A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment as liquid stool in the skin is clean and intact. The students like the nursing diagnosis impaired skin integrity. The faculty member explains that the student has made a diagnostic air for which of the following reasons? Show
Wrong diagnosis A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asked whether she has to go to the bathroom at night and then patient responds yes usually twice or more the patient had an episode of diarrhea one week ago. She weighs 300 pounds and reports having difficulty cleansing herself after voiding or passing stool. Which finding demonstrates assessment findings that cluster to indicate the nursing diagnosis impaired urination. Dysuria, nocturia Review the Following diagnoses and identify the diagnoses that are stated correctly Risk of infection, activity intolerance related to physical deconditioning Which of the following best describes a collaborative health problem An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status A language used by healthcare providers to communicate and consider each other's unique perspectives so they can better manage the multiple factors that influence the health of individuals Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need Patient obtains social support care related to caregiver stress A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making nursing diagnoses in correct order 1. Review assessment data noting objective and subjective clinical information 2. Cluster clinical data elements that form a pattern 3. Identify nursing diagnosis 4. Consider the context of patient's health problem and select a related factor 5. Identify appropriate assessment findings for diagnosis A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduce movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of: Data cluster A nurse reviews data gathered regarding a patient's response to diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for anxiety with those of fear and selects anxiety as a correct diagnosis this is example of the nurse avoiding an error in? Data clustering, Data Interpretation, making a diagnostic statement A __________ diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem Risk diagnosis Setting priorities for a patient's nursing diagnosis or health problems is an important step in planning patient care. Which of the following statements describes elements to consider in planning care? Priority setting establishes a preferential order for a nursing interventions. Recognition of symptom patterns helps in understanding when to plan interventions. What does the acronym smart stand for
Specific, Measurable, Attainable, Realistic, Timely Specific (SMART) Be sure and outcome addresses only one patient behavioral response Measurable (SMART) Use a term in an outcome statement that allows for observation as to whether a change takes place in patient status Attainable (SMART) Mutually set an outcome that a patient agrees to meet Realistic (SMART) Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources Timed (SMART) Include when an outcome is to be met
A nursing student is providing a handoff report to the RN assuming her patient care. She explains I ambulated him twice during the shift he tolerated walking to the end of the hall each time and back with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I change the dressing over his IV site and started a new bag of D 5 1/2 NS. Which intervention is a dependent intervention? Administering IV fluids A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse as a result of a call-in. A patient care technician from another area is coming to the nursing unit to assist because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asked about another patient. Which factor in the nurses unit environment will affect the ability to set priorities. Staffing level A nursing student is providing a handoff report to a registered nurse who is assuming her patient care at the end of the clinical day. The student states the patient had a good day. His IV fluid is infusing at 124 mL/hr with 5 1/2 NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift he tolerated walk into the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after exercise. He uses his walker without difficulty, gait normal. The patient ate 3/4 of his dinner with no gastrointestinal complaints. For the goal of improving the patient's activity tolerance, which expected outcomes were shared in the handoff? Walk to visitors lounge Which of the following factors should be considered when choosing an intervention for a patient's plan of care? The specific patient outcome against which to judge effectiveness of interventions The scientific evidence available in support of an intervention The amount of time required for implementation in consideration of patient's condition The patient values and beliefs regarding the intervention A patient diagnosed with colon cancer has been receiving chemotherapy for six weeks. The patient visits outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty assessing the patient's IV port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This also occurred two weeks earlier what steps should the nurse follow to make a consultation with a member of the IV infusion team? Specifically identify the problem of the port obstruction, and attempt to flush the port to resolve the problem. Explain to the IV nurse the frequency in which this port has obstructed in the past. Describe to the IV nurse the type and condition of the port currently in use. A nurse assesses a 78-year-old patient who weighs 108.9 kg (240lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in that area. The patient has had fecal incontinence on and off for the past two days the nurse identifies the nursing diagnosis of risk for impairment skin integrity. Which of the following outcomes is appropriate for the patient? Erythema of skin will be mild to none within 48 hours An 82-year-old patient who resides in a nursing home has the following three nursing diagnosis: risk for fall, impaired physical mobility related to pain, and in balance nutrition: less than body requirements related to reduce ability to feed self. The nursing staff identified several goals of care. Goal #1: patient will ambulate independently in three days Goal #2: patient will be injury free for one month Goal #3: patient will achieve 5 pound weight gain in one month Goal #4: patient will
achieve pain relief by discharge A nurse is assigned to five patients including one who was recently admitted and one returning from diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? The nurse directs the patient care technician to go to the patient in pain and reposition an offer comfort measures until the nurse can bring an ordered analgesic to the patient. The nurse direct the patient care technician to set up meal trays for patients. The nurse directs the patient care technician to assist one of the stable patients up in the chair for his meal. A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesic ordered PRN for pain and has been using cold applications on his surgical site for pain relief. The last time the analgesic was given was four hours ago. The patient is scheduled for a physical therapy visit in two hours. Which of the following demonstrates good clinical decision making during intervention? The nurse reviews the options for pain relief for the patient. The nurse assesses whether the PRN medication, ordered every 4 to 6 hours and last given four hours ago, is effective and whether a new type of medication is needed The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy. A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly minted, and one has requested a pain medication. The patient who has returned from surgery just a minute ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an IV line. One of the other patients has just called out for assistance in setting up a meal train. Another patient is stable and resting comfortably. Which patient is the nurses greatest priority? Patient who returned from surgery The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? Physical care technique Which principle is most important for the nurse to follow when using a clinical practice guideline for an assigned a patient? Individualizing how to apply the clinical guideline for a patient A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient's adherence to medication. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? Determining the value the patient places and taking medications Determine all consequences associated with patient missing specific medicines The nurse enters a patient's room and finds that the patient was in continent of liquid stool. Because the patient has recurrent redness in the perineal area, The nurse worries about risk of the patient developing a pressure injury. The nurse cleanses the patient, inspect the skin, and applies a skin barrier appointment to the perineal area. The nurse consult the ostomy and wound care nurse specialist recommended skin care measurements. Which of the following correctly describes the nurses actions? The call to The ostomy and wound care specialist is an incident care measure The cleansing of the skin is a direct care measure Specific direct care activity: counseling Discussing a patient's options and choosing palliative care Specific direct care activity: life-saving measure Protecting a violent patient from injury Specific direct care activity: physical care technique Using safe patient handling during positioning of a patient Specific direct care activity: activity of daily living Assisting patient with oral care Which measures does a nurse follow when being asked to perform an unfamiliar procedure? Check scientific literature or policy and procedure Determines whether additional assistance is needed Collect all necessary equipment Considers all possible consequences of the procedure A nurse is conferring with another nurse about the care of a patient with stage 2 pressure injury. The two decide to review the clinical practice guideline of the hospital for a pressure injury care. The use of clinical practice guideline achieves which of the following? Allows nurses to act more quickly and appropriately Set a level of clinical excellence for practice Incorporates evidence-based interventions for stage 2 pressure injury A nurse administer 32-year-old patient for treatment of acute asthma. The patient has labored breathing, respiratory rate of 28 per minute, and lung sounds bilaterally wheezing. The nurse makes the patient comfortable and starts an ordered IV infusion to administer medication that will relax the patient's airways. The patient tells the nurse after the first medication infusion I feel as if I can breathe better. The nurse auscultates the patient's lungs and notes decrease wheezing with respiratory rate of 22 per minute. Which of the following is an evaluative measure? Counting respirations per minute Asking the patient to describe how his breathing feels Auscultating lung sounds A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts and ordered IV infusion to administer medication that will relax to patients airways with a nurse as how the patient feels, he responds by saying I feel as if I can breathe better. The nurse asked dissipations lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in patient's condition Asking the patient to describe how his breathing feels Which of the following statements correctly describes the evaluation process? Evaluation involves reflection on the approach to care. Evaluation involves making clinical decisions. Evaluation requires the use of assessment skills. A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurses goal of care for this patient is to achieve self management of insulin medication. Identify appropriate evaluation measures for self management for this patient. Quality of life Clinic follow up visits Adherence to self administration of insulin From the following list of indicators determine which indicators are goals in which indicators or outcomes Will achieve pain relief (G) A nurse has been caring for a patient over two consecutive days. During that time the patient had an IV catheter in the right forearm. At the end of the shift on the second day the nurse inspect the catheter site, observes for redness, and ask for the patient feels tenderness when the site is palpated. Nurse reviewed the medical records from 24 hours ago in fines the catheter site was without redness or tenderness. Which of the following activities below reflect the nurses ability to perform patient evaluation? Comparing patient response with previous response Examining results of clinical data A nurse asked how a patient's condition from a serious infection change since yesterday while receiving handoff report. The nurse leaving the sheriff reports the patient has to priority nursing diagnosis is fluid in balance and fever. The receiving nurse begins to provide care by measuring the patient's body temperature, inspecting the condition of the skin, and the intake and output record, and checking the summary notes describing the patient's progress since the day before. The nurse as a technician to measure intake and output during the shift. What critical thinking indicators are affecting his ability to perform evaluation? Checking summary notes Asking the leaving RN about the patient's condition Comparing current outcomes with those set for the patient's goals Reflecting on patient progress A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning the patient's heart rate is 92 compared to 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse knows that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on this patient situation? The delay in administration of analgesic A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how patient is tolerating a new diet plan. The nurse decides to evaluate the patient's expectations of care. Which of the following is appropriate for evaluating a patient's expectations of care? The nurse asks did you believe that you receive the information you needed to follow your diet? Which of the following statements correctly describes the evaluation process Evaluation is an ongoing process Evaluation involves a gathering of data recognizing errors or omissions in care Evaluation involves making clinical decisions Evaluation requires the use of assessment skills An experienced nurse is explaining the use of touch from a caring perspective. What information does the nurse include in the discussion with the student about touch? Touch forms a connection between nurse and patient Before implementing touch, what does the nurse need to know about touch? Some cultures may have specific restrictions about non-skill based touch Touch can successfully influence a patient's level of comfort A young woman comes to the clinic for the first Time for a gynecological examination. Which nursing behavior applies Swanson's caring process of knowing the patient Recognizing that the patient is modest and maintaining her privacy during the examination The patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The nurse replies: Spiritual, mind, and body connections can affect health. Which of the following are strategies for creating work environments that support nurse care interventions? Increasing technological support Providing opportunities to discuss care Promoting autonomy of practice A nurse is caring for a patient newly diagnosed with testicular cancer. He asked the nurse to help him find the meaning of cancer by supporting beliefs about his life. This is an example of: Instilling Hope and Faith An example of a nurse caring behavior that families of acutely ill patients perceive as important to patient's well-being is: Asking permission before performing a procedure on a patient A nurse demonstrates caring by helping family members to: Become active participants in care Planning on interrupted time for family and patient to be together Discuss their concerns The hospice nurses at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches a patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? Caring touch Caring behavior: knowing Striving to understand and event as it has meaning in the life of the other Caring behavior: being with Being emotionally present to the other Caring behavior: doing for Doing for the other as he or she would do for itself if it were at all possible Caring behavior: maintaining belief Sustaining faith in the others capacity to get through an event or transition and face a future with meaning The nurse is caring for a patient who needs a liver transplant to survive. This patient has been out of work for several months, does not have health insurance, and cannot afford the procedure. Which of the following statements speaks to the ethical element of this case? The healthcare team should select a plan that considers the principle of justice as it pertains to the distribution of healthcare resources When designing a plan for care management for a patient following surgery, the nurse assesses the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continue reviews the plan with the patient to ensure that the patient's priority is met. If the nurses actions are driven by respect for autonomy, what aspect of the scenario best demonstrates that? Asking the patient to establish the goal for pain control The application of deontology does not always resolve an ethical problem which of the following statements best explains one of the limitations of Deontology? In a diverse community it can be difficult to find agreement on which principles or rules are most important The ethics of care suggests that ethical dilemmas can be best served by attention to relationships. How does this differ from other approaches to ethical problems? Ethics of care pays attention to the context in which caring occurs. Ethics of caring requires understanding the relationships between involved parties Ethics of care considers the decision makers relationship with other involved parties The following are steps in the process to help resolve an ethical problem. What is the best order of the steps to achieve resolution? 1: recognize that the problem requires ethics 3: take time to clarify values and identify the ethical elements, such as principles and key relationships involved 4: articulate a statement of the problem or dilemma that you are trying to resolve 5: List all possible actions that could be taken to resolve the problem 6: develop and implement a plan to address the problem What is the best response for the nurse to give if a patient asked the nurse to send a photo of an x-ray to him via messaging tool in a social media site? No, because health information of any kind should not be shared on social media Resolution of an ethical problem involves discussion with the patient, the patient's family, participants and from appropriate healthcare disciplines. Which statement best describes the role of the nurse in the resolution of an ethical problem? To articulate the nurses unique point of you, including knowledge based on clinical and psychosocial observations Which statement reflects the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life Community values influence definitions of quality, and they are subject to change over time Individual experiences influence perceptions of quality in different ways, making consensus difficult Statistical analysis is difficult to apply when the outcome cannot be quantified Which statement properly apply an ethical principle to justify access to healthcare? Access to healthcare reflects the commitment of society to principles of Beneficence and justice If low income compromises access to care, respect for autonomy is compromised. Port access to affordable healthcare causes harm that is ethically troubling because nonmaleficence is a basic principle of healthcare ethics Advocacy A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request Responsibility You tell your patient that you will return in 30 minutes to give him his next pain medication Accountability You administer once a day cardiac medication at the wrong time, but nobody sees it. However, you contact the provider and your head nurse and follow agency procedure. Confidentiality You see an open medical record on the computer and close it so that no one else can read the record without proper access What factors influence most prioritization of needs?Prioritization means more than just making decisions about which interventions to do first, second, or third. Factors that influence prioritization include client condition, safety factors, available time, and client preferences.
Which priority action would the nurse take before administering a new drug quizlet?Which priority action would the nurse take before administering a new drug? Confer with a colleague before giving the medication.
Which measures should the nurse take to ensure effective planning of patient care?Using standardized forms or checklists and doing thorough prework enhance the nurse's ability to communicate the plan of care effectively during a hand-off. It is also important to include patient and family when possible.
Which type of needs would be placed as an intermediate priority in the prioritization of client care?Intermediate priority nursing diagnoses involve non-emergent, non-life-threatening needs of patients. Low-priority nursing diagnoses are not always directly related to a specific illness or prognosis but affect the patient's future well-being.
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Which factor would the nurse consider when setting priorities for care during a shift quizlet?
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