse use when developing a care plan for a newly admitted patient? (All that apply) | A. Experience B. Reasoning D. Observation |
| Which overlapping phases are concepts included in Hildegard Peplau's Theory of Interpersonal Relations? (All that apply) | B. Orientation D. Working E. Resolution |
| Which theorist stated that the imbalance between the patient and environment decreased the patient's capacity for health? | D. Florence Nightingale |
| Steps of the nursing process serve which purpose? | Enable organization of patient care Ensure comprehensive patient care Facilitate evaluation of patient care |
| Information received from the patient's family members, friends, or other nurses is what type of data? | Secondary, Subjective |
| What type of patient assessment takes into account factors such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health? | Holistic |
| What determines if an assessment is primary or secondary? | Data source |
| Obtained directly from patient | Primary |
| Obtained from other healthcare professionals, medical records, test results | Secondary |
| Direct quotes describing patient feelings | Subjective |
| Blood pressure reading and weight | Objective |
| The nursing __________ identifies an actual or potential problem or response to a problem. | Diagnosis |
| Why must nursing diagnoses include up-to-date diagnostic labels as determined by NANDA International? | Standardized language facilitates care recognized by all health care team members. |
| When a patient reports feeling anxious, what is the subjective data called? | Symptom |
| Actual: Objective | Skin red with open lesion |
| Risk | Patient unsteady when walking |
| Health-promotion | Patient voices readiness to learn |
| Actual: Subjective | “My head hurts” |
| What type of patient-centered care respects the input of family members and other members of the health care team? | Collaborative |
| Within 1 week, the patient will stand with support to brush teeth. | Short-term goal |
| Within 3 months, the patient will stand unsupported for 20 minutes. | Long-term goal |
| Classification of patient outcomes evaluating the effects of interventions. | Nursing Outcomes Classification (NOC) |
| Classification of interventions that nurses perform on behalf of patients. | Nursing Interventions Classification (NIC) |
| What is the most important aspect of a patient-centered care plan? | Matching the patient’s goals and relevant current status |
| The nurse establishes the ____ of unlicensed health care team members as a crucial balance between collaboration and overlapping responsibilities | scope of practice |
| What is the primary purpose for documenting nursing interventions? | Facilitate communication |
| Nursing care can be categorized as direct or indirect, depending on the nursing | Interventions |
| What types of care plans are used in implementation? | Standing orders that describe specific actions to be taken by a nurse., General protocols that apply to patients with similar clinical needs., Care pathways that combine several areas of health care expertise. |
| A nurse is creating a care plan and wants to put direct care items before indirect care items. Which of these is in the correct order? | Help the patient ambulate, and then order occupational therapy to come. |
| What is the fifth step of the nursing process that includes a decision point on whether to discontinue, continue, or revise the plan of care? | evaluation |
| What questions should the nurse ask when evaluating the effectiveness of nursing interventions? | Did the patient meet the goals established during the planning phase?, Should the plan of care be discontinued?, Does the care plan need to be modified in response to patient changes? |
| The evaluation phase loops back to which earlier phases of the nursing process when considering new data? | Assessment, Diagnosis, Planning |
| What does the evaluation phase include? | Patient’s achievement of short- and long-term goals. |
| A nurse is ready to set goals for a patient who is recovering from a hip replacement. The nurse sets goals for the first three days and for the first three weeks. What part of the nursing process is this? | Planning |
| What word does the nurse use to describe the five steps? | process |
| A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen? | Information from other steps will be used to complete the plan of care. |
| A nurse is caring for a patient at risk for appendicitis. When considering the assessment, why should the nurse use the five-step nursing process? | To systematically identify actual or potential patient problems |
| A nurse is caring for a patient who is cyanotic and has edema. The nurse is making a list of the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health. What stage of the nursing process is this? | Assessment |
| A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient’s pain level, is the nurse assessing subjective or objective data? | Subjective data, because only the patient can experience the pain. |
| A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care? | Risk, since the patient is at risk for infection at the site of the surgical incision. |
| A nurse is caring for a patient with a UTI. The nurse’s selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain? | Low back aching, Burning upon urination |
| A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers should initiate the nurse to change the nursing care plan? | new decubitus ulcers have formed |
| The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient? | Respiratory therapist, cardiologist, and pulmonologist |
| A nurse is caring for a patient with a UTI. Which of these interventions address the patient’s short-term goals? | Applying a heating pad to the low back or abdomen., Refraining from sexual intercourse. |
| A nurse determines the patient’s goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised? | Add a step to avoid eating after 7 p.m. |
| A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits? | Ensure individualized care. |
| A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard? | Implementation |
| A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient’s wife prepares the family meals. Why is it important to include the patient’s wife in the teaching? | The wife can learn how to follow his new diet too. |
| When does care planning begin? | When patient and nurse first interact. |
| The office nurse contacts a patient before surgery and informs the patient about what he can expect. What is the nurse performing? | Preadmission planning. |
| When planning care, which need is the highest priority? | Physiologic. |
| When creating the care plan for the patient, what does the nurse analyze to prioritize the patient needs? | Nursing diagnoses. |
| What is an example of a long-term goal for the patient? | Achieve wound healing in 3 weeks. |
| Within what timeframe is a short-term goal achieved? | One week. |
| What is the patient more likely to do when the nurse collaborates with the patient to set goals? | -Be aware of priority needs. -Accept realistic goals. -Be more successful in achieving goals. -Comply with interventions and behavior changes. |
| What makes a goal useful and effective? | -Realistic. -Patient-centered. -Measurable. -Time-limited. |
| Why is outcome identification important to the achievement of patient goals? | Indicates goal attainment. |
| Which statement about interventions, as they relate to the planning step of nursing process, is true? | Interventions are activities that assist the patient in achieving goals. |
| What is the purpose of interventions as they relate to the nursing process? | Assist the patient in achieving goals and improving health. |
| How does the nurse ensure individualization of the selected interventions? | -Evaluates patient assessment findings. -Consults other professionals involved in the patient's care. -Ensures interventions align with patient acceptance. -Considers the related factors identified in the nursing diagnosis. |
| Which part of the nursing care plan would contain the statement, "Patient will display complete healing of surgical area within 3 weeks"? | Measurable goal. |
| What are the components of the nursing care plan? | -Nursing diagnosis. -Measurable goal. -Interventions. -Evaluation. |
| Which statement about the nursing care plan is true? | It summarizes patient's condition, goals, and planned interventions. |
| Which information would the nurse expect to find on a conceptual care map (CCM)? | -Nursing plan of care. -Medical history. -Provider orders. -Medications. |
| What does the planning step of the nursing process involve? | -Prioritizing nursing diagnoses. -Developing patient-centered goals. -Creating a personalized plan of care. |
| The patient is being scheduled for knee surgery. When does the nurse expect the care planning process to begin? | When the patient is contacted by the office nurse to schedule surgery. |
| List the nursing diagnoses in priority from highest to lowest according to Maslow’s theory. | Ineffective Airway Clearance, Risk for Loneliness, Readiness for Enhanced Knowledge, Risk for Falls |
| The patient is admitted after an automobile accident and now has paraplegia. Following Maslow's Hierarchy of Needs, which nursing diagnosis has the highest priority? | Impaired urinary elimination. |
| Prioritize each need as life-threatening, clinically urgent, or routine. | Life---Ineffective airway clearance Clinically urgent---Impaired tissue integrity Routine---Disturbed sleep pattern |
| A patient is admitted to the hospital with pneumonia. He has diabetes and a partial thickness pressure ulcer on his sacrum. He hasn't had a bowel movement in 3 days. Which nursing diagnosis should be the highest priority? | Impaired gas exchange. |
| What is the order of the planning step components within the nursing process? | Prioritize nursing diagnoses->establish goals and outcomes->select interventions->create a plan of care. |
| Readiness for Enhanced Knowledge | Self-actualization |
| The nurse is identifying a goal related to weight loss for an obese patient. In order for the patient to be successful with the goal, what should the nurse do? | Ask the patient what he would like to achieve. |
| The patient needs to lose 60 pounds. The nurse thinks a goal should be that the patient will exercise for 30 minutes a day 4 times per week. The patient wants the goal to be that she will exercise for 15 minutes per day 2 times a week. ??? | Consider the patient's social and cultural factors that might be influencing her priorities. |
| Heart rate (HR) 34 beats per minute | Key assessment data |
| Decreased Cardiac Output related to altered HR, as evidenced by bradycardia | Nursing diagnosis |
| HR return to between 60-90 in 48 hours; monitor cardiac rhythm continuously | Measurable goal and intervention |
| HR in 70’s × 48 hours; goal met; discontinue goal | Evaluation |
| What is an example of a long-term goal for the patient? | Achieve wound healing in 3 weeks. |
| The immobile patient has a goal of maintaining tissue integrity. Why does the nurse consult the Nursing Outcomes Classification (NOC) when evaluating the achievement of the goal? | To determine the level of goal achievement. |
| Why would the nurse use a conceptual care map (CCM) to develop a plan of care? | Provides a quick, yet comprehensive, overview of the patient's status and plan. |
| A nurse is discussing short-term goals with a patient in the rehab unit. Why is it important for the nurse to include the patient in the goal-setting phase? | Provides motivation for the patient to achieve goals. |
| Disturbed Body Image | Self-esteem |
| Risk for Falls | Safety and security |
| Decreased Cardiac Output | Physiological needs |
| What nursing skill is essential when utilizing the nursing process? | critical thinking |
| The term “nursing process” was first used by Lydia Hall. | 1955 |
| The nursing process was first used to define steps used in patient care. | 1960s |
| ANA identified 5 steps of the nursing process in its Standards of Practice. | 1973 |
| Outcome identification was added to the nursing process by the ANA. | 1991 |
| Which method was developed to advance the nursing profession and how nurses provide care to all patients? | nursing process |
| How are the steps of the nursing process utilized? | -Diagnose needs and plan goals. -Assess individuals, families, and communities. -Identify outcome criteria and implement interventions. -Identify specific nursing interventions. |
| Which characteristic of the nursing process refers to changes over time in response to patients' individual needs? | dynamic |
| Nurses use critical thinking for each step of the nursing process. | Analytical |
| The nursing process changes over time in response to patient needs. | Dynamic |
| The nursing process helps ensure that patient care is well planned. | Organized |
| Nurses evaluate patient outcomes to determine effectiveness. | Outcome-oriented |
| The _____________ characteristic of the nursing process describes when nurses ask questions and demonstrate the use of critical thinking for each step. | Analytical. |
| The _________characteristic of the nursing process is that nursing care plans can be developed for patients in any care setting, as well as for targeted populations and communities. | Adaptable. |
| Which step of the nursing process does a nurse use when finding blood pressure of 180/75, a heart rate of 90, and a patient complaint of chest pain? | Assessment. |
| Which best describes the diagnosis step of the nursing process? | The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. |
| Which term describes the nurse prioritizing the diagnoses and identifying goals that are realistic, measurable, and patient-focused with specific outcomes? | Planning. |
| Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site? | The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. -The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. -The nurse assesses vital signs and checks to see |
| A patient reports that his pain level is now 6 out of 10. The patient's goal for a pain level of 3-4 out of 10 is not met. Which step of the nursing process does this statement reflect | Evaluation |
| A nurse educator is reviewing the steps of the nursing process with the class. While reviewing a case study, the educator asks the students to determine which part of the process a nurse uses when establishing short- and long-term goals with the patient. | During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. |
| A nurse is preparing a presentation to the unit on ANA, the organization that identified the five steps of the nursing process. What does ANA stands for? | American Nurses Association. |
| What is the primary purpose of the nursing diagnosis? | Communicating patient needs. |
| A patient comes to the emergency department complaining of fever and diarrhea. What should the nurse ask the patient first? | "What is the severity and duration of your fever and diarrhea?" |
| Stella Jones, RN, reassesses a patient one hour after giving morphine for the patient’s pain. The patient states that she is still in horrible pain, eliciting a response of 8 out of 10. What would be the most appropriate intervention? | Give additional breakthrough pain medication. |
| Who first pioneered the term “nursing process?” | Lydia Hall. |
| The five steps that make up the nursing process allow it to be: | Dynamic. |
| What does the term "dynamic nature" of the nursing process refer to? | Change over time in response to the patient's needs. |
| What is a part of the assessment process? | Data collection. |
| What analytical questions are asked at each step in the nursing process? | -"Is the data collection thorough and accurate?" -"Have all underlying factors been addressed in the care plan?" -"Could interventions impact the patient negatively?" |
| Which statement illustrates the collaborative characteristic of the nursing process? | Nurses may incorporate actions by the patient or family to address patient goals. |
| Which subcategory of planning is recognized by professionals and educators as part of the traditional five-step nursing process? | Outcome identification. |
| Which option exemplifies a short-term goal the nurse may identify during the planning step of the nursing process? | Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. |
Created by:
colby.caswell