NURS 205 - NURSING PROCESS, SAFETY, INFECTION CONTROL, AND SKIN INTEGRITY TEST QUESTIONS AND ANSWERS

Appropriate nursing care is driven by what (3) forces? (In order)? Critical Thinking ---> Clinical Reasoning---> Clinical Judgement Assessment is a _______ - step process 2 Brainpower Read More 0:07 / 0:15 The first step of assessment is ______ ______ Collect Data What are the (2) classifications of data? Source Type A source can either be __________ or ___________ Primary Secondary Assessment data: ____________ data is patient provided Primary Assessment data: __________ data comes from family/significant others, health care team, medical records, or scientific literature. Secondary What is the BEST source of data? Primary Assessment: _______________ is a verbal description related to the patients health problem ---> what the PATIENT SAYS Subjective Assessment: _______________ is observations and measurements of the patients health ---> WHAT YOU SEE/OR WHAT YOU DO Objective Objective data is always what? Measured against a standard What is an example of preparing beforehand for a interview? Viewing the medical record What are the (4) C's of Successful Data Collection Courtesy Comfort Connection Confirmation True/False: It is important to look at the BIG picture in the initial interview. True Types of Questions: Open Types of Questions: Closed Types of Questions: Leading When was nursing diagnosis first introduced? (year) 1950 This international organization is a representation of nursing diagnosis was founded in 1982 NANDA-I What is the importance of the nursing diagnosis? (3) Provide precise definition of patients response to health issues Allow nurse to communicate with nursing specific work Distinguish difference between nurse and hcp role What is the CORRECT way of formulating a nursing diagnostic statement? Identify nursing dx Identify related factor (r/t) Identify symptoms (aeb) When do diagnostic errors usually occur? (4) Data collection Interpretation of data Clustering Statement formulation How should you determine urgency/importance of diagnosis? (4) Maslows Hierarchy Priority Pt as individual Ethics Priority Classification: __________ - Emergent ____________ - Non-life threatening ___________ - Affect pt's future well being High Moderate Low ______________ = a broad statement that describes the desired change in a patients condition, perceptions, or behavior Goal True/False: Goals are NOT patient centered False. They are always! True/False: A goal has to be measurable True Define SMART goal Specific Measurable Attainable Realistic Timed What defines a short term goal? A week or less What defines a long term goal? More than a week Intervention: __________ __________ = Independent, actions that a nurse initiates Nurse-initiated Intervention: ___________ ________ = Dependent ; require an order from physician or hcp HCP- initiated Intervention: ________________ = Interdependent ; require combined knowledge, skill, expertise of multiple HCP Collaborative This type of intervention is described as: treatments performed through interactions with patients Direct Care What are some examples of direct care? IV admin Med admin Counseling This type of intervention is described as: treatments performed away from the patient but on behalf of the patient Indirect Care What are some examples of indirect care? Managing pt's environment Documentation Collaboration _______________ = Reflection in action This is when you decide to discontinue or modify care Evaluation What (2) tasks CANNOT be delegated Nursing process Patient teaching Who is "DELEGATION" regulated by? Nurse Practice Act Name the (5) rights of delegation (p.287) Right task Right circumstance Right person Right communication Right supervision True/False: Patients CAN be delegated False! You can delegate tasks but never patient _____________ = freedom from accidental injuries; establishing operational systems and process to minimize likelihood of errors Safety During a patient safety assessment, what should you always obtain? What does that include? (4) Baseline measurements VS, mental status, mobility, and neuro status Name the (3) Basic Needs Oxygen Nutrition Temperature What are some examples of physical hazards? (5) MVA Disasters Poison Fire Falls Developmental stages: Infant, Toddler, and Preschooler Risks? Developmental stages: School-Age Child Risks Developmental stages: Adolescent Risks? Developmental stages: Adult Risks Developmental stages: Older adult Risks? __________ - inherited accidents = an accident that occurs by the patients actions Patient ________ - inherited accidents = an accident that occurs during a surgical procedure Procedure