Week 2 Flashcards by Kaitlyn Kohlbecker

Nurse-initiated interventions are

Determined by state Nurse Practice Acts

How well did you know this?

Not at all

Perfectly

Mr. Bagley is placed on Isolation Precautions.
Isolation Precautions as a treatment intervention are an example of which type of care?

Indirect care

How well did you know this?

Not at all

Perfectly

Nursing process: ADPIE

Assess
Diagnosing
Planning
Implementing
Evaluating

How well did you know this?

Not at all

Perfectly

For a student to avoid a data collection error, the student should:

Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient

How well did you know this?

Not at all

Perfectly

Actual Nursing Diagnosis

Describes human responses to health conditions or life processes

How well did you know this?

Not at all

Perfectly

Risk Nursing Diagnosis

Describes human responses to health conditions/life processes that MAY develop

How well did you know this?

Not at all

Perfectly

Health Promotion Nursing Diagnosis

A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential

How well did you know this?

Not at all

Perfectly

What are the three parts of writing nursing diagnoses?

Problem
Etiology
Signs and symptoms

How well did you know this?

Not at all

Perfectly

Direct care

Treatments performed through interactions with patients

Examples:
Medication administration
Insertion of an intravenous (IV) infusion
Counseling during a time of grief

How well did you know this?

Not at all

Perfectly

Indirect care

Treatments performed away from the patient but on behalf of the patient, or group of patients

Examples:
Managing the patient’s environment
-safety
-cleanliness
-infection control
Documentation
Interdisciplinary collaboration

How well did you know this?

Not at all

Perfectly

Your patient has met the goals set for the improvement of ambulatory status. You would now:

Discontinue the care plan.

How well did you know this?

Not at all

Perfectly

You have finished with several nursing interventions. To evaluate interventions, you need to examine the:

Appropriateness of the interventions and the correct application of the implementation process

How well did you know this?

Not at all

Perfectly

The acronym PES stands for:

Problem
Etiology
Signs and symptoms

How well did you know this?

Not at all

Perfectly

The nurse reviews gathered data regarding a patient’s pain symptoms and compares defining characteristics of acute pain with those for chronic pain. This process helps the nurse avoid making an error in which area of the nursing diagnostic process, leading to a correct diagnosis of acute pain?

Data interpretation

How well did you know this?

Not at all

Perfectly

Which result could be caused by an incorrect nursing diagnosis?

Affects the quality of patient care

How well did you know this?

Not at all

Perfectly

Which is a benefit of an accurate nursing diagnosis?

Helps ensure effective and efficient nursing interventions

How well did you know this?

Not at all

Perfectly

Which type of interpretation error may occur with a nursing diagnosis?

Inaccurate interpretation of cues
Use of an insufficient number of cues
Failure to consider conflicting cues

How well did you know this?

Not at all

Perfectly

Which diagnosis type is a form of nursing diagnosis according to NANDA International (NANDA-I)?

Risk diagnoses
Problem-focused diagnoses
Health promotion diagnoses

How well did you know this?

Not at all

Perfectly

Which related factor in the patient falls under health promotion nursing diagnosis?

Is willing to eat nutritious foods
Is ready to increase his or her coping skills
Demonstrates a willingness to perform regular exercise

How well did you know this?

Not at all

Perfectly

A patient is anxious about an operation scheduled for the next day. Which interventions would the nurse use to decrease the patient’s surgery-related anxiety?

Provide satisfactory answers to the patient’s questions
Provide detailed instructions about the recovery process
Provide detailed instructions about the surgical procedure

How well did you know this?

Not at all

Perfectly

Which guideline will the nurse follow to reduce errors in the diagnostic statement?

Identify a treatable etiology or risk factor
Identify the problem caused by the treatment, not the treatment itself
Identify the patient’s response to the equipment rather than the equipment itself

How well did you know this?

Not at all

Perfectly

Which category of sources of error may occur in the nursing diagnostic process according to NANDA International (NANDA-I)?

Collecting, clustering, interpreting

How well did you know this?

Not at all

Perfectly

Which error may occur when the nurse makes the nursing diagnosis prior to grouping all data?

Error in data clustering

How well did you know this?

Not at all

Perfectly

Which intervention will the nurse implement to reduce anxiety in a patient who is a football player scheduled for ankle surgery with noted fidgety hands and legs whose voice quivers as he expresses his worry about not being able to play post-surgery?

Explain the recovery process to the patient
Provide detailed instructions about the surgery
Teach postoperative care to the patient and his caregiver

How well did you know this?

Not at all

Perfectly

Which component of the assessment data will the nurse include as part of the related factors for the patient diagnosed with pneumonia with impaired gas exchange in the lungs?

Decreased ventilatory effort caused by fatigue Accumulation of secretions within the alveoli

Which action will the nurse take that reflects the diagnostic reasoning used to arrive at a nursing diagnosis?

Observe for a pattern of data clusters.

The nurse notes that a postoperative patient has a risk of infection. Which cue supports the diagnosis?

Inflamed incision Wound separation Purulent drainage from the wound

Which nursing diagnosis is appropriate for the patient who reports an inability to lose weight despite participating in an exercise program 3 times a week when the clinic uses the International Classification for Nursing Practice (ICNP) terminology system?

Body weight problem

Which statement indicates the need for further education regarding NANDA International (NANDA-I) terminologies in the medical record entry?

"Diagnoses do not consider evidence-based diagnoses." "Diagnoses are refined by the health care provider on a regular basis.

Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis?

Related factors

Which diagnostic error is made when the nurse asks a patient complaining of pain when swallowing solid food if the pain is caused by a history of substance abuse?

Error in data collection

Which nursing action will lead to a nursing diagnostic error?

Assessing the edema in a patient’s lower leg when being unsure of how to assess the severity of the edema Identifying a diagnosis based on a single defining characteristic Determining a risk diagnosis related to a medical diagnosis

Which category will the nurse classify as related factors according to NANDA International (NANDA-I) diagnoses?

Situational Maturational Treatment-related Pathophysiological

Which statement indicates the need for further teaching regarding the application of nursing diagnoses to clinical practice?

"Nursing diagnoses improve the selection of nursing interventions by nurses in certain practice settings."

Place the steps in the correct order for making a nursing diagnosis when caring for a new patient admitted to the nursing unit through the emergency department.

Reviews assessment data, noting objective and subjective clinical criteria Clusters clinical criteria that form a pattern Chooses diagnostic label Considers context of patient’s health problem and selects a related factor

Which type of diagnosis is related to the patient' s motivation and desire to increase well-being and actualize human health potential?

Health promotion nursing diagnosis

Which statement indicates the need for further learning regarding the use of a standard formal nursing diagnostic statement from the NANDA International (NANDA-I)?

"Nursing diagnoses emphasize following traditional practice guidelines." "These statements align the role of the nurses with other health care providers." "Nursing diagnoses help the nurses focus on the scope of medical practice as a whole."

Which order will the nurse use to record data from the patient's assessment and formulate the nursing diagnosis?

Record symptoms Assess for related factors Identify patient needs Formulate the nursing diagnosis

When a patient is newly admitted to the unit, which action will the nurse take that reflects critical thinking and analysis during the planning phase of the nursing process?

Check the policy and procedures to ensure proper monitoring of the patient.

Which criterion is used to evaluate efficacy of interventions?

Expected outcomes

Which type of nursing intervention is an interdependent intervention?

Collaborative

Which action describes an independent nursing intervention?

Offering counseling for coping Initiating early mobility protocols Instructing patients on side effects of medications Positioning patients to prevent pressure injury formation

Which expected outcome for the goal "Patient will achieve a gain of 10 pounds (4.5 kg) in body weight in a month" is written correctly?

Patient will eat at least three-fourths of each meal by the end of 1 week.

Which patient care goal is a long-term goal for a newly diagnosed medically unstable patient with diabetes?

Patient will achieve glucose control as demonstrated by a decrease in hemoglobin A1C level.

How many classes are included in the second level of the Nursing Interventions Classification (NIC) model?

Which priority level would be assigned to the patient diagnosed with decreased gas exchange?

High

Which goal is appropriate for the patient who is at high risk of skin injuries?

Patient’s skin will remain intact through discharge.

Which action is an example of an independent nursing intervention?

Provide health education Assist with daily activities Reposition a patient

What kind of nursing interventions require the health care provider’s prescriptions to treat a medical diagnosis

Dependent

Which option would be an appropriate goal statement for a patient at risk of an infection?

Patient’s wound will remain free of infection by discharge

During which step of the nursing process would the nurse review the patient’s plan of care and determine whether a goal was met?

Evaluation

Once a patient meets a goal, which action would the nurse take?

Decide whether to continue or discontinue the goal.

A patient sets a goal to quit smoking within the next 30 days. After 30 days, the patient has not quit but reports that their smoking is reduced by 50%. The goal for the next 30 days is revised. Which outcome would the nurse document regarding goal attainment?

Goal partially met

Which process occurs when the nursing staff of a small emergency department implements a process to reduce wait times?

Quality Improvement

Which statement explains the importance of making modifications to the plan of care when a patient’s status changes?

Revision is a necessary component of providing safe patient care.

What step of the Plan-Do-Study-Act (PDSA) is related to: Consider what the data show, and revise the plan of care if needed

Act

What step of the Plan-Do-Study-Act (PDSA) is related to: State the objective and develop a plan

Plan

What step of the Plan-Do-Study-Act (PDSA) is related to: reviewing results

Study

What step of the Plan-Do-Study-Act (PDSA) is related to: Implementing interventions

Which statement describes the nurse’s role during the analysis step of the nursing process?

Apply critical thinking to recognize data patterns and identify patient problems.

Which phrase describes the purpose of the nursing diagnosis?

Identify health problems or life processes

Which aspect of nursing did the North American Nursing Diagnosis Association (NANDA) influence and lead pioneering efforts to develop?

Classification of nursing language

Which statement describes the International Classification for Nursing Practice (ICNP) taxonomy?

Translation of the taxonomy to multiple languages has enabled widespread application and ease of use.

Which explanation describes the use of supporting data in the International Classification for Nursing Practice (ICNP) nursing taxonomy?

Supporting data are the assessment findings that direct the nurse to an appropriate nursing diagnosis.

Which explanation describes the use of supporting data in the International Classification for Nursing Practice (ICNP) nursing taxonomy?

Supporting data are the assessment findings that direct the nurse to an appropriate nursing diagnosis.

During which step of the nursing process does the nurse select nursing diagnoses?

Second

Which actions does the nurse take during the analysis step of the nursing process?

Selects nursing diagnoses Individualizes nursing diagnoses

Which component does the nurse analyze to identify patient problems and select appropriate nursing diagnoses?

Assessment data

Which phrase describes how the nursing diagnosis provides an effective means of communicating the patient’s status?

Consolidating a great volume of information into a concise statement

Which comparison reflects the characteristics of nursing and medical diagnoses?

Nursing diagnoses identify problems for nursing care to address, whereas medical diagnoses identify illnesses needing medical treatment.

For which reasons is the International Classification for Nursing Practice (ICNP) taxonomy updated every 2 years?

Taxonomy revision Compliance with standards Validation that the language is easy to understand

Which trends can the nurse project by using the International Classification for Nursing Practice (ICNP) taxonomy to promote safe patient care and effective decision-making?

Patient needs Nursing interventions Outcomes of nursing care

Which characteristic is a benefit of using the International Classification for Nursing Practice (ICNP) taxonomy?

Used in a variety of settings where nursing care is provided

Which characteristic is a benefit of using the International Classification for Nursing Practice (ICNP) taxonomy?

Used in a variety of settings where nursing care is provided

Which statement describes how the International Classification for Nursing Practice (ICNP) taxonomy is valuable to the nursing profession?

Documentation using the ICNP taxonomy validates nursing practice.

Place the nursing actions in the order they should be completed according to the first three steps of the Clinical Judgment Measurement Model.

Complete health history Cluster patient data Prioritize hypotheses

Which characteristic best explains why it is important to prioritize hypotheses?

Allows the nurse to identify the patient’s most immediate needs

Which aspects might cause the nurse to develop different plans of care for two patients with the same medical diagnosis?

Culture Patient cues Personal goals Past medical history

Which patient feature does the nurse consider when setting priorities to meet patient needs?

Overall perspective

Which characteristics would the nurse use to evaluate and rank hypotheses?

Life-threatening Most likely to occur Effect on other hypotheses Potential to increase risk for complications

Types of infections related to airborne precautions

Measles, chickenpox (varicella), varicella zoster, TB

Types of infections related to Droplet precautions

Diptheria, rubella, streptococcal pharyngitis, pneumonia or scarlet fever, pertussis, mumps, sepsis, pneumonic plague

Types of infections related to protective environment precautions

Allogeneic hematopoietic stem cell transplants

Types of infections related to contact precautions

VRE, MRSA, C diff

Which questions would the nurse consider when prioritizing hypotheses?

What are the risks for other hypotheses? Which findings are expected based on the patient’s condition? Which hypothesis is most important and should be managed first?

Place the nursing actions associated with applying the Clinical Judgment Measurement Model to nursing practice in the order they should occur.

Recognize cues Cluster cues Form hypotheses Evaluate hypotheses Rank hypotheses

4 Indications of an indwelling catheter

-Urinary retention -Incontinence with skin integrity issues, surgical sites, fall risk -Surgery -Comfort care/End of Life care -Trauma/positioning precautions (can't provide peri-care effectively) -Strict intake/output measurements -Obstruction -Bladder surgery, bladder irrigation -Medication administration

Which functions does the nurse complete during the second step of the Clinical Judgment Measurement Model?

Relate findings to potential disease processes. Examine subjective and objective patient cues. Correlate patient cues to conditions by clustering data.

Which questions help the nurse to cluster and analyze patient data during the second step of the Clinical Judgment Measurement Model?

Which patient findings fit together? Which conditions present with cues like the patient’s cues? Are there any findings or patient cues that seem contradictory? Which patient conditions are expected based on the medical diagnosis?

Which questions help the nurse to cluster and analyze patient data during the second step of the Clinical Judgment Measurement Model?

Which outcome results from analysis of patient assessment data during the second step of the Clinical Judgment Measurement Model?

Grouping of patient cues according to similarities

Which labels describe a hypothesis?

Patient problem Diagnosed medical condition Ailment the patient is at risk for developing

Place in order the actions the nurse takes when applying the Clinical Judgment Measurement Model to nursing practice.

Recognize cues Cluster cues Link cues Form hypotheses

Which statement describes how nurses apply the International Classification for Nursing Practice (ICNP) terminology to the second step of the Clinical Judgment Measurement Model?

Select nursing diagnoses

Which action is essential for the nurse to complete during step two of applying the Clinical Judgment Measurement Model to nursing practice?

Cluster subjective and objective data

When analyzing patient cues during the second step of the Clinical Judgment Measurement Model, which strategy provides meaning to cues and insight into the patient’s unique circumstances?

Asking questions to identify patterns among collected cues

Which concepts does the nurse apply when clustering patient data?

Anticipated findings Potential disease processes Prior patient care experiences Stages of growth and development

Which types of factors influence the development of a hypothesis?

Risk Social Cultural

The nurse clustered the following patient cues during the assessment: Sharp pain in lower right abdomen, patient pain rating 9 on a 0-to-10 pain scale, and facial grimacing. Which hypothesis based on International Classification for Nursing Practice (ICNP) terminology can the nurse select when clustering the data?

Abdominal Pain

Which statement describes why nurses identify supporting data for a hypothesis?

Identification of supporting data allows the nurse to individualize the plan of care.

Which action describes the generation of solutions during the fourth step of the Clinical Judgment Measurement Model (CJMM)?

Identify expected outcomes based on priority hypotheses.

Which questions would help the nurse generate solutions during the fourth step of the Clinical Judgment Measurement Model (CJMM)?

What are the desired outcomes for the patient? What interventions can help achieve patient goals?

Which functions would the nurse complete when generating solutions in accordance with the Clinical Judgment Measurement Model?

Consider patient care options Connect needs to a course of action Identify appropriate nursing interventions

Which factors would the nurse consider when establishing patient goals and outcomes during the “generate solutions” step of the Clinical Judgment Measurement Model?

Patient expectations Best available clinical evidence Expertise of the health care team Collaborative Approaches to care

Which characteristics describe patient goals developed during the fourth step of the Clinical Judgment Measurement Model (CJMM)?

Are either short- or long-term Are supported by nursing interventions Describe anticipated changes in a patient’s condition