Exam 2 - revised

Question 1

Patient centered care?

Answer 1

patient as source of control and full partner- respect for preferences, values, and needs.

Question 2

4 attributes of PCC?

Answer 2

respect and dignity
information sharing
participation
collaboration

Question 3

3 theoretical links to PCC?

Answer 3

Watson caring theory
Core of nursing: interaction and caring
knowledge of limitations

Question 4

Cultural background?

Answer 4

the environment in which people and families develop values and preferences

Question 5

Exemplars of PCC?

Answer 5

kangaroo care
rooming in (newborns)
bed-side reporting for shift change
family advisory boards
discharge teaching

Question 6

Mayo clinic slogan (Berry)?

Answer 6

the best interest of the patient is the only interest to be considered

Question 7

ADPIE? define each.

Answer 7

Assessment: what needs to be noticed in order to provide PCC- data collection and history review

diagnosis: organizing data and determining needs based on analysis
planning: establishing measurable priorities and outcomes, selecting interventions, goal setting

intervention/implementation: actual treatment/procedures, focused on symptom management, independent or collaborative

evaluation: reassessment of symptoms, patients response, documentation

Question 8

4 interrelated concepts of PCC?

Answer 8

professionalism
therapeutic communication
safety
ethics

Question 9

Clinical judgment?

Answer 9

interpretation/conclusion about a patients needs, concerns, or health problems AND the decision to take action, use/modify standard approaches, or improvise appropriately.

Question 10

7 interrelated concepts of clinical judgment?

Answer 10

patient education
professionalism
care coordination
leadership
safety
health care quality
evidence

Question 11

5 exemplars of standard v. interpretivist?

Answer 11

rules v. context specific
standard v. individualized
algorithms v. holistic
new practitionars v. expert
analytical v. intuitive

Question 12

3 types of reasoning?

Answer 12

analytical: novice
intuitive: experienced (application of past to present)
narrative: full application based on present situation

Question 13

3 attributes of nursing care?

Answer 13

NON-LINEAR
multiple factors
no clear-cut answers

Question 14

Clinical judgment process?

Answer 14

noticing
interpreting
responding
reflecting

Question 15

2 types of reflection?

Answer 15

in action: understanding of patient responses WHILE care is occuring

on action: contemplation and consideration of a situation on what is successful/unsuccessful

Question 16

2 things to remember when considering clinical judgment?

Answer 16

it is an aspect of nursing in all settings

it is NOT required in all patient interactions

Question 17

nurses judgment based on what 4 things?

Answer 17

nurse’s knowledge

experience

ethical perspective

knowledge of patient

Question 18

What is clinical reasoning?

Answer 18

nurse’s ability to collect the right cues and take the right action for the right client at the right time.

Question 19

purpose of the nursing process?

Answer 19

thinking
identifying
determining outcomes
prioritization

Question 20

What are the steps of the nursing process based on?

Answer 20

scientific process.

ADPIE

Question 21

Tanners model of noticing?

Answer 21

nurse notices things about patient in the context of the nurses background and experience, environment, and knowledge of the patient.

LOOKING FOR PATTERNS TO GUIDE CARE.

Question 22

2 different types of data?

Answer 22

subjective: info from patient or patients family via verbal/nonverbal communication
objective: tests, records, assessments

Question 23

2 sources of data?

Answer 23

primary subjective: what the patient tells the nurse
primary objective: nurse data via observation and examination

secondary subjective: what others tell the nurse about the patient
secondary objective: nurse data via sources other than the patient

Question 24

Tanner interpretation?

Answer 24

assembling info to make sense of it- looking for patterns and analyzing them

Question 25

4 types of nursing diagnosis?

Answer 25

actual: responses to health conditions in a family, group, or community risk: judgment of experiences/responses to health conditions that have a likelihood of developing in a vulnerable person, family, group, or community health promotion: clinical judgment of person, family, or groups motivation to increase well-being and health potential. syndrome: clinical judgment describing a cluster of diagnoses that occur together and through similar interventions. have both defining characteristics and related factors

Question 26

How do you select a diagnosis? 2 types of diagnoses?

Answer 26

look for patterns group common patterns identify possible diagnosis(s) independent collaborative

Question 27

Etiology of clinical judgment?

Answer 27

R/t (relationship to the diagnosis)

Question 28

What phrase links the etiology and the defining characteristics?

Answer 28

as evidenced by (AEB)

Question 29

2-part nursing diagnosis? 3-part diagnosis?

Answer 29

NANDA-I label r/t statement Problem: NANDA-I label etiology: contributing factors symptom: defining characteristics

Question 30

Composition of PES?

Answer 30

Problem: risks, current issues, and diagnosis etiology: r/t symptom: defining characteristics, signs, "patients story"

Question 31

steps of planning?

Answer 31

determine problem urgency prioritize which interventions most effective?

Question 32

3 types of planning?

Answer 32

comprehensive plan: based on comprehensive assessment ongoing: completed throughout care discharge: anticipated and planned for after discharge

Question 33

ABCs of prioritization?

Answer 33

airway breathing circulation

Question 34

3 types of prioritization?

Answer 34

emergent: life threatening urgent: needs treatment, not life threatening non-urgent/routine

Question 35

patient safety (fall and injury prevention) is a goal of what?

Answer 35

the joint commission

Question 36

Responding?

Answer 36

implementation of actions based on needs. | Judgment of effectiveness depends on level of expertise.

Question 37

SMART outcomes?

Answer 37

``` specific measurable attainable realistic timed ```

Question 38

Nursing outcomes classification (NOC)?

Answer 38

nursing: sensitive outcome measured along continuum response to interventions 5-pt Likert rating scale

Question 39

2 types of collaborative intervention?

Answer 39

interdependent: participation of other providers dependent: requires an order

Question 40

3 attributes of intervention/implementation?

Answer 40

research evidence client values expertise

Question 41

institute of medicine? | institute of health care improvement?

Answer 41

improve patient safety and care quality 100,000 lives campaign

Question 42

When do early changes in condition occur most often?

Answer 42

48 hours before code blue

Question 43

changes to report (3) in danger of decline?

Answer 43

vital signs behavior/mental status pain

Question 44

MEWS?

Answer 44

modified early warning system (stony brook) physiologic scoring system with indicators

Question 45

failure to rescue?

Answer 45

inability to save a patients life upon complications that were not present on admission

Question 46

rapid response team?

Answer 46

critical care experts onsite and available anytime. respond to actual/perceived changes in patients condition.

Question 47

situational awareness?

Answer 47

promotes safer patient care environment and helps develop priorities and attention to clinical details