NUR 221 Foundations Exam 2 questions and answers

NUR 221 Foundations Exam 2 questions and
answers

What is critical thinking? - answer-The process of problem solving
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- We gather data, validate data, and weigh options
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Ways in which nurses utilize critical thinking - answer-- Assessing our patients and
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vmaking decisions about their care
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-Re-evaluating pt's condition and making changes to the plan v v v v v v v v


-Communicating changes in pt's status to the provider and collaborating in creating
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vsolutions
-Determining relevant data and discarding irrelevant data v v v v v v




Theoretical knowledge - answer--Science based facts
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-Pathophysiologic principles v


-Evidence which policies v v


and protocols are based on
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Example of theoretical knowledge - answer-The FACT that Heparin is a medication that
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reduces blood clots by increasing blood clotting time
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Practical knowledge - answer-Knowing when and how to do tasks and skills safely.
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Example of using practical knowledge - answer-when we use the technique of pinching
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the skin inserting a 5/8-inch needle at a 45-degree angle of the abdominal fold when
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giving a subcutaneous injection of Heparin.
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Self-knowledge - answer-Our own preferences or biases that may influence our thinking
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Example of self-knowledge and possible repercussions - answer--First time I gave a
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sub-Q injection at clinical last week, the patient flinched and it made me nervous to do it
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again.
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-This self-knowledge is important to be aware about as it may influence decisions in an
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vunintended way. v




Contextual awareness - answer-Reflection on past experiences
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Ethical knowledge - answer--Helps us to handle situations where there is an element of
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right and wrong.
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,-We can recognize the situations as sometimes we may need to provide care that it's
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vethically confusing or not so black and white.
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-Ethical knowledge of boundaries and guidelines will help us remain true to our
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vprofession in providing this care. v v v v




5 steps of the nursing process - answer-1. Assessment
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2. Diagnosisv


3. Planning v


4. Implements
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5. Evaluating
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Assessment - answer-Data gathering; interpreting/analyzing data. v v v v v




-This is a nursing professional responsibility as recommended by the American Nurses
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vAssociation and therefore cannot be delegated to assistive personnel.v v v v v v v v




Can assistive personnel perform assessments? - answer-NO!!!!
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We can enlist the help of unlicensed assistive staff in the action of collecting the data -
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such as taking vital signs, asking about the presence of pain or measuring the amount
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of urine voided, but it is a nursing responsibility to interpret and analyze that data
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What is involved in all steps of the nursing process? - answer-Assessment
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- We assess data
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- When we implement our interventions, we assess its effectiveness and patient's
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vresponse
- When we evaluate expected outcome, we are assessing their success
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What is the frequency of assessments regulated by? - answer-Accrediting bodies
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-Always check with your facility, as each hospital usually has their own guidelines about
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vhow often and which assessments are done
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Types of assessments - answer-1. Initial
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2. Ongoing v


3. Comprehensive
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4. Focused v


5. Cultural v


6. Nutritional
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7. Psychosocial
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8. Communityv


9. Functional ability
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, Initial Assessments - answer-Initiated upon first contact with the patient.
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-This may be in the emergency department or ED, pre-operatively, or upon admission to
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vthe unit. v


-The first time the patient has contact with the health care system an initial assessment
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vis completed.
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-This is typically done within twelve hours of admission.
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Ongoing Assessments - answer-Continuing the plan of care.
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- Nurses generally are required to complete a head to toe assessment every shift, and
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vperhaps focused assessments more often in higher levels of care.
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- These follow up assessment are ongoing assessments
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Comprehensive Assessments - answer-More than a head to toe assessment and v v v v v v v v v v


include information about social and situational status, home support systems, holistic
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assessment of the patient's beliefs and spiritual needs, and what kind of assistance they
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have or may need at discharge (DISCHARGE IS THE GOAL!!)
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When does discharge planning begin? - answer-At admission
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Focused assessment - answer--Different from head to toe assessment as it is directed
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and, well, focused.
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-Focused assessment explores a single patient complaint or symptom, and may focus
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von one body system (such as the respiratory assessment for a patient with shortness of
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vbreath) or several body systems (such as respiratory, G.I., and cardiac if the patient is
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vexperiencing chest pain). v v v




-It is concentrated on that primary concern. You may also do a focused assessment at
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vchange of shift when there is a wound or dressing and you go in with that nurse to
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vassess just the wound dressing to make sure your initial shift assessment is not different
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vfrom her last reported assessment.
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-You do not need to do an entire head to toe assessment at that time, but just focusing in
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von that one particular abnormality.
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Cultural Assessments - answer-exploring what unique preferences and expectations the
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patient will bring with their cultural background.
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Nutritional assessments - answer-focus on whether the patient is nourished, has access
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to nutrition, and the ability to eat and tolerate their meals.
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-This is a requirement by the joint commission, an accrediting body of hospitals.
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Psychosocial assessments - answer-Done on every patient at every admission.
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