Chapters 3,5 and 6

Question 1

During which phase of the nursing process does documentation take place?

Answer 1

Implementation

Question 2

When charting by exception, which acronym is generally used?

Answer 2

PIE

Question 3

What are nursing interventions?

Answer 3

Activities that promote the achievement of desired patient goal

(Classified as physician-prescribed or nurse-prescribed)

Question 4

What is nurse initiated/dependent interventions?

Answer 4

Legally autonomous actions to benefit clients (DO NOT NEED ORDER)

Ex: turning and repositioning every 2 hours, ambulating, I&O monitoring intake, encouraging fluids, monitoring for complications

Question 5

What is provider-initiated/dependent interventions?

Answer 5

Providers prescription(written, standing or verbal) or the facility’s protocol (blood administration procedures)

Question 6

What is collaborative interventions?

Answer 6

Collaboration with other health care team professionals

Ex: diet and speech

Question 7

What is nursing process?

Answer 7

Cyclical
Systematic method
Scientific
Critical thinking process (DECISION MAKING FRAMEWORK FOR ORGANIZING CARE)
Purposeful
Goal-directed
Way to achieve optimal client outcomes through planning and providing

Question 8

What are the SIX phases of the nursing process?

Answer 8

🔴 Assessment
🔴 Diagnosis 
🔴 Outcomes identification 
🔴 Planning 
🔴 Implementation 
🔴 Evaluation

Question 9

Define assessment?

Answer 9

🔺Primary goal is to collect data🔺

A systematic process to collect and analyze information about clients health to identify needs and additional data to collect based on findings

Question 10

What are the 2 types of data?

Answer 10

Objective - observable, measurable finding the NURSE collects

Ex: VS, lab work, assessment findings (lung sounds, skin color, etc)

Subjective - self reported by the patient

Ex: pain, feelings, sensations, dizziness, palpitations, nausea, etc

Question 11

What are the sources of data?

Answer 11

Primary and secondary

Primary is the PATIENT

Secondary:
Family(spouse, parents and children)
Med records
Other healthcare providers
Diagnostic studies (X-ray, MRI)
Lab work
Nurse Shift report

Question 12

Methods of data collection?

Answer 12

Interview
Physical exams:
Focused (problem oriented)
Comprehensive/complete head to toe (review of ALL systems, done on assessment)
Observation 
Medical history 
Diagnostic and lab reports

Question 13

What is acute conditions?

Answer 13

Rapid onset
Limited duration of time
Can become chronic if unresolved

Question 14

What is chronic conditions?

Answer 14

Always present or consistently reoccur

Last at least 3 months or longer

Question 15

Define data clustering?

Answer 15

Method of data organization (defining characteristics)
Related cues are grouped together
Helps to identify patterns and select most appropriate diagnosis

Question 16

RN vs LPN Assessment

Answer 16

RN is responsible for the INITIAL assessment

LPN assists with ongoing assessment

Question 17

What is nursing diagnosis?

Answer 17

Identification of human response to health problems and life processes

Can be treated by the nurse

Written using NANDA

LPN assists

Question 18

Types of nursing diagnoses and examples?

Answer 18

Actual (present now) TAKES PRIORITY
EX: acute pain

Potential/At risk (possible in the future
Ex: at risk for acute pain

Collaborative problems (involve other disciplines

Health promotion (willingness)
Ex: readiness for enhanced nutrition

Question 19

What is medical diagnosis and examples?

Answer 19

Identification of disease or condition
Healthcare provider is licensed to diagnose and treat

Ex: congestive heart failure, diabetes Miletus, myocardial infarction

Question 20

How to formulate nursing diagnosis?

Answer 20

Use NANDA
Chosen based on defining characteristics
Identify patient’s problems rather than your problems with nursing care as a nursing diagnosis
IT CANNOT CONTAIN MEDICAL DIAGNOSIS

Question 21

How to prioritize nursing diagnosis?

Answer 21

Actual problems may be ranked before risk problems
Use Maslow to prioritize diagnoses
Unstable before stable
Acute before chronic
Life threatening before non-life- threatening
Unexpected before expected

Question 22

What are the parts of nursing diagnosis and give examples?

Answer 22

Actual - problem exists
🔴 3 part statement 
1. Problem statement 
2. Related to (contributing factors)
3. As evidenced by (specific S&S)

Ex: infrequent bowel elimination related to insufficient water intake as evidenced by no vowel movement in 5 days

Potential/at risk
Problem can happen in a future (strong possibility)
🔴 2 part statement
1. Potential Problem statement
2. Related to (risk factors)

Ex: at risk for compromised skin integrity related to immobility

Question 23

Define culture?

Answer 23

Set of values, benefits, customs and practices (similarities shared among members)
Learned from birth through socialization
Adaptation to specific condition/location
Evolves overtime (dynamic and ever-changing but stable)
Shared by a group
Passes from one generation to another
Can be linked by ethnicity, race, nationality, language, religion, location, sexual orientation, class or gender

Question 24

Define subculture?

Answer 24

Share characteristics with the primary culture

Has characteristic patterns of behavior and ideals that distinguish it from the rest of cultural groups

Question 25

Define society?

Answer 25

A nation, community or broad group of people who establish particular aims, beliefs or standards

Question 26

What is transcultural nursing?

Answer 26

Culture competence Understand and address the entire cultural context of each client, integrate culture into all aspects of care Need to develop to be able to function effect in multi-cultural environment Assess for preferred language, provide teaching in language spoken Encourage family to participate in care as appropriate

Question 27

What is a teach back method?

Answer 27

A method used to evaluate patient teaching Used to verify or evaluate a patient’s understanding after you explains something to them Ask them to repeat information back to you

Question 28

What is the planning stage involve?

Answer 28

Identify nurse interventions Ex: scheduling fluid intake for a patient on dehydration- give fluids every hour while awake

Question 29

What is needed to identify the needs of the patient and design care?

Answer 29

Individualized care plan

Question 30

What is the best time to document nursing care?

Answer 30

As soon as it’s completed

Question 31

What are the guidelines for documentation?

Answer 31

Accurate and complete Date and time on all entries Should be detailed and document only facts-because it is a legal record Never chart for others Chart facts/objective/descriptive data and not opinions Document immediately after completion of care Do not erase or scratch or apply correction fluid Do not record “physician made an error” Use only facility abbreviations Use black ink Begin entry with time and end with signature For late entry write “late entry, 1/1/16… When you make an error, draw one line across, put your initials or sign your name on top and write the correct entry beside it

Question 32

What is an incident report form?

Answer 32

A form that explains any event that are not consistent with facility or national standards

Question 33

What are the guidelines for filing out a incident report?

Answer 33

Description of the injury, including diagrams of the injury Date, time and location Name of physician and family member notified Chronologic order of the event

Question 34

What does a therapeutic communication accomplish?

Answer 34

Facilitates a positive nurse-patient relationship

Question 35

What is included in a medical record?

Answer 35

A patient’s nursing problems, medical problems, care planned for the patient, care given to the patient, and patient’s response to treatment

Question 36

Examples of incidences/occurrences that s nurse would include in an incident report?

Answer 36

Falls, omission of prescription, needle stick injuries, medication errors, omission of therapies, a visitor who exhibits symptoms of communicable disease

Question 37

When should we use patient as the main source of data?

Answer 37

When assessing variables from a cultural perspective

Question 38

Muslim women prefer to be cared by?

Answer 38

Female providers

Question 39

Before a nurse could provide patient-centered and culturally competent care, what should the nurse do first?

Answer 39

Assess your own biases (prejudices) and attitudes