Exam 2 professional nursing practice questions with 100% correct answers verified for accuracy 2023 update

Discuss the relationship between critical thinking and nursing assessment. - assessment involves collecting information from the patient and from secondary sources, along with interpreting and validating the information to form a complete database Two stages of assessment: - collection and verification of the data - analysis of data Critical thinking approach to assessment: knowledge-standards-attitudes-experience ties in with nursing process: assessment, diagnosis, planning, implementation, evaluation · Differentiate between subjective and objective data Subjective- what the patient states - document data in patient's own words Objective- what you observe or assess - document using specific, measurable terms · Explain nursing responsibilities related to making a nursing diagnosis Nursing diagnosis: -to clarify the exact nature of the problems and risks that must be addressed to achieve the overall expected outcomes of care - the conclusions you make affect the entire plan of care - diagnoses are actual and potential patient problems Responsibilities: the term diagnosis implies that there is a situation requiring appropriate, qualified treatment - that means that if you diagnose an actual or potential problem, you: - must be qualified to make the diagnosis - must be willing to accept the responsibility to treat it - if not, you are accountable for getting the qualified help - if you miss key problems or risks, you are accountable for what happens to the patient - recognizing safety and infection transmission risks and addressing these immediately - identifying human responses - anticipating possible complications - initiating urgent interventions · Discuss the value of the rapid response team in decreasing failure to rescue Def: clinician's failure to prevent death or disability in a patient who is experiencing a complication from an underlying illness or from medical care - provides a measure of the degree to which providers responded to adverse occurrences that developed on their watch. It may reflect the quality of monitoring, the effectiveness of actions taken once early complications are recognized, or both Rapid response team: critical care nurse, respiratory therapist, physician - respond to emergencies, follow up on patients discharged from ICU, proactively evaluate high risk ward patients, educate and act as liaison to ward staff · Contrast the "diagnose and treat" model of health care to the "predictive model of care" Diagnose and treat: - assessment: collecting data, identifying cures and making inferences, validating data, clustering related data, identifying patterns/ testing first impressions, reporting and recording data - clinical reasoning: analyzing synthesizing, reflecting, drawing conclusions - diagnosis: creating a list of suspected problems/ diagnosis, 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 Predictive model of care: PREDICT- most common and dangerous complications - look for evidence of risk factors PREVENT- take immediate action to prevent the most common and dangerous complications, reduce risk factors MANAGE- take immediate action to manage them if they can't be prevented, control risk factors PROMOTE- ensure safety and learning needs are met, promote optimum comfort, function, and independence · Explain how use of standard terms in health care reduces errors and facilitates communication -increases the visibility of nursing's contribution to patient care by continuing to develop, refine and classify phenomena of concern to nurses - identify, label, classify actions nurses perform, including direct and indirect care interventions - identify, label, validate classify nursing sensitive patient outcomes and indicatiors - everyone knows what you are talking about · Distinguish between common nursing and medical diagnoses notes · Based upon specific data, determine the type of diagnosis that should be made - risk for infection or infection transmisssion - risks to safety - airway and breathing problems - altered mental status or confusion - pain, nausea, discomfort - anxiety- fear- coping issues - altered bowel elimination - patient education - smoking cessation · Appraise clinical data and nursing diagnoses for 5 causes of diagnostic error data collection, interpretation and analysis of data, clustering, diagnostic statement sources of diagnostic error: 1. identify the patient's response, not the medical diagnosis 2. identify a NANDA-1 diagnostic statement rather than the symptom 3. identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing interventions 4. identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself 5. identify the patient response to the equipment rather than the equipment itself · Identify and explain ADPIE Assessment Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data in and assist in assessment. Critical thinking skills are essential to assessment, thus the need for concept-based curriculum changes. Diagnosis The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community. A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the foundation for physical and emotional health.[4][5] Maslow's Hierarchy of Needs Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC's), sleep, sex, shelter, and exercise. Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease). Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, sexual intimacy. Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one's physical appearance or body habitus. Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one's maximum potential. Planning The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals should be: Specific Measurable or Meaningful Attainable or Action-Oriented Realistic or Results-Oriented Timely or Time-Oriented Implementation Implementation is the step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols and EDP standards. Evaluation This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. · Identify common nursing diagnosisin ineffective airway clearance, disturbed body image, risk for unstable BG, impaired urinary elimination, self care deficit, dressing and grooming Explain 4 purposes of the student nurse care plan 1. Directs care and documentation 2. Promotes communication among caregivers, thus promoting continuity of care 3. Creates a record that can later be used for evaluation, research and legal reasons 4. Provides documentation of health care needs for medicare, medicaid, and other insurance reimbursement purposes Label components of the nursing plan of care EASE Expected outcome- measurable change that must be achieved to reach a goal, many times, several must be met to meet a single goal Actual problems specific interventions evaluation Perform care planning activities in the proper order 1. Attend to urgent priorities- ABC. -determine urgent problems before taking time to clarify outcomes - determine overall expected results, discharge outcomes so you know how to prioritize considering the bigger picture of pt care 2. clarify expected outcomes (results) - be data driven on the outcomes - outcomes help direct interventions - outcomes are motivating factors 3. decide which problems must be recorded - make a list of pt problems - decide which problems must be managed in order to achieve the overall outcomes of care - determine what documentation will guide how each problem will be managed 4. determine individualized nursing interventions - monitor pt health status and response to treatments - reduce risks - resolve, prevent, manage problems - promote independence with activities of daily living - promote optimum sense of physical, psychological and spiritual well being - give patients the information they need to make informed decisions and be independent