EXAM 2 NUR 170 REVIEW SHEET COMPLETE QUESTIONS ANSWERS GRADED A PLUS
Question:
What is the assessment data and the analyzed problems including priority problem? You are caring
for a 90-year-old female patient, M.W., in a skilled nursing facility. Her past medical history
includes dementia, stroke and dysphagia (difficulty swallowing). She has right-sided paralysis from
her stroke. M.W. is unable to feed herself, requires a pureed diet and thickened liquids. She has lost
a significant amount of weight over the last month and is ordered daily weights. M.W. is alert and
oriented to person only. Her last documented weight was 45kg (99 lbs). Vital signs are T 36.0, HR
80, RR 16, BP 110/60. The nursing assistant has reported M.W. was coughing while she was eating
breakfast this morning.
Answer:
-Assessment 90-year old dementia, stroke and dysphagia (difficulty swallowing) right-sided
paralysis unable to feed herself alert and oriented to person only vital signs weight cough while
eating Analyzed impaired mobility: no as mobile as normal risk for aspiration (ingest food into
lungs, can cause choking and pneumonia risk for skin breakdown: not as mobile, right side paralysis
imbalanced nutrition: lost weight, don't taken as much risk for falls/injury: confused, 90 years old
Priority Problem: risk for aspiration
Question:
What is planning?
Answer:
-where you determine what you want the patient's goal to be, making our goals goals need to be
observable patient repsonses: broad statements about what the patient strives to acheive short term:
(few hours to a few days) packing lunch to save money next 3 days long term (a week to serval
months): pack lunch everyday for the next month patient goals will always start with patient will
Question:
Goals will need to be SMART. what does that mean?
,Answer:
S: specific, patient will walk 20 feet with a walker M: measurable, you can measure the 20 ft A:
attainable, appropriate for the individual patient, some patients can walk 20 ft by day 1 and the other
can only do 10 ft R: realistic, would not give the same goal to different patients, wouldn't give 20 ft
to some with Parkinson's vs hip surgery T: time frame, patient will do xyz by end of nurses shift
Question:
Priority Problem: Risk for Aspiration. what goals?
Answer:
- patient will not cough during each meal patient will remain free of aspiration pneumonia during
duration of long term care stay: long term patient will have clear lung sounds each shift: short term
Question:
What is implementation?
Answer:
-how will the nurse assist in meeting the goals the selection and implementation of appropriate
therapeutic interventions that the nurse will perform (or appropriately delegate/collaborate on) to
specific problem identified and the outcome desired everything before is patient will, now it is nurse
will, what are we doing to get that patient where they need to be
Question:
Short term/long term goal: Patient will remain free of aspiration pneumonia. What are our
interventions? Can any of these actions be delegated? interventions mean implementations
Answer:
Nurse will: 1. Check for correct food and liquid consistency 2. Ensure head of bed is raised above
30-45 degrees; 90 degrees when feeding 3. Implement aspiration precautions (dependent on facility
what it includes) Assess lung sounds before and after feeding 5. Educate the staff and family
members about the importance of feeding the patient the correct foods, placing her in correct
position at meal times, feeding her slowly, alternating food and liquid 6. Perform oral care after
meals Assess for coughing during meal time 7. Monitor for any signs of aspiration pneumonia
,Question:
What is evaluation?
Answer:
-outcomes are used to evaluate the patient's response to the plan of care - they are specific
measurable criteria used to determine if goals have been met did our nursing interventions work and
did we achieve our outcome (goal) do we need to make modifications within that SMART plan
Question:
What is a care plan?
Answer:
document that outlines the individual needs of the patient
Question:
What phase: The nurse modifies the plan of care because the wound has become larger:
Answer:
Evaluation
Question:
What phase: Patient has a Stage 3 pressure ulcer on his sacrum. Area is red, malodorous, and has
purulent drainage.
Answer:
Assessment
Question:
What phase: Skin breakdown:
Answer:
analysis
, Question:
What phase: Patient will have a decrease in wound dimensions within 3 weeks:
Answer:
Planning
Question:
What phase: Nurse will assist patient to change position frequently, perform the ordered dressing
change daily, measure wound dimensions weekly:
Answer:
Implementation -> Nurses will
Question:
What is critical thinking?
Answer:
-thinking like a nurse or thinking in action active, orderly, well-thought-out reasoning process that
guides the nurse improves over time with the acquisition of knowledge and experience includes
questioning, analysis, interpretation, inference, inductive and deductive reasoning, intuition,
application and creativity something I need to respond to now or later?
Question:
What is Maslow's hierarchy of needs?
Answer:
identifies 5 categories of human needs, shown on a pyramid, with 5 basic psychological needs
(breathing, food, water, shelter, clothing, sleep) that every human needs for survival, low levels on
pyramid must be met first before the next can achieved
Question:
What is ABCDE?
Question:
What is the assessment data and the analyzed problems including priority problem? You are caring
for a 90-year-old female patient, M.W., in a skilled nursing facility. Her past medical history
includes dementia, stroke and dysphagia (difficulty swallowing). She has right-sided paralysis from
her stroke. M.W. is unable to feed herself, requires a pureed diet and thickened liquids. She has lost
a significant amount of weight over the last month and is ordered daily weights. M.W. is alert and
oriented to person only. Her last documented weight was 45kg (99 lbs). Vital signs are T 36.0, HR
80, RR 16, BP 110/60. The nursing assistant has reported M.W. was coughing while she was eating
breakfast this morning.
Answer:
-Assessment 90-year old dementia, stroke and dysphagia (difficulty swallowing) right-sided
paralysis unable to feed herself alert and oriented to person only vital signs weight cough while
eating Analyzed impaired mobility: no as mobile as normal risk for aspiration (ingest food into
lungs, can cause choking and pneumonia risk for skin breakdown: not as mobile, right side paralysis
imbalanced nutrition: lost weight, don't taken as much risk for falls/injury: confused, 90 years old
Priority Problem: risk for aspiration
Question:
What is planning?
Answer:
-where you determine what you want the patient's goal to be, making our goals goals need to be
observable patient repsonses: broad statements about what the patient strives to acheive short term:
(few hours to a few days) packing lunch to save money next 3 days long term (a week to serval
months): pack lunch everyday for the next month patient goals will always start with patient will
Question:
Goals will need to be SMART. what does that mean?
,Answer:
S: specific, patient will walk 20 feet with a walker M: measurable, you can measure the 20 ft A:
attainable, appropriate for the individual patient, some patients can walk 20 ft by day 1 and the other
can only do 10 ft R: realistic, would not give the same goal to different patients, wouldn't give 20 ft
to some with Parkinson's vs hip surgery T: time frame, patient will do xyz by end of nurses shift
Question:
Priority Problem: Risk for Aspiration. what goals?
Answer:
- patient will not cough during each meal patient will remain free of aspiration pneumonia during
duration of long term care stay: long term patient will have clear lung sounds each shift: short term
Question:
What is implementation?
Answer:
-how will the nurse assist in meeting the goals the selection and implementation of appropriate
therapeutic interventions that the nurse will perform (or appropriately delegate/collaborate on) to
specific problem identified and the outcome desired everything before is patient will, now it is nurse
will, what are we doing to get that patient where they need to be
Question:
Short term/long term goal: Patient will remain free of aspiration pneumonia. What are our
interventions? Can any of these actions be delegated? interventions mean implementations
Answer:
Nurse will: 1. Check for correct food and liquid consistency 2. Ensure head of bed is raised above
30-45 degrees; 90 degrees when feeding 3. Implement aspiration precautions (dependent on facility
what it includes) Assess lung sounds before and after feeding 5. Educate the staff and family
members about the importance of feeding the patient the correct foods, placing her in correct
position at meal times, feeding her slowly, alternating food and liquid 6. Perform oral care after
meals Assess for coughing during meal time 7. Monitor for any signs of aspiration pneumonia
,Question:
What is evaluation?
Answer:
-outcomes are used to evaluate the patient's response to the plan of care - they are specific
measurable criteria used to determine if goals have been met did our nursing interventions work and
did we achieve our outcome (goal) do we need to make modifications within that SMART plan
Question:
What is a care plan?
Answer:
document that outlines the individual needs of the patient
Question:
What phase: The nurse modifies the plan of care because the wound has become larger:
Answer:
Evaluation
Question:
What phase: Patient has a Stage 3 pressure ulcer on his sacrum. Area is red, malodorous, and has
purulent drainage.
Answer:
Assessment
Question:
What phase: Skin breakdown:
Answer:
analysis
, Question:
What phase: Patient will have a decrease in wound dimensions within 3 weeks:
Answer:
Planning
Question:
What phase: Nurse will assist patient to change position frequently, perform the ordered dressing
change daily, measure wound dimensions weekly:
Answer:
Implementation -> Nurses will
Question:
What is critical thinking?
Answer:
-thinking like a nurse or thinking in action active, orderly, well-thought-out reasoning process that
guides the nurse improves over time with the acquisition of knowledge and experience includes
questioning, analysis, interpretation, inference, inductive and deductive reasoning, intuition,
application and creativity something I need to respond to now or later?
Question:
What is Maslow's hierarchy of needs?
Answer:
identifies 5 categories of human needs, shown on a pyramid, with 5 basic psychological needs
(breathing, food, water, shelter, clothing, sleep) that every human needs for survival, low levels on
pyramid must be met first before the next can achieved
Question:
What is ABCDE?
