Test 2 Flashcards
1
Q
What is the nursing process in order?
A
ADPIE (Assessment, Diagnosis, Planning, Implementing, Evaluating)
2
Q
The type of knowledge that is based on scientific facts (akin to the knowledge found in a textbook).
A
Theoretical Knowledge
3
Q
The type of knowledge which involves what to do and how to do tasks and skills safely.
A
Practical Knowledge
4
Q
The type of knowledge that includes our own preferences or biases that may influence our thinking.
A
Self-Knowledge
5
Q
Which knowledge is based on HOW to do something.
A
Practical Knowledge
6
Q
Which knowledge is based on what to do and why to do it?
A
Theoretical Knowledge
7
Q
What knowledge is based off of experiences?
A
Self-Knowledge
8
Q
What knowledge helps a person handle situations where there is an element of right and wrong?
A
Ethical knowledge
9
Q
This type of data comes directly from the patient.
A
Subjective data
10
Q
This type of data is quantitative data or observable that is easily measured.
A
Objective data
11
Q
This type of data can be deemed as “factual.”
A
Objective data
12
Q
This part of the nursing assessment is the data gathering.
A
Assessment
13
Q
This type of assessment is initiated upon first contact with a patient.
A
Initial assessment
14
Q
This type of assessment is continuing the plan of care.
A
Ongoing assessment
15
Q
This type of assessment explores the patient’s single complaint or symptom (often focuses on the primary concern).
A
Focused assessment
16
Q
This type of assessment includes information about a person’s social and situational status, home support systems, holistic assessment of the patient’s beliefs and spiritual needs, what kind of assistance the patient has, and if the patient needs a discharge.
A
Comprehensive assessment
17
Q
If information comes from another source than the patient, it is considered a ________ source.
A
Secondary
18
Q
If the information comes directly from the patient, it is considered a __________ source
A
Primary
19
Q
The statement of client health status that nurses can identify, prevent, or treat independently.
A
Nursing diagnosis
20
Q
What is the major difference between nursing and medical diagnoses?
A
Medical is narrow; Nursing is broad. Nursing diagnoses are customizable to the patient’s individual needs.
21
Q
What are the five types of nursing diagnoses?
A
- Actual
- Potential
- Collaborative
- Wellness
- Syndrome
22
Q
What type of diagnoses are a predetermined cluster of nursing diagnoses that occur together? (Chronic Pain Syndrome)
A
Syndrome Diagnoses
23
Q
What type of diagnoses are not identifying a problem but rather an area for improvement or to support health behaviors that are already happening? (Readiness for enhanced nutrition)
A
Wellness Diagnoses
24
Q
What type of diagnoses address a problem with the probably cause and observable evidence? (Impaired swallowing related to sore throat)
A
Actual Diagnoses
25
What type of diagnoses focuses on problems that a patient may not have ye, but are clearly at risk for developing? (Risk for Falls)
Potential Diagnoses
26
What type of diagnoses requires collaboration with a provider to get orders in place?
Collaborative Diagnoses
27
What are the steps of developing a nursing diagnosis?
ADPIE
28
What is a PES statement?
Problem-Etiology-Symptoms
29
How does a PES statement work?
Problem (related to) etiology (as evidenced by) symptoms
30
What is the first part of the nursing diagnosis statement?
The NANDA label
31
What is the second part of the nursing diagnosis statement?
The etiology
32
What is the third part of the nursing diagnosis statement?
Evidence supporting your diagnosis or symptoms the patient is manifesting
33
What is a three part nursing diagnosis statement called?
A PES statement
34
What the five Maslow's Hierarchy of Needs?
1. Physiological Needs (Most Important)
2. Safety Needs
3. Belongingness and Love
4. Esteem Needs
5. Self-Actualization (Least Important)
35
What are the two main ways to prioritize the patient's needs?
1. ABC's
| 2. Maslow's Hierarchy of Needs
36
Which is higher priority out of acute vs chronic?
Acute
37
Which is the higher priority out of actual vs potential?
Actual
38
Critical thinking is the process of ______ ______.
Problem Solving
39
Theoretical knowledge is ______ based, whereas practical knowledge is knowing _____ to do a task properly.
science; how
40
________ may not be delegated to an assistive personnel.
Assessment
41
A head-to-toe assessment done during every shift is an example of what kind of assessment?
Ongoing
42
Does a focused assessment always only focus on one body system?
No
43
Which type of assessment evaluates the potential presence of domestic violence?
Psychosocial
44
Vital signs using a Dinamap are an example of what kind of data? Coming from what kind of source?
Objective; Secondary
45
Patient's blood pressure is elevated, so the nurse checks with the patient to assess for a probable cause is what?
Validation
46
What will help the nurse to make sure that they gather all the necessary information to make an informed decision and draw correct conclusions?
Having a questioning attitude
47
The process of analyzing data, identifying patterns, and drawing conclusions.
Diagnostic Reasoning
48
True or False: There will always be exactly one nursing diagnosis for every medical diagnosis
FALSE
49
Nursing diagnoses are judgments based on ______ made in our nursing assessments.
Inferences
50
How many nursing diagnoses are there?
234
51
What type of nursing diagnosis only uses the NANDA label (problem statement) and an evidence statement?
Wellness diagnosis
52
What type of nursing diagnosis only uses the problem statement and etiology?
Potential Diagnosis (Risk For)
53
When would you include a "secondary to" statement?
When we are pointing out that we are address the collateral health manifestation and not the prevailing condition
54
What is the primary concern in Maslow's Hierarchy of Needs?
Physiological (What is going to kill your patient the fastest?)
55
Love and belonging is what level of Maslow's?
Third
56
Nursing diagnosis is always the result of a nursing ___________.
Assessment
57
What are continuous and change over time?
Plans
58
Predictions of changes in a patient's health status that we expect the patient to achieve.
Expected Client Outcome (ECO)
59
ECO is always written in the terms of _____ ______.
Patient activity
60
In an ECO, what always must be the priority?
The Patient
61
What drives the ECO statement?
The NANDA problem and symptoms
62
What is the SMART mnemonic used for?
To narrow in your ECO goal.
63
What does SMART stand for?
```
Is the goal:
S: Specific
M: Measurable
A: Attainable/Achievable
R: Relevant/Realistic
T: Time Bound
```
64
If a nurse delegates a task to an aid or NCP, who is responsible for making sure the task gets completed?
The nurse
65
Short term ECOs usually take place for how long?
During the admission of the patient
66
What type of intervention are those that nurses can put into place without the guidance of a provider? (Ex: ambulating a patient)
Independent intervention
67
What type of intervention involves collaboration with ancillary staff? (Ex: utilizing physical therapy)
Interdependent intervention
68
What type of intervention requires a provider order? (Ex: medications and diagnostics tests)
Dependent intervention
69
Transferring responsibility for the performance of a task while retaining accountability for a safe outcome.
Delegation
70
What type of intervention includes monitoring the patient or collecting data to evaluate their status?
Assess Intervention
71
What type of intervention is something the patient or the nurse will perform in order to effect a change?
Action intervention
72
What type of intervention includes teaching the patient?
Education intervention
73
What type of intervention is preventing the potential problem from becoming an actual problem?
Prevention intervention
74
Patients plans of care based on selected nursing diagnoses are called _____ ______.
Standardized plans
75
A pre-set plan based on standard of care for the predetermined diagnosis.
Critical pathways
76
What are the three phases of implementation?
- Doing
- Delegating
- Documenting
77
Knowing that patient's needs and advocating for their care with other providers is considered what?
Collaboration
78
Communicating the plan of care to multiple providers.
Coordination of Care
79
What are the 5 Rights to Delegation
1. Right Task
2. Right Circumstance
3. Right Person
4. Right Communication
5. Right Supervision
80
The close the loop communication is what right?
Right Communication
81
This type of evaluation is performed while:
- implementing an intervention
- immediately after an intervention
- with each patient contact
Ongoing evaluation
82
This type of evaluation is performed at specific times and is conditional.
Intermittent evaluation
83
This type of evaluation is the assessment of the progress made towards the goal at the time of discharge.
Terminal evaluation
84
What are the three ways to determine if an ECO has been met?
- Met
- Partially Met
- Not Met
85
Under what circumstances should a goal be revised?
If the outcome is partially met or not met
86
What must you do if a goal is partially met or not met?
Revise for a more attainable goal
87
What portions of the plan must be reviewed if a goal is partially met or not met?
All steps
- Diagnosis
- Assessment
- Planning Outcomes
- Planning Interventions
- Implementation
88
Nurse driven outcomes are an outcome where nurses have a direct, autonomous impact. What is an example of a nurse driven outcome?
Hospital Acquired Pressure Injury (HAPI)
89
True or False: It is easier to measure demonstration than it is to measure understanding.
True
90
A nutrition consult is an example of what type of intervention?
Collaborative
91
What type of intervention requires a provider's order?
Dependent
92
Vital signs are an example of what kind of intervention?
Assess
93
Speaking with a provider to obtain an order for medication is an example of what kind of intervention?
Dependent
94
"Bridging the Gap" by providing information between 2 separate health care providers in providing care for a patient is an example of what?
Coordination of Care
95
A conditional assessment to re-evaluate for improvement after an intervention is what kind of evaluation?
Intermittent
96
Reassessments during an evaluation of the ECO is an ______ assessment.
Focused
97
If a desired patient response is observed some of the time, but not 100% of the time, the goal is what?
Partially met
98
An evaluation is an assessment that occurs ______ an action or intervention.
after
99
When can you discontinue a care plan, based on your evaluation?
After goals have been met
100
Which of the following is the primary nursing diagnosis?
A. Risk For Falls
B. Readiness for Enhanced Resilience
C. Constipation
C. Constipation
101
What is the priority nursing diagnosis?
A. Acute Pain
B. Chronic Urine Retention
C. Disturbed Sensory Perception (Visual)
A. Acute Pain
102
What is the priority nursing diagnosis?
A. Sleep Deprivation
B. Ineffective Breathing Pattern
C. Dysfunctional GI motility
B. Ineffective Breathing Pattern
103
According to Maslow's, what is the priority nursing diagnosis?
A. Disturbed sensory perception (auditory)
B. Disturbed body image
C. Spiritual Distress
A. Disturbed sensory perception (auditory)
104
Using ABCs, what is the priority nursing diagnosis?
A. Ineffective breathing pattern
B. Ineffective airway clearance
C. Deficient fluid volume
B. Ineffective airway clearance
105
What is the priority nursing diagnosis?
A. Impaired mobility
B. Risk for Injury
C. Anxiety
A. Impaired mobility
106
What is the priority nursing diagnosis?
A. Deficient fluid volume
B. Impaired gas exchange
C. Chronic pain
B. Impaired gas exchange
107
What is the priority nursing diagnosis?
A. Risk for infection
B. Acute Confusion
C. Complicated grieving
B. Acute Confusion
108
Which lab is the best indicator of nutritional status in a patient?
Pre-albumin
109
True or False: Albumin is not the most accurate way of measuring the patient's nutritional status if they also have a fluid imbalance.
True
110
Obesity occurs in how many adults in the United States?
2/3 of the population
111
What are the interventions for Imbalance: More Than (Name 4)
- Evaluate Endocrine Problems
- Food Diary
- Make healthy choices (shop smart)
- Weekly weigh-ins
- Calorie Counting/Meal Planning
- Adequate Sleep
- Exercise
- Emotional Support
112
What are the interventions for Imbalance: Less Than (Name 4)
- Supplements (Vitamins, Minerals, Diet-Specific)
- Food stamps/Community Resources
- Meals on Wheels
- Increase community and socialization
- Assist to feed the patient
- Increase Appetite
- Enteral/Parenteral Feedings
113
True or False: Enteral feedings are preferred to parenteral or IV nutrition because they have lower incidence of sepsis or infection.
True
114
How long can a closed feeding system be run for? (Max)
24 hours
115
How long can an open feeding system be run for? (Max)
4 hours
116
What are 2 subjective assessments of a patient's nutritional status?
- Food diary
| - 24 hour recall
117
What are 3 objective measurements of a patient's nutritional status?
- Abdominal appearance
- Skin fold measurements
- Lab Values
118
What developmental stage does the patient need to eat frequently?
Newborn
119
What developmental stage does the patient tend to have body image issues?
Adolescence
120
What development stage does the patient have decreased senses?
Older adult
121
What developmental stage does the patient need more calcium, protein, and folic acid?
Childbearing
122
What developmental stage does the patient have newfound independence which puts them at a risk of nutritional imbalance?
Preschool
123
What are the risks of obesity?
- Obstructive Sleep Apnea
- Stroke
- HTN
- Diabetes
- Gallbladder disease
- Heart Disease
124
What nutrients are those who follow a vegetarian or vegan diet most likely to experience a deficiency?
Protein, Calcium, Vit B12
125
What must be done prior to the first infusion of tube feeding through a nasogastric (NG) tube?
A chest xray to check for placement
126
Name 5 interventions done for a patient who is at risk for aspiration
1. Auscultate breath sounds after meals
2. Keep suction nearby
3. Keep neck in forward flexion
4. Avoid straws
5. Check Mouth for pocketing
127
Name 5 interventions done for a patient with nausea
1. Keep mouth moist
2. Encourage small meals
3. Eat bland foods
4. Remain in upright position after eating for 30-45 min
5. Limit offense/strong odors
128
How long must a patient be NPO after vomiting?
30 min
129
How often is the UDSA guidelines updated?
Every 5 years
130
What do the colors stand for in the "Choose My Plate" Guide?
```
Red- Fruits
Green- Vegetables
Orange- Grains
Purple- Proteins
Blue- Dairy
```
131
Water, Black coffee, Tea (with no cream), Chicken broth, clear juices (apple juice, grape juice, cranberry juices), popsicles, carbonated beverages, and Jello are examples of what?
Clear liquid diet
132
Creamy soups, milk or milkshakes, pudding, custards, cream of wheat hot cereal, yogurt, orange and tomato juice (in addition to clear liquid diet) are examples of what?
Full liquid diet
133
A mechanical soft diet is typically low in what?
Fiber
134
Healing with minimal scarring (usually by surgical incision)
Primary intention
135
This type of healing has the largest scarring
Secondary intention
136
This healing is a combination of primary and secondary
Tertiary intention
137
This type of healing is where the wound is left open
Tertiary intention
138
The type of wound that extends beyond the dermis into the subcutaneous layer or even beyond into the muscular layer is called?
Full thickness wound
139
This type of wound only includes the top layer or two of skin: the dermis and epidermis
Partial thickness wound
140
What kind of wound drainage is yellow?
Serous
141
What kind of wound drainage is bright red?
Sanguineous
142
How often should a NG tube be flushed?
Anytime a feeding cycle is started and stopped and both before and after a medication
143
What kind of wound drainage is pink and watery?
Serosanguineous
144
What kind of wound drainage is creamy and yellow (pus)?
Purulent exudate
145
What are the two types of wound drainage that are related to pressure injuries?
- Slough
| - Eschar
146
What kind of wound drainage is necrotic tissue that's black?
Eschar
147
What kind of wound drainage is a thick, stringy, and waxy yellow substance?
Slough
148
What are the most vulnerable to increased pressure?
Bony prominences
149
What are the four risk factors for pressure injury?
1. Patient is already having problem with decreased blood flow (ex: diabetics)
2. Prolonged immobility
3. The presence of pressure from medical devices/tubes
4. Decreased sensation
150
What are the six categories that the Braden Scale includes?
1. Sensory Perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction & Shear
151
What kind of nursing plan is a Braden Scale assessment?
Independent
152
What score on the Braden Scale indicates risk for pressure injury?
Anything 18 or less.
153
A wound where it cannot be seen or assessed because of the tissue covering it.
Unstageable wound
154
A wound that involves only the epidermis and the skin is nonblanchable.
Stage I Pressure Injury
155
A wound that goes beyond the dermis and the subcutaneous layer into the muscular layer, sometimes exposing the bone
Stage IV pressure injury
156
A wound that is the breakdown beyond the dermis and extends into the subcutaneous tissue.
Stage III pressure injury
157
A wound that has broken into the skin but only affects the superficial dermal layer
Stage II pressure injury
158
What stage(s) of a pressure injury involve full thickness loss?
Stage III and IV
159
What stage(s) of a pressure injury involve partial thickness loss?
Stage II
160
Are pressure injuries always preventable?
YES
161
What are the 6 interventions for risk of pressure injuries?
- Prevention
- Skin Care/Moisture Control
- Adequate Nutrition
- Frequent repositioning
- Therapeutic Mattresses
- Client/Family Teaching
162
How long can a patient remain NPO before requiring alternative nutrition?
6 days
163
What is the criteria to advance a patient's diet from full liquids to a regular diet?
No nausea/vomiting after a meal
164
This type of wound healing consists of the wound healing from the "inside out" or the tissue filling in the wound bed from the bottom up.
Secondary intention
165
This type of wound healing involves a delayed surgical closure.
Tertiary intention
166
Ischemia from decreased blood flow causes breakdown in the skin which causes what?
pressure injury
167
A patient who is incontinent and requiring linen changes 3 times each shift would score what on a Braden scale?
2
168
What are the 6 things to include when documenting a wound assessment?
1. Size
2. Location
3. Appearance
4. Drainage
5. Peri-wound areas
6. Pain
169
How many extra calories does a pregnant woman need a day?
300 calories
170
What substance can interfere with the absorption of nutrients in food?
Alcohol
171
Individuals with traumatic injuries need what extra nutrients for wound healing and tissue rebuilding?
Proteins and Vitamin C
