Material
Nursing Diagnosis - correct answer ✔✔ A clinical judgement about individual, family, or
community responses to actual or potential health problems/life processes. They provide the
basis for selection of nursing interventions to achieve outcomes for which the nurse is
accountable
ADPIE - correct answer ✔✔ Assessment, diagnosis, plan, implement, evaluate
PES - correct answer ✔✔ Problem, etiology, s/s
2 part diagnosis - correct answer ✔✔ Diagnoses about potential illnesses/problems. There is no
S in the PES due to the fact that it has not yet happened.
Also, used in health promotion when the client shows readiness to increase wellbeing and
actualize human health potential
3 part diagnosis - correct answer ✔✔ Used to describe an undesirable human response to a
health condition/life process that exists in a person
Modifiable health determinants - correct answer ✔✔ Nutritional patterns, weight, smoking,
diet, exercise
Non-modifiable health determinants - correct answer ✔✔ Genetics, economic status, gender,
age
,Health belief model - correct answer ✔✔ Based on readiness for change, the value of health,
belief of susceptibility, perception of threat/serious nature of disease, risk factors, belief in
benefit of action, barriers, self-efficacy
Pt will change if they believe it is absolutely necessary
TTM - correct answer ✔✔ Model assists the nurse in assessment of patient readiness for
change using precontemplation, contemplation, preparation, action, and maintenance
Red flags of IP violence (9) - correct answer ✔✔ 1. Multiple healthcare visits-psychogenic
complaints
2. Non-adherence with tx plan
3. Difficulty coping- drug or ETOH abuse
4. Trauma sx, PTSD
5. Any injury during pregnancy
6. Evidence of recent assault injury- Delay in seeking care
7. Illogical explanation, minimization of injuries
8. Multiple areas of injury with major organ involvement
9. Evidence of old injury, recurrent injury
How to document IP violence (7) - correct answer ✔✔ 1. Use quotes regarding chief complaint
2. Document name/relationship of assailant if possible
3. Document patient demeanor
4. Be specific in your description of injuries
5. Document all consents-referrals
6. Document all illogical explanation of injuries
7. Document increased injuries over time
, What types of abuse have to be reported? (3) - correct answer ✔✔ 1. All child abuse
2. Vulnerable adult abuse
3. IP violence
What can we say to the abused? - correct answer ✔✔ I'm here for you, no one deserves to be
abused, there is no excuse for abuse, etc.
Strangulation - correct answer ✔✔ A person commits the offense of strangulation if the person
knowingly and intentionally impedes the normal breathing or circulation of the blood of
another person by applying pressure on the throat or neck of the other person
Learning domains (3) - correct answer ✔✔ 1. Cognitive (application of facts/information)
2. Psychomotor (acquiring skills)
3. Affective (Taking on new attitudes/beliefs about decision making)
Often nurses select content from more than one to teach
Outcome measurment - correct answer ✔✔ Outcomes are often the measurable statement,
importance is that the statement is measurable and the patient/family can describe what it
means to them
Example: Goal is to prevent infection
Outcome is that the pt can demonstrate 3 steps for completing a dressing change
Nurse/environmental barriers to learning (6) - correct answer ✔✔ 1. Time
2. Preparation
3. Organization doesn't make pt a priority