Foundations of Nursing Exam #1 With Correct Answers

Foundations of Nursing Exam #1Foundations of Nursing Exam #1 Which organization is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice? a. American Association of Colleges in Nursing b. (AACN) National League for Nursing (NLN) c. International Council of Nurses (ICN) d. American Nurses Association (ANA) - ANS D. American Nurses Association What was one barrier to the development of the nursing profession in the United States after the Civil War? endence of nursing orders of educational standards tal-based schools of nursing of influence from nursing leaders - ANS b. lack of education standards Which nurse posited a theory that can be practically applied to nursing as follows: "Nurses modify unhealthy aspects of the environment to put the client in the best condition for nature to act." a. Dorothea Orem b. Sister Callista Roy c. Florence Nightingale d. Virginia Henderson - ANS c. Florence Nightingale What historical event led to the demise of nursing in England before the time of Florence Nightingale? - ANS When religions groups were exiled to western Europe during the schism between King Henry VIII and the Catholic Church. (The management of parochial hospitals and the ill within them fell to the state) Reforms for which Florence Nightingale is responsible. - ANS Training women for future work Selecting only those with upstanding characters as potential nurses Improving sanitary conditions for the sick and injured Significantly reducing the death rate of British soldiers Providing classroom education and clinical teaching Advocating that nursing education should be lifelong Name three ways that nurses used their skills in the early history of US nursing. - ANS 1. Nurses moved into communities and established "settlement houses 2. Provided midwifery services 3. Volunteered during wartime Art of Nursing - ANS Ability to perform act skillfully Science of Nursing - ANS body of knowledge unique to a particular subject; develops from observing and studying the relationship of one phenomenon to another Nursing Theory: Environmental Theory - ANS External conditions such as ventilation, light, odor, and cleanliness can prevent, suppress, or contribute to disease or death. Florence Nighingale Nursing Theory: Basic Needs Theory - ANS People have basic needs that are components of health. The significance and value of these needs are unique to each person. Virginia Henderson Nursing Theory: Self-Care Theory - ANS People learn behaviors that they perform on their own behalf to maintain life, health, and well-being. Dorothea Orem Nursing Theory: Adaptation Theory - ANS Humans are biopsychosocial beings; a change in one component results in adaptive changes in the others. Nursing Process - ANS organized sequence of problem-solving steps used to identify and manage the health problems of clients Assessment Diagnosis Planning Implementation Evaluation Characteristics of Nursing Process - ANS Within the legal scope of nursing. Based on knowledge Planned. Client-centered. Goal-directed. Prioritized. Dynamic. The sources of Assessment Data - ANS -database assessment (initial information about the client's physical, emotional, social, and spiritual health -focus assessment (information that provides more details about specific problems and expands the original database.) -functional assessment is a comprehensive evaluation of a client's physical strengths and weaknesses in areas such as (1) the performance of activities of daily living, (2) cognitive abilities, and (3) social functioning. Three parts of nursing diagnostic statement - ANS P: Name of the health-related issue or problem as identified in the NANDA-I list E: Etiology (its cause) S: Signs and symptoms also called defining characteristics standards for care - ANS policies that ensure quality client care What do nursing care plans include? - ANS nursing diagnoses, outcome criteria, nursing interventions, and their rationale for each assigned client Objective Data - ANS observable and measurable data ("signs") obtained through observation, physical examination, and laboratory and diagnostic testing Subjective Data - ANS information from the client's point of view ("symptoms"), including feelings, perceptions, and concerns obtained through interviews How does World Health Organization (WHO) define health? - ANS "a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." What is holism? - ANS the study of the whole of the human condition: past, present, and future; biology, society; philosophical concept of interrelatedness What are the five levels of human needs? (Maslow's hierarchy) - ANS -Physiological needs -Safety and Security -Love and Belonging needs -Esteem & Self Esteem needs -Self Actualization needs When providing care to a client, what perspective is followed by the nurse? ng the client's health as treating the client's body ng the client's health as a balance of body, mind, and spirit ng the client's health as per the client's health belief ng the client's health along with the client's family's health - ANS ng the client's health as a balance of body, mind, and spirit Medicaid - ANS A federal and state assistance program that pays for health care services for low-income people. Medicare - ANS A federal program of health insurance for persons 65 years of age and older, permanently disabled workers and their dependents, and people with end-stage renal disease secondary care - ANS health services to which primary caregivers refer clients for consultation and additional testing tertiary care - ANS health services provided at hospitals or medical centers that offer specialists and complex technology extended care - ANS services that meet the health needs of clients who no longer require acute hospital care Patient Protection and Affordable Care Act - ANS a health reform law enabling many uninsured people to acquire health insurance Managed care organizations (MCOs) - ANS private insurers who carefully plan and closely supervise the distribution of their clients' health care services. The two most common types of managed care systems are health maintenance organizations (HMOs) and preferred provider organizations (PPOs) What are the national health goals targeted for 2020? - ANS Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote healthy development and healthy behaviors across every stage of life. If all the following client problems exist, which is of highest priority for nursing management? Low self-esteem Labored breathing Feeling powerless Lack of family support - ANS Labored breathing Name seven components of a drug order. - ANS The clients name, the date and time the order is written, the drug name,the dose to be administered, the route of administration,the frequency of administration, and the signature of the person ordering the drug. generic name - ANS chemical drug name that is not protected by a manufacturer's trademark (always in lowercase) trade name - ANS name by which a pharmaceutical company identifies its drug Name four common routes for medication administration. - ANS Oral Topical Inhalant Parenteral Route Medication Administration Record (MAR) - ANS A sheet used for documentation listing medications prescribed and times to be given Name three ways that drugs are supplied. - ANS -individual supply is a container with enough of the prescribed drug for several days or weeks - unit dose supply (a self-contained packet that holds one tablet or capsule) is most common in acute care hospitals that stock drugs for individual clients several times in one day - automated medication-dispensing systems. These systems usually contain frequently used medications for that unit, any as-needed (p.r.n.) medications, controlled drugs, and emergency medications. What are two nursing responsibilities that apply to the administration of opioids? - ANS -They keep a record of each drug used from the stock supply -Nurses count controlled substances regularly, usually at each change of shift. Name the five "rights" of medication administration. - ANS Right Drug Right Dose Right Route Right Time Right Client Right Documentation *ALLERGIES* Describe three appropriate actions in the event of a medication error. - ANS 1. the nurse checks the client's condition 2. report the mistake to the prescriber and the supervising nurse immediately 3. Document on incident report/sheet homeostasis - ANS relatively stable state of physiologic equilibrium Adaptation - ANS (the response of an organism to change) requires the use of self-protective properties and mechanisms for regulating homeostasis Sympathetic Nervous System - ANS prepares the body for a fight-or-flight response; accelerates the physiologic functions that ensure survival Parasympathetic Nervous System - ANS a set of nerves that helps the body return to a normal resting state; restores equilibrium after danger is no longer apparent Factors that affect the stress response - ANS (1) the intensity of the stressor, (2) the number of stressors, (3) the duration of the stressor, (4) physical health status, (5) life experiences, (6) coping strategies, (7) social support, (8) personal beliefs, (9) attitudes, and (10) values. The three stages of general adaptation syndrome - ANS 1. Alarm 2. Resistance 3. Exhaustion Coping Mechanisms vs Coping Strategies - ANS Mechanism: unconscious tactics to defend the psyche to prevent their ego, or reality base, from feeling inadequate Strategies: stress-reduction activities selected consciously to help people to deal with stress-provoking events or situations Primary prevention - ANS involves eliminating the potential for illness before it occurs. An example is teaching principles of nutrition and methods to maintain normal weight and BP to adolescents. Secondary prevention - ANS includes screening for risk factors and providing a means for early diagnosis of disease. An example is regularly measuring the BP of a client with a family history of hypertension. Tertiary prevention - ANS minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is frequently turning, positioning, and exercising a client who has had a stroke to help restore functional ability. Name three stress management techniques - ANS -Endorphines -Sensory Manipulation -Adaptive Activies Name three different adaptive activities - ANS -Alternative Thinking Techniques -Alternative Behavior Techniques -Alternative Lifestyle Techniques When the nurse cares for an older adult, if all of the following events have occurred recently, which one likely represents the greatest stressor? Death of a spouse Change in living conditions Planned retirement Change in financial state - ANS Death of a spouse When the nurse interacts with a client, which coping mechanism is being demonstrated when a client refuses treatment because she believes her breast biopsy indicating cancer is incorrect? Somatization Regression Displacement Denial - ANS Denial Repression - ANS Forgetting about the stressor Suppression - ANS purposely avoiding thinking about a stressor Denial - ANS Rejecting information Rationalization - ANS Relieving oneself of personal accountability by attributing responsibility to someone or something Displacement - ANS Taking anger out on something or someone else who is less likely to retaliate Regression - ANS behaving in a manner that is characteristic of a much younger age Projection - ANS attributing that which is unacceptable in oneself onto another Somatization - ANS manifesting emotional stress through a physical disorder compensation - ANS excelling at something to make up for a weakness of another kind Sublimation - ANS channeling one's energies into an acceptable alternative Reaction Information - ANS acting just the opposite of one's feelings Identification - ANS taking on the characteristics of another Name four roles that nurses perform in nurse-client relationships - ANS -caregiver -educator -collaborator -delegator Describe the current role expectations for clients. - ANS Identify current problem. Describe desired outcomes. Answer questions honestly. Provide accurate historical and subjective data. Participate to the fullest extent possible. Be open and flexible to alternatives. Comply with the plan for care. Keep appointments for follow-up care. List at least five principles that form the basis of the nurse-client relationship. - ANS treat each client as unique, respect feelings promote physical, social, emotional, and spiritual well-being believe client can grow and change communicate in terms client understands use the nursing process to individualize care involve the client's support system implement techniques compatible with client's value system/culture social communication vs therapeutic verbal communication - ANS -social is superficial, includes common courtesies and exchanges about general topics -therapeutic verbal communication is communicating to accomplish a particular objective, interpersonal and purposeful What are the four forms of nonverbal communication - ANS -kinesics -paralanguage -proxemics -touch What are the benefits of client teaching? - ANS reduced length of stay cost-effectiveness of health care better allocation of resources increased client satisfaction decreased readmission rates Describe the domains of learning. - ANS -cognitive domain information usually provided in oral or written forms -affective domain information that appeals to a person's feelings, beliefs, or values motivation to learn, valuing what is learned, and incorporating learning into one's life -psychomotor domain learning by doing Pedagogic Learners - ANS Physically immature; lack experience; compulsory learners; passive; need direction and supervision; subject centered learning; short attention span; short-term retention; task oriented; respond to competition Andragogic Learners - ANS Physically mature; building experience; voluntary learners; active; self directed and Independent; problem centered learning; longer attention span; long-term retention; goal oriented; respond to collaboration Gerogogic Learners - ANS Undergoing degenerative changes; vast experience; crisis learners; passive/active; need structure and encouragement; self-centered learning; attention affected by low energy levels fatigue and anxiety; outcome oriented; responds to family encouragement Components generally found in a medical record - ANS information about the client medical information a plan of care nursing documentation medication administration records laboratory and diagnostic test results source-oriented vs. problem-oriented records - ANS source-oriented records categorize information according to the source reporting it problem-oriented records are organized according to the client's health problems, regardless of who does the documentation narrative charting - ANS recording of patient care in descriptive form; resembles a log or journal SOAP charting - ANS Subjective Objective Assessment Plan helps demonstrate interdisciplinary cooperation because everyone in focus charting - ANS A focus can be the client's current or changed behavior, significant events in the client's care, or a (NANDA-I) nursing diagnosis. DAR model (D = data, A = action, R = response DAR notations reflect the steps in the nursing process PIE charting - ANS recording the client's progress under the headings of problem, intervention, and evaluation assessments documented separately in a different form charting by exception - ANS nurses chart only abnormal assessment findings or care that deviates from a standard norm more efficient, quick access to abnormal finding computerized electronic charting - ANS documenting client information via computer component of informatics: the collection, storage, retrieval, and sharing of recorded data What is the Health Insurance Portability and Accountability Act (HIPAA)? - ANS enacted originally to protect health information communicated from one insurance company to another when a person changed employment Recent revisions regulate methods for further ensuring the client's privacy in the workplace and security of data Required aspects of documentation - ANS ongoing assessment data a plan of care a record of the care provided outcomes of the implemented care