Exam 2 Study Guide Review

Question 1

ISBAR - R

Answer 1

Introduction
Situation
Background
Assessment
Recommendation

-Readback

Question 2

Differences between stool softeners and laxatives

Answer 2

laxative defines any medicine that facilitates a bowel movement which includes a broad range designed to treat varying levels of severity. A stool softener is a mild (OTC) over-the-counter laxative used to soften the stool for easier passage and less strain.

Question 3

Describe hypoglycemia

Answer 3

Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than the standard range.

Question 4

Signs related to hypoglycemia

Answer 4

Looking pale (pallor)
Shakiness.
Dizziness or lightheadedness.
Sweating.
Hunger or nausea.
An irregular or fast heartbeat.
Difficulty concentrating.
Feeling weak and having no energy (fatigue)

Question 5

Describe hyperglycemia

Answer 5

Hyperglycemia is the technical term for high blood glucose (blood sugar). High blood glucose happens when the body has too little insulin or when the body can’t use insulin properly.

Question 6

Signs related to hyperglycemia

Answer 6

Fruity-smelling breath.
Dry mouth.
Abdominal pain.
Nausea and vomiting.
Shortness of breath.
Confusion.
Loss of consciousness.

Question 7

A body of law known as statutory law has evolved from accumulated judiciary decisions.

A. True
B. False

Answer 7

B. False

Rationale: A body of law known as common law has evolved from accumulated judiciary decisions. Most law involving malpractice is common law.

Question 8

The state nurse practice act is the most important law affecting nursing practice.

A. True
B. False

Answer 8

A. True

Rationale: The state nurse practice act is the most important law affecting nursing practice. Each nurse practice act protects the public by broadly defining the legal scope of nursing practice.

Question 9

What are reasons for revoking or suspending a license?

Answer 9

Drug or alcohol abuse
Fraud
Deceptive practice
Criminal acts
Previous disciplinary actions
Gross or ordinary negligence
Physical or mental impairments, including age

Question 10

Which is the correct term for this nursing action: A nurse falsely imprisons a patient by an unauthorized use of restraints.

A. Crime
B. Tort
C. Misdemeanor
D. Felony

Answer 10

B. Tort

Rationale: A tort is a wrong committed by a person against another person or that person’s property. False imprisonment is an intentional tort. A crime is a wrong against a person or that person’s property as well as the public. Crimes can be classified as misdemeanors or felonies.

Question 11

What are intentional torts?

Answer 11

Assault and battery
Defamation of character
Invasion of privacy
False imprisonment
Fraud

Question 12

What are unintentional torts?

Answer 12

Negligence
Malpractice

Question 13

In all health care agencies, informed and voluntary consent is needed for admission, for specialized diagnostic procedures or medical–surgical treatment, and for any experimental treatments or procedures.

A. True
B. False

Answer 13

A. True

Rationale: In all health care agencies, informed and voluntary consent is needed for admission, for specialized diagnostic procedures or medical–surgical treatment, and for any experimental treatments or procedures.

Question 14

What does ANA stand for?

Answer 14

American Nurses Association

Question 15

A nurse’s personal moral code is to assist all patients to the best of one’s ability. What blended skill would the nurse use when seeking out special services for a homeless patient with a diabetic foot ulcer?

A. Cognitive
B. Technical
C. Interpersonal
D. Ethical/Legal

Answer 15

D. Ethical/Legal

Rationale: Using ethical/legal skills is the best answer as it involves following a moral code and acting professionally. Cognitive skills involve thinking through a situation to achieve outcomes. Technical skills relate to the proper use of equipment. Interpersonal skills are used to develop caring relationships.

Question 16

What are potential errors in decision making?

Answer 16

Bias
Failure to consider the total situation
Impatience

Question 17

Five Steps of the Nursing Process

Answer 17

Assessing: collecting, validating, and communicating patient data

Diagnosing: analyzing patient data to identify patient strengths and problems

Planning: specifying patient outcomes and related nursing interventions

Implementing: carrying out the care plan

Evaluating: measuring extent to which patient achieved outcomes

Question 18

Which step of the nursing process is a nurse using when analyzing patient data to determine a patient’s strengths following a CVA?

A. Assessing
B. Diagnosing
C. Planning
D. Implementing
E. Evaluating

Answer 18

B. Diagnosing

Rationale: The diagnosing step involves analyzing patient data to determine strengths and weaknesses. The assessing step refers to the collection, validation, and communication of patient data. In the planning step, the nurse determines patient outcomes and related nursing interventions, and in the implementing step, the nurse carries out the plan. When evaluating, the nurse measures the extent to which the patient achieved outcomes.

Question 19

Which of the following characteristics of the nursing process describes the interaction and overlapping of steps within the process itself?

A. Systematic
B. Dynamic
C. Interpersonal
D. Universally Applicable

Answer 19

B. Dynamic

Rationale: The nursing process is dynamic in that there is much interaction and overlapping of the steps. It is systematic since it is an ordered sequence of activities. Interpersonal refers to the human being at the heart of nursing. The nursing process is universally applicable in that it is a framework for all nursing activities

Question 20

What are the characteristics of the nursing process?

Answer 20

Systematic: part of an ordered sequence of activities

Dynamic: great interaction and overlapping among the five steps

Interpersonal: human being is always at the heart of nursing

Outcome oriented: nurses and patients work together to identify outcomes

Universally applicable: a framework for all nursing activities

Question 21

What are the steps in concept mapping?

Answer 21

Collect patient problems and concerns on a list.

Connect and analyze the relationships.

Create a diagram.

Keep in mind key concepts: the nursing process, holism, safety, and advocacy

Question 22

Concept mapping is an instructional strategy that requires learners to identify, graphically display, and link key concepts.

A. True
B. False

Answer 22

A. True

Rationale: Concept mapping is an instructional strategy that requires learners to identify, graphically display, and link key concepts.

Question 23

Describe Reflection in Action

Answer 23

Happens in the here and now of the activity and is also known as “thinking on your feet.”

Question 24

Describe Reflection on Action

Answer 24

Occurs after the fact and involves thinking through a situation that has occurred in the past

Question 25

Describe Reflection for Action

Answer 25

Helps the person to think about how future actions might change as a result of the reflection.

Question 26

Tanner’s Clinical Judgment Model

Answer 26

Noticing: initial grasp and perceptions of the situation that are impacted by context, the nurse’s practical experience, knowledge of expected versus unexpected data, ethical perspectives, and the nurse–patient relationship

Interpreting: attributing meaning to the data through multiple reasoning patterns

Responding: deciding on an action (or inaction) and monitoring outcomes

Reflecting: in-action and on-action

Question 27

Lasater Clinical Judgment

Answer 27

Based on Tanner’s model; describes the development of clinical judgment

Effective Noticing
- Focused observation
- Recognizing deviations rom expected patterns
- Information seeking

Effective Interpreting
- Prioritizing data
- Making sense of data

Effective Responding
- Calm, confident manner

Effective Noticing
- Clear communication
- Well-planned intervention/flexibility
- Being skillful

Question 28

Recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes are steps included in which model?

A. Clinical Judgment Measurement Model
B. Tanner’s Model
C. The Nursing Process
D. Developing Nurses’ Thinking Model

Answer 28

A. Clinical Judgment Measurement Model

Rationale: The six cognitive operations included in layer 3 of the CJMM include recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes.

Question 29

Which of the following includes four components of moral reasoning and captures the cognitive processes that precede moral action?

A. Information-Processing Model
B. Cognitive Continuum Theory
C. Rest Framework
D. Humanistic - Intuitive Approach

Answer 29

C. Rest Framework

Rationale: The Rest framework includes four components of moral reasoning and captures the cognitive processes that precede moral action. The information-processing model informs decision making and mirrors the way we think of a computer processor. The cognitive continuum theory (CCT) integrates both intuitive and analytical cognitive characteristics. The Humanistic–intuitive approach believes that clinical judgment and decision-making models move from facts and rules to dynamic decision making with clinical experience.

Question 30

Assessment

Answer 30

Preparing for data collection
Collecting data
identifying cues and making inferences
Validating data
Clustering related data and identifying patterns
Reporting and recording data

Question 31

Which one of the following assessments would be performed on a patient to gather data about their previously diagnosed liver cancer?

A. Initial comprehensive assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment

Answer 31

B. Focused assessment

Rationale: In a focused assessment, the nurse gathers data about a condition that has already been diagnosed

Question 32

A nursing assessment duplicates a medical assessment by focusing on the patient’s responses to the health problem.

A. True
B. False

Answer 32

B. False

Rationale: A nursing assessment does not duplicate a medical assessment, rather it focuses on the patient’s responses to the health problem.

Question 33

Medical vs. Nursing Assessments

Answer 33

Medical-rule out-tests, assessments-based on results- narrow down pathology- focus on the illness and treatment

Nsg- care of the person behind the illness. Focus on the person, physiological and psychological response to the illness. able to meet basic human needs? perform ADL’s
Actual or potential health problems

Question 34

A patient rates his pain as a “7” on a pain rating scale. This rating is considered to be objective data.

A. True
B. False

Answer 34

B. False

Rationale: A patient rating his pain on a pain rating scale is considered to be subjective data.

Question 35

Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.

A. True
B. False

Answer 35

A. True

Rationale: Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data.

Question 36

Clinical Reasoning

Answer 36

Analyzing
Synthesizing
Reflecting
Making Judgments
Drawing Conclusions

Question 37

Describe OLD CARTS

Answer 37

Onset: “When did your symptom(s) begin”?.

Location: “Where is the symptom”?.

Duration: “Is it episodic or constant?” or “How long does it last”?. Characteristics: “How would you describe it?.”

Alleviating and Aggravating factors: “What makes it better or worse?.” Relieving factors: “What makes it better?.”

Treatments: “Have you tried anything to make it better?.”

Severity: “On a scale of 1–10, with 1 being the lower number, how serious is the symptom?.”

Question 38

Diagnosing

Answer 38

Creating a list of suspected problems/diagnoses

Ruling out similar problems/diagnoses

Naming actual and potential problems/diagnoses and clarifying what’s causing or contributing to them

Determining risk factors that must be managed

Identifying resources, strengths, and areas for health promotion

Question 39

Nursing Concerns and Responsibilities

Answer 39

Recognizing safety and infection-transmission risks and addressing these immediately.

Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients’ lives—and promoting optimum function, independence, and quality of life.

Anticipating possible complications and taking steps to prevent them.

Initiating urgent interventions. You should not wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment.

Question 40

A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most likely be determined?

A. Recognizing significant data
B. Recognizing patterns or clusters
C. Identifying strengths and problems
D. Reaching conclusions

Answer 40

D. Reaching conclusions

Rationale: A possible problem, such as high blood pressure, is diagnosed as a conclusion of data interpretation.
Recognizing significant data refers to the comparison of data to a standard or norm (e.g. normal blood pressure values).
A data cluster is a grouping of patient data or cues that points to the existence of a problem (e.g. a series of readings).
The nurse must then identify strengths and problems to determine if the patient is motivated to address them.

Question 41

A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on their symptoms and a series of test results. Which of the following is the etiology in this scenario?

A. Lung cancer
B. Test results
C. Smoking cigarettes
D. The subjective and objective data

Answer 41

C. Smoking cigarettes

Rationale: The etiology is the factor that maintains the unhealthy condition (smoking cigarettes).
Lung cancer is the problem, and the remaining factors are the distinguishing characteristics.

Question 42

Formulation of Nursing Diagnoses

Answer 42

Problem—identifies what is unhealthy about patient

Etiology—identifies factors maintaining the unhealthy state

Defining characteristics—identify the subjective and objective data that signal the existence of a problem

Question 43

The nursing diagnosis risk for impaired skin integrity is an example of a correctly written risk problem.

A. True
B. False

Answer 43

B. True.

Rationale: The nursing diagnosis risk for impaired skin integrity is an example of a risk diagnosis.

Question 44

A nursing diagnosis may be used to seek reimbursement for nursing services.

A. True
B. False

Answer 44

A. True

Rationale: A nursing diagnosis may be used to seek reimbursement for nursing services.

Question 45

Which of the following nursing diagnoses is written correctly?

A. Child Abuse related to maternal hostility
B. Breast Cancer related to family history
C. Deficient Knowledge related to alteration in diet
D. Imbalanced Nutrition related to insufficient funds in meal budget

Answer 45

D. Imbalanced Nutrition related to insufficient funds in meal budget

Rationale: Answer A makes legally inadvisable statements, answer B is a medical diagnosis, and answer C reverses the clauses in the statement.

Question 46

Outcome Identification and Planning

Answer 46

Establish priorities
identify expected patient outcomes
Select evidence-based nursing intervention
Communicate the plan of care

overall treatment plan
nursing standards

Question 47

Which nursing action would most likely occur during the ongoing planning stage of the comprehensive care plan?

A. The nurse collects new data and uses them to update the plan and resolve health problems.

B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home.

C. The nurse who performs the admission nursing history develops a patient care plan.

D. The nurse consults standardized care plans to identify nursing diagnoses, outcomes, and interventions.

Answer 47

A. The nurse collects new data and uses them to update the plan and resolve health problems.

Rationale: In the ongoing planning stage, any nurse who interacts with the patient updates the plan to facilitate the resolution of health problems, manage risk factors, and promote function.
Teaching and counseling are the key to discharge planning.
The nurse performing the admission nursing history consults standardized care plans during initial planning to formulate the initial care plan.

Question 48

1st part of the nursing diagnosis

Answer 48

“problem statement”

identifies the unhealthy response
indicates what should change

suggest patient goals/outcomes (expectations for change)

Question 49

2nd part of the nursing diagnosis

Answer 49

Etiology

identifies factors causing or contributing to the undesired response and preventing desired change

suggests nursing interventions

Question 50

Which nursing diagnosis would most likely be considered a high priority?

A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance

Answer 50

Answer: B. Impaired gas exchange

Rationale: Impaired gas exchange poses a threat to the patient’s well-being.
Disturbed personal identity and risk for powerlessness are non–life-threatening and are ranked as medium priorities.
Activity intolerance, if not specifically related to the current health problem, is a low priority.

Question 51

Maslow’s Hierarchy of Human Needs

Answer 51

Physiologic needs
Safety needs
Love and belonging needs
Self-esteem needs
Self-actualization needs

Question 52

IOM’s Six Aims to be Met by Health Care Systems Regarding Quality of Care

Answer 52

Safe: avoiding injury
Effective: avoiding overuse and underuse
Patient-centered: responding to patient preferences, needs, and values
Timely: reducing waits and delays
Efficient: avoiding waste
Equitable: providing care that does not vary in quality to all recipients

Question 53

Categories of Outcomes

Answer 53

Cognitive: describes increases in patient knowledge or intellectual behaviors

Psychomotor: describes patient’s achievement of new skills

Affective: describes changes in patient values, beliefs, and attitudes

Question 54

Which outcome is an affective outcome?

A. By 6/09/19, the patient will correctly demonstrate the procedure for washing her newborn baby.
B. By 6/09/19, the patient will list three benefits of eating a healthy diet.
C. By 6/09/19, the patient will use a walker to ambulate the hallway.
D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking.

Answer 54

Answer: D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking.

Rationale: An affective outcome describes changes in patient values, beliefs, and attitudes. Answers A and C are psychomotor outcomes (learning a new skill) and Answer B is a cognitive outcome (increase in patient knowledge).

Question 55

A collaborative intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician’s order.

A. True
B. False

Answer 55

Answer: B. False

Rationale: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis, but carried out by a nurse in response to a physician’s order.

Question 56

Types of Nursing Interventions

Answer 56

Nurse-initiated: actions performed by a nurse without a physician’s order

Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

Collaborative: treatments initiated by other providers and carried out by a nurse

Question 57

A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort.

A. True
B. False

Answer 57

Answer: A. True

Rationale: A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort.