Exam 1; 113 lecture Flashcards
Clinical Judgment; Growth and development; Pain; Rest
1
Q
What is the purpose of an assessment?
A
Collect patient data
2
Q
There are 4 assessments, What are they for?
- Initial Assessment
- Focused Assessment
- Emergency Assessment
- Time-Lapsed Assessment
A
Initial Assessment: Done upon admission to gather baseline data.
Focused Assessment: Gathers data on a specific problem that’s already identified.
Emergency Assessment: Quick evaluation to identify life-threatening conditions.
Time-Lapsed Assessment: Compares current status to baseline data over time.
3
Q
What is Clinical Judgment?
A
Result or reserved outcome of critical thinking and decision making.
4
Q
What demonstrates Clinical Judgement?
A
- Recognizing Cues
- Analyze Cues
- Generate Solution
- Take action
- Evaluate outcomes
5
Q
Mnemonic for Nursing Process
A
ADPIE
6
Q
What does ADPIE stand for?
A
A- Assessment
D- Diagnosis
P-Planing
I- Implementation
E- Evaluation
7
Q
what does the A in ADPIE mean?
A
A- Assessment;
Collecting patient data
8
Q
what does the D in ADPIE mean?
A
D- Diagnosis;
Analyzing patient data(collected from assessment) and concluding.
9
Q
What does the P in ADPIE stand for?
A
P-Planing;
SMART goal: Prioritizing patient issues, setting goals, and establishing outcomes.
Specific
Measurable
Achievable
Relevant
Time-bound
10
Q
What does the E in ADPIE stand for?
A
E- Evaluation;
Have you met the SMART goal? area for further reassessment.
11
Q
What does the I in ADPIE stand for?
A
I- Implementation;
Nursing interventions that would be implemented into patient care.
12
Q
What is the Nursing Process?
A
How nurses think.
13
Q
What are the Five Dimensions of a Person?
A
Physical (body health)
Psycho-social (relationships, social well-being)
Intellectual (cognitive abilities)
Emotional (feelings and emotional state)
Spiritual/Cultural (beliefs, values)
14
Q
What types of Data are there?
A
Subjective
Objective
15
Q
What is subjective data?
A
Data that is perceived only by the affected person.
16
Q
What is Objective data?
A
Observable + Measurable data; Seen, heard, felt, and measured by someone other than the affected person.
17
Q
Mnemonic for pain (referenced from the textbook).
A
OLDCARTS
18
Q
What does OLDCARTS stand for?
A
O- onset
L- location
D- duration
C- characteristics
A- Alleviating and Aggravating factors
R- relieving factors
T- treatment
S- severity
19
Q
Question(s) for onset (pain assessment).
A
” When did your symptoms begin?”
20
Q
Question(s) for location (pain assessment).
A
“Where is your pain?”
“Can you show me where you are hurting?”
21
Q
Question(s) for duration (pain assessment).
A
” is it episodic?”
“how long does it last?”
22
Q
Question(s) for characteristics (pain assessment).
A
“How would you describe your pain?”
(Sharp, dull)
23
Q
Question(s) for Alleviating and Aggravating factors (pain assessment).
A
” What makes it worse”
“is there anything that provokes it?”
24
Q
Question(s) for Relieving factors (pain assessment).
A
“What makes it better?”
25
Question(s) for Treatment (pain assessment).
"Have you done anything to make it better?"
26
Question(s) for Severity (pain assessment).
"How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you've ever experienced?"
27
What is the psychosocial conflict for the stage of Infancy (0- 18 months)?
Trust vs. Mistrust
28
What is the Erikson’s 8 stages of psychosocial development used for?
Understanding patients across the lifespan.
29
What is the key challenge during the Early Childhood stage (18 months- 3 years)?
Autonomy vs. Shame and Doubt
30
What is the primary psychosocial conflict in the Preschool stage (3-6 years)?
Initiative vs. Guilt
31
What is the central issue during the School Age stage (6-12 years)?
Industry vs. Inferiority
32
What is the main conflict during Adolescence (12-18 years)?
Identity vs. Role Confusion
33
What is the primary psychosocial challenge for Young Adulthood (18-35 years)?
Intimacy vs. Isolation
34
What is the central issue in Middle Adulthood (35- 55 years)?
Generativity vs. Stagnation
35
What is the key conflict for Late Adulthood (55 years and older)?
Integrity vs. Despair
36
At what stage does an individual begin to reflect on their life and face the prospect of death?
Late Adulthood (55+ years)
Integrity vs. Despair
37
During which stage does a person struggle with feelings of inadequacy or failure in their work or personal life?
Middle Adulthood (35- 55 years)
Generativity vs. Stagnation
38
What stage involves developing a sense of independence and self-control?
Early Childhood (18 months - 3 years)
Autonomy vs. Shame and Doubt
39
At which stage does an individual explore their own identity and personal values?
Adolescence (12- 18 years)
Identity vs. Role Confusion
40
What is the key issue in the stage where a person focuses on creating meaningful relationships and career achievements?
Young Adulthood (18- 35 years)
Intimacy vs. Isolation
41
During which stage do people work on contributing to society and helping the next generation?
Middle Adulthood (35- 55 years)
Generativity vs. Stagnation
42
What conflict involves developing a sense of purpose and initiative?
Preschool (3- 6 years)
Initiative vs. Guilt
43
At which stage do children develop a sense of competence and achievement in their skills and abilities?
School Age (6-12 yrs)
Industry vs. Inferiority
44
What conflict involves balancing between maintaining close relationships and feeling alone?
Young Adulthood (18- 35 years)
Intimacy vs. Isolation
45
During which stage do individuals face the challenge of making sense of their lives and accepting their mortality?
Late Adulthood (55+ yrs)
Integrity vs. Despair
46
What stage is characterized by the exploration of different roles and identities?
Adolescence (12- 18)
Identity vs. Role Confusion
47
At what stage does the struggle with the balance between self-confidence and self-doubt occur?
Early Childhood (18 months- 3 years)
Autonomy vs. Shame and Doubt
48
What type of assessment is performed shortly after a patient’s admission?
Initial Assessment.
49
Which type of assessment focuses on a specific problem already identified?
Focused Assessment.
50
What is the primary purpose of the Evaluation step in the Nursing Process?
To determine if goals were met and if the outcomes were achieved.
51
Scenario: A 65-year-old patient is admitted with complaints of shortness of breath and swelling in the legs. The patient has a history of hypertension and diabetes.
Question: What type of assessment should the nurse perform initially, and what specific information should the nurse gather?
Initial Assessment
Specific Information to Gather: The nurse should gather baseline data including the patient’s history of hypertension and diabetes, current symptoms (shortness of breath, swelling in legs), vital signs, and any other relevant health information. This will help in forming a comprehensive picture of the patient's current health status.
52
Scenario: After a comprehensive assessment, the nurse identifies that a patient is experiencing significant pain in the lower abdomen and reports nausea and vomiting.
Question: Develop a 3-part Nursing Diagnosis statement for this patient, including Problem, Etiology, and Signs/Symptoms
Nursing Diagnosis Statement:
Problem (P): Acute pain
Etiology (E): related to lower abdominal issues
Signs/Symptoms (S): as evidenced by pain in the lower abdomen, nausea, and vomiting.
Full Statement: Acute pain related to lower abdominal issues as evidenced by pain in the lower abdomen, nausea, and vomiting.
53
Scenario: A patient with newly diagnosed Type 2 diabetes is being discharged with a goal to manage blood sugar levels more effectively.
Question: Create a SMART outcome statement for this patient related to blood glucose management.
Outcome/Planning Scenario:
SMART Outcome Statement:
Specific: The patient will maintain blood glucose levels within the target range.
Measurable: Blood glucose levels will be checked daily.
Achievable: With proper medication and diet.
Relevant: Important for diabetes management.
Time-bound: By the next follow-up visit in 4 weeks.
Full Statement: The patient will maintain blood glucose levels within the target range (70-130 mg/dL) by checking daily and adjusting
medication and diet as needed, with a follow-up visit in 4 weeks.
54
Scenario: A patient recovering from surgery is experiencing difficulty with mobility. The care plan includes a goal of improving mobility.
Question: What are some specific nursing interventions the nurse could implement to help achieve this goal?
Nursing Interventions:
Assist the patient with mobility exercises several times a day.
Use assistive devices (e.g., walkers) if needed.
Educate the patient on safe movement techniques.
Provide pain management strategies if needed.
Encourage gradual increases in activity levels.
55
Scenario: A patient’s care plan includes goals to reduce blood pressure and improve dietary habits. After two weeks, the patient reports no changes in blood pressure and minimal dietary improvements.
Question: How should the nurse evaluate the effectiveness of the care plan, and what actions might be taken next?
Evaluation of Effectiveness:
Determine if Goals were Met: Review the patient’s blood pressure readings and dietary changes.
Actions to Take Next:
If goals are not met, reassess the care plan and interventions.
Consult with the patient about any barriers they faced.
Adjust the plan as necessary, possibly involving a dietitian or other specialists.
56
Scenario: A 6-month-old infant is frequently crying and has difficulty being comforted by the caregivers.
Question: According to Erikson’s stages, what stage is the infant in, and what might be a potential developmental concern?
Stage: Trust vs. Mistrust.
Potential Developmental Concern: The infant may be experiencing difficulty in developing trust with caregivers if they are frequently crying and not being comforted effectively.
57
Scenario: A 3-year-old child is trying to dress themselves but often gets frustrated and asks for help.
Question: What stage is the child in according to Erikson, and what developmental task are they working on?
Early Childhood Stage Scenario:
Stage: Autonomy vs. Shame and Doubt.
Developmental Task: The child is working on developing independence and self-control. Frustration with dressing themselves is a normal part of this developmental stage.
58
Scenario: A 16-year-old teenager is struggling with their identity and often changes their interests and group of friends.
Question: What Eriksonian stage is the teenager in, and what conflict might they be experiencing?
Adolescence Stage Scenario:
Stage: Identity vs. Role Confusion.
Conflict: The teenager is exploring different roles and identities, which can involve changing interests and friend groups as they seek to establish a stable sense of self.
59
Scenario: A 28-year-old individual is finding it challenging to form deep, meaningful relationships and feels isolated.
Question: According to Erikson, which stage is this individual in, and what psychosocial challenge are they facing?
Young Adulthood Stage Scenario:
Stage: Intimacy vs. Isolation.
Psychosocial Challenge: The individual is struggling to form meaningful relationships and is feeling isolated, which reflects the challenge of establishing close, intimate connections.
60
Scenario: A 45-year-old person is feeling a lack of purpose and has concerns about their contributions to their work and family.
Question: What Eriksonian stage are they in, and what conflict might they be experiencing?
Middle Adulthood Stage Scenario:
Stage: Generativity vs. Stagnation.
Conflict: The person is feeling a lack of purpose and concern about their contributions, reflecting the struggle to find meaningful ways to contribute to society and guide the next generation.
61
Scenario: An 80-year-old individual is reflecting on their life and feeling a sense of fulfillment and acceptance.
Question: Which Eriksonian stage are they in, and what is the main developmental task of this stage?
Late Adulthood Stage Scenario:
Stage: Integrity vs. Despair.
Developmental Task: The individual is reflecting on their life and achieving a sense of fulfillment and acceptance, which indicates a successful resolution of this stage’s conflict.
62
Actual (Active) Nursing Diagnosis
Describes an existing problem that is validated by defining signs and symptoms.
63
Actual (Active) Nursing Diagnosis- 3-Part Diagnosis: PES or PEDS
Problem (P): The patient’s issue (e.g., "Acute Pain").
Etiology (E): The cause or related factors (e.g., "related to surgical incision").
Signs/Symptoms (D or S): The supporting evidence or cues (e.g., "as evidenced by facial grimacing and guarding of abdomen").
64
At Risk (Potential or High Risk) Nursing Diagnosis
Describes a potential problem that the patient could develop and must be prevented.
65
At Risk (Potential or High Risk) Nursing Diagnosis- 2-Part Diagnosis: PE
Problem (P): The potential issue (e.g., "Risk for impaired skin integrity").
Etiology (E): The cause or risk factor (e.g., "related to immobility").
66
What are the components of a Nursing Diagnosis?
Problem (P)
Etiology (E)
Defining Characteristics (D) / Signs and Symptoms (S)
67
Which of the following is the primary focus of the Assessment step in the Nursing Process?
A. Setting patient goals
B. Collecting and analyzing patient data
C. Performing nursing interventions
D. Evaluating the effectiveness of interventions
B. Collecting and analyzing patient data
68
What does the Diagnosis step of the Nursing Process involve?
A. Determining the patient's responses to the interventions
B. Identifying the patient’s health problems and potential problems
C. Creating a care plan with specific interventions
D. Reviewing the patient’s goals and outcomes
B. Identifying the patient’s health problems and potential problems
69
A patient presents with chronic fatigue, weight gain, and cold intolerance. The nurse suspects a thyroid disorder. Which type of nursing diagnosis is most appropriate?
A. At Risk Diagnosis
B. Actual Diagnosis
C. Wellness Diagnosis
D. Syndrome Diagnosis
B. Actual Diagnosis
70
Which of the following is included in a 2-part nursing diagnosis statement?
A. Problem and Etiology
B. Problem, Etiology, and Signs/Symptoms
C. Etiology and Signs/Symptoms
D. Problem, Signs/Symptoms, and Outcome
A. Problem and Etiology
71
What is the main difference between an Actual (Active) Nursing Diagnosis and a At Risk Nursing Diagnosis?
A. An Actual Nursing Diagnosis describes an existing problem, while an At Risk Diagnosis identifies potential problems.
B. An Actual Nursing Diagnosis is used only in emergency situations, while an At Risk Diagnosis is for chronic conditions.
C. An Actual Nursing Diagnosis includes only physical symptoms, while an At Risk Diagnosis includes only psychological factors.
D. An Actual Nursing Diagnosis is only used in hospital settings, while an At Risk Diagnosis is used in outpatient settings.
A. An Actual Nursing Diagnosis describes an existing problem, while an At Risk Diagnosis identifies potential problems.
72
When writing a 3-part nursing diagnosis statement, what should be included?
A. Problem, Etiology, and Outcome
B. Problem, Etiology, and Signs/Symptoms
C. Signs/Symptoms, Outcome, and Interventions
D. Problem, Interventions, and Evaluation
B. Problem, Etiology, and Signs/Symptoms
73
A nurse identifies that a patient is experiencing "Acute pain related to surgical incision as evidenced by facial grimacing, guarding of abdomen, and refusal to eat." What type of diagnosis is this?
A. Wellness Diagnosis
B. At Risk Diagnosis
C. Actual Diagnosis
D. Syndrome Diagnosis
C. Actual Diagnosis
74
In the context of a Nursing Diagnosis, what does the Etiology (E) component describe?
A. The patient's immediate symptoms
B. The cause or contributing factors to the patient's problem
C. The expected outcomes of the care plan
D. The interventions planned to address the problem
B. The cause or contributing factors to the patient's problem
75
What is the correct order for forming a Nursing Diagnosis?
A. Assessment, Diagnosis, Outcome/Planning, Implementation, Evaluation
B. Diagnosis, Assessment, Implementation, Outcome/Planning, Evaluation
C. Outcome/Planning, Assessment, Diagnosis, Implementation, Evaluation
D. Assessment, Diagnosis, Implementation, Evaluation, Outcome/Planning
A. Assessment, Diagnosis, Outcome/Planning, Implementation, Evaluation
76
When should a nurse use a Time-Lapsed Assessment?
A. When there is a new and urgent health problem
B. When comparing a patient’s current status to baseline data obtained earlier
C. When gathering data about a specific problem that has already been identified
D. When initially assessing a patient upon admission
B. When comparing a patient’s current status to baseline data obtained earlier
