NUR 310 Chapter 1 Questions And Answers With Verified Study Solutions

What are the different parts of The Nursing Process? - CORRECT ANSWER-Assessment, Diagnosis/Analysis, Planning, Implementation, and Evaluation What happens in the "Assessment" portion of The Nursing Process? (This is the first step) - CORRECT ANSWER-Nurse collects data, and health assessment data is characterized as either subjective or objective What is subjective data? - CORRECT ANSWER-Data that includes interpretations and information provided by an individual about himself or herself - typically gathered from health history; pt. presents this information to you (ex: "I feel nauseous") What is objective data? - CORRECT ANSWER-Data that is measurable and observable - typically obtained through physical examination or lab/diagnostic tests - can be observed by someone else **ALWAYS verify information from the patient!! What is a health database? - CORRECT ANSWER-The patient's laboratory and diagnostic studies, and objective and subjective data collected by the nurse What happens during the "Diagnosis/Analysis" portion of The Nursing Process? (this is the second step) - CORRECT ANSWER-the nurse analyzes the data collected during the assessment using clinical judgement; nursing diagnosis is formed here; nurse collaborates with patient to develop the plan of care and will identify both actual and potential problems What happens during the "Planning" step of The Nursing Process? (third step) - CORRECT ANSWER-The nurse establishes priorities based on the patient outcomes and starts to identify interventions that will allow those outcomes to be met within a timeframe - identifies priorities: 1st, 2nd, 3rd level First level priority problems - CORRECT ANSWER-emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing Second-level priority problems - CORRECT ANSWER-those that are next in urgency requiring your prompt intervention to prevent further deterioration. (mental status change, acute pain, acute urinary elimination problem, untreated medical problems, abnormal lab test results Third-level priority problems - CORRECT ANSWER-those that are important to the patient's health but can be addressed after more urgent health problems are addressed. (Knowledge deficit, altered family processes, and low self esteem) What happens during the "Implementation" stage of The Nursing Process? (fourth step) - CORRECT ANSWER-the nurse will DO something - implement evidence-based interventions in a safe and timely manner using collaboration and delegation What happens during the "Evaluation" stage of The Nursing Process? (fourth and final step) - CORRECT ANSWER-The nurse will refer to established outcomes to: 1) evaluation individual's condition and progress toward outcomes 2) identify reasons for failure to achieve expected outcomes 3) take corrective action to modify plan of care 4) Document evaluation in plan of care medical diagnosis - CORRECT ANSWER-has an actual pathophysiology; (ex: broken arm, depression); the basis on which a nursing diagnosis can be made nursing diagnosis - CORRECT ANSWER-NOT medical; decisions nurses make in response to a medical diagnosis Nonmaleficence - CORRECT ANSWER-Duty to do no harm Beneficence - CORRECT ANSWER-The "doing of good" ; return to health is the goal for the patient! Autonomy - CORRECT ANSWER-Individuals have the right to determine their own actions and freedom to make their own decisions Justice - CORRECT ANSWER-treat everyone fairly, regardless of their ability to pay for treatment, social status, etc Confidentiality - CORRECT ANSWER-respecting the rights of the pt. to maintain privacy What are the ethical principles of nursing care? - CORRECT ANSWER-Nonmaleficence, Beneficence, Autonomy, Justice, Confidentiality What does the CDC recommend as the first line of defense to decrease nosocomial infections and prevent transmission of microorganisms? - CORRECT ANSWER-hand washing Alcohol based hand rub - CORRECT ANSWER-kill more organisms more quickly, less damaging to skin - use mechanical soap-and-water washing when hands are visibly soiled Standard precautions - CORRECT ANSWER-consider all waste and contact as potentially infectious; they also ensure that all health care providers treat all patients equally What is the intent of standard precautions? - CORRECT ANSWER-prevent disease transmission during contact with non-intact skin, mucous membranes, body substances, and blood-borne contacts What can a latex allergy result from? - CORRECT ANSWER-repeated exposure to proteins found in natural rubber latex through skin contact or inhalation - reaction can occur within minutes or hours Why should gloves be worn, according to the CDC? - CORRECT ANSWER-1) to reduce the risk of acquiring infections from patients 2) to prevent the transmission of flora from health care workers to patients 3) to reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another **Gloves should NOT be worn from room out into the hallway What are the different aspects of The Process of Communication? - CORRECT ANSWER-Sending (nurse conscious of messages sent), Receiving (receiver uses his or her own interpretations to process sent messages), Internal Factors (nurse maintains respect, empathy, listening factors, self-awareness), External factors (nurse should make sure the physical setting is comfortable) What should be done to prepare for the physical assessment? - CORRECT ANSWER-1) organize the examination 2) prepare the environment 3) prepare the patient What are the four assessment techniques in order? - CORRECT ANSWER-Inspection, Palpation, Percussion, Auscultation What is the assessment order for the abdomen? - CORRECT ANSWER-Inspection, Auscultation, Percussion, Palpation What should be done during the "inspection" portion of the physical assessment? - CORRECT ANSWER-look carefully and thoroughly at the patient; this offers an overall impression of the patient and severity of the situation - most revealing and provides a LOT of info - note symmetry b/w right and left side, skin characteristics, shape of chest, facial features, patient mood what should be done during the "Palpation" portion of the physical assessment? - CORRECT ANSWER-touch to assess for findings such as texture, temperature, moisture, tenderness, and edema what are the finger pads used to palpate for? - CORRECT ANSWER-- pulses, lymph nodes, small lumps, skin texture, edema what are the palmar surfaces of the fingers and finger joints used to palpate for? - CORRECT ANSWER-firmness, contour, position size, paint and tenderness what is the douse (back side) of the hand used to palpate for? - CORRECT ANSWER-temperature what is the ulnar (outside) surface of the hand used to palpate for? - CORRECT ANSWER-vibratory tremors light palpation - CORRECT ANSWER-assessment of skin characteristics deep palpation - CORRECT ANSWER-firmer, deeper pressure; used to confirm superficial findings and to assess size, shape, and consistency od deep organs What should be done during the "percussion" step of the physical assessment? - CORRECT ANSWER-vibrations are produced through tapping of the skin with short, sharp strokes what does dense tissue vibrations percussions sound like? - CORRECT ANSWER-quiet, flat what does air/fluid sound like when percussed? - CORRECT ANSWER-loud tones what are the different types of sounds used to describe when percussing? - CORRECT ANSWER-resonance, hyperresonance, dull, flat, or tympanic resonance - CORRECT ANSWER-loud, hollow, air filled tones heard over healthy lung tissue hyper-resonance - CORRECT ANSWER-very loud, almost "booming" sounds heard over lung tissue that has too much air present dull tones - CORRECT ANSWER-heard over dense organs such as spleen or liver flat tones - CORRECT ANSWER-when no air is present; muscle, bone, or tumor tympanic - CORRECT ANSWER-loud, drum like sounds heard over air-filled areas of the stomach or intestines What happens during the "Auscultation" stage of the physical assessment? - CORRECT ANSWER-the nurse listens to the sounds of the heart, lungs, stomach, intestines, and arteries; most common assessment technique in healthcare diaphragm of stethoscope - CORRECT ANSWER-the flat end bell of the stethoscope - CORRECT ANSWER-cup-shaped endpiece used for soft, low-pitched heart sounds What does written documentation entail? - CORRECT ANSWER-it involves entering patient information into the written or computerized patient medical record, which serves as a health database of recorded info from all health care encounters What is documentation? - CORRECT ANSWER-anything written or printed on which you rely as record or proof of patient actions and activities What are Electronic Health Records? (EHR) - CORRECT ANSWER-provides an integrated, real-time method of informing the healthcare team about the patient status What are the purposes of the Medical Record? - CORRECT ANSWER-Communication with Other Professionals Credentialing and Quality Assurance Legal Document Regulation and Legislation Financial Reimbursement Research Quality Precess and Performance Improvement What are the principles governing documentation? - CORRECT ANSWER-Confidentiality Accurate, Relevant and Consistent Auditable Clear, Consise, and Complete Legible/Readable Thoughtful Timely, Contemporaneous and Sequential Reflective of the Nursing Process Retreivable on a permanent basis in a nursing-specific manner What does the health history acronym PLEASE stand for? - CORRECT ANSWER-Past medical history Last Oral Intake Events leading up to illness Allergies and types of reactions Symptoms or chief complaint Each prescribed medication Complete Database (part of Health History) - CORRECT ANSWER-a broad, comprehensive assessment that includes a complete health history and a full physical exam Focused (Problem-Centered) Database - CORRECT ANSWER-more targeted in scope and is based on the patient's specific health issues; used for a limited or short term issue (focuses on mainly one or two problems and body systems) Follow-Up Database - CORRECT ANSWER-involves evaluating any identified problem at regular & appropriate intervals. Asssessing what changes have occurred, if it is getting better or worse. Emergency Database - CORRECT ANSWER-urgent, rapid collection of crucial information during a life-threatening or unstable situation What are the phases of the nursing interview? - CORRECT ANSWER-Introduction, Working Phase, and Close of the Interview Describe the directive interview technique - CORRECT ANSWER-highly structured; nurse controls the elements of the interview; allows nurse to gain precise details about a patient's reported condition Describe the closed or direct interview technique - CORRECT ANSWER-this is when questions ask for specific information and usually yield a short one or two worded response or a forced choice, such as "yes" or "no" ex: How old are you? Describe the non directive interview technique - CORRECT ANSWER-nurse lets the patient control the pace and the information seeking route; useful for developing a rapport with the pt. and contains more open ended questions Describe the open-ended interview technique - CORRECT ANSWER-the nurse asks questions for narrative information and encourages the patient to respond in any way on their own terms (Ex: Describe how you are feeling) symptom - CORRECT ANSWER-subjective sensation that the person feels from the disorder sign - CORRECT ANSWER-an objective abnormality that you as the examiner can detect on physical examination or lab testing What does the OLD CARTS acronym stand for when you are assessing history of present illness? - CORRECT ANSWER-Onset Location Duration Characteristics Aggravating and alleviating factors Related symptoms Treatment Severity Onset - CORRECT ANSWER-when did the symptoms begin? Location - CORRECT ANSWER-where do the symptoms occur? Duration - CORRECT ANSWER-How long do the symptoms last? Characteristics - CORRECT ANSWER-What are the symptoms like? Characteristics? Aggravating and Alleviating factors - CORRECT ANSWER-What affects the symptoms? Related Symptoms - CORRECT ANSWER-What other symptoms are present? Treatment - CORRECT ANSWER-What treatments have been tried? Severity - CORRECT ANSWER-How severe are the symptoms? What are the 5 key determinants of health? - CORRECT ANSWER-1) financial stability 2) education 3) social and community aspects 4) access to health care 5) neighborhood and environment Gravida - CORRECT ANSWER-number of pregnancies term - CORRECT ANSWER-the number of term deliveries preterm - CORRECT ANSWER-the number of preterm deliveries abortions - CORRECT ANSWER-the number of elective or spontaneous living (in regards to obstetrical history) - CORRECT ANSWER-current number of living children What does the functional assessment do? - CORRECT ANSWER-It assesses a person's daily functioning What is ADLs in regards to the functional assessment? - CORRECT ANSWER-Activities of daily living (the ability to meet the needs of daily activities and life) What does the acronym FICA mean when assessing spirituality in Internal Factors? - CORRECT ANSWER-Faith Influence Community Address What does the acronym CAGE stand for when assessing substance use in Internal Factors? - CORRECT ANSWER-Questions to ask: C - Have you ever thought you should Cut down your drinking? A - Have you every been Annoyed by criticism of your drinking? G - Have you ever felt Guilty about your drinking? E - Do you drink in the morning, an Eye opener? What are some examples of external factors? - CORRECT ANSWER-Occupational health, Living environment, relationships, abuse What is the General Survey used for? - CORRECT ANSWER-a study of the whole person, covering the general health state and any obvious physical characteristics that apply to the whole person, not just to one body system What will the nurse assess in the initial surgery and assessment? - CORRECT ANSWER-patient's: - physical appearance - behavior - body structure - mobility - height, weight, BMI, vital signs, and pain measurements What should facial features look like? - CORRECT ANSWER-symmetrical with movement What is the nurse looking for while assessing appearance? - CORRECT ANSWER-facial features, emotional state, eye contact, level of consciousness, skin color What is the nurse looking for while assessing behavior? - CORRECT ANSWER-speech, mood and affect, personal hygiene, dress What is the nurse looking for when assessing body structure? - CORRECT ANSWER-posture, overall build, obvious physical deformities what is the nurse looking for when assessing mobility? - CORRECT ANSWER-gait (manner or style of walking), range of motion, involuntary movements spasticity - CORRECT ANSWER-increased tonicity/muscle tone rigidity - CORRECT ANSWER-resistance to any manipulation of the joint; stiffness fasciculation - CORRECT ANSWER-continuous, rapid twitching of a muscle at rest myoclonus - CORRECT ANSWER-a sudden jerking of muscle tic - CORRECT ANSWER-involuntary, repetitive movement of a muscle group related to a neurologic or psychogenic cause tremors - CORRECT ANSWER-seen in opposing muscle groups that results in a rhythmic movement of one or more joints What do measurements tell about a patient's health? - CORRECT ANSWER-it provides critical information about the adult's state of health and the child's growth pattern; used to evaluate nutritional status, access fluid gain or loss, and calculate medication dosages How should you measure a patient's height? - CORRECT ANSWER-Use a stadiometer; have patient take off shoes What is the conversion of kilograms to pounds? - CORRECT ANSWER-1 kg = 2.2 lbs unexplained weight loss - CORRECT ANSWER-may be a sign of a short-term illness (fever, infection, disease of mouth or throat), or a chronic illness (endocrine disease, malignancy, depression, eating disorder) What is Body Mass Index (BMI)? - CORRECT ANSWER-a practical marker of optimal healthy weight for body height and is an indicator or obesity or malnutrition Underweight BMI - CORRECT ANSWER-less than 18.5 kg/m Healthy weight BMI - CORRECT ANSWER-18.5-24.9 kg/m Overweight BMI - CORRECT ANSWER-25 -29.9 kg/m Obese BMI - CORRECT ANSWER-30 kg/m and above What happens to patients who have a BMI of greater than 30? - CORRECT ANSWER-increased risk for hypertension, diabetes mellitus, cardiovascular disease, some cancers weight gain - CORRECT ANSWER-overabundant caloric intake, unhealthy eating habits, and sedentary lifestyle unexplained weight gain - CORRECT ANSWER-may indicate fluid retention (which could be a result of heart failure) Waist circumference - CORRECT ANSWER-a numerical measurement of the waist, used to assess an individual's abdominal fat and establish ideal body weight; - excess abdominal fat is a risk factor for diabetes, hypertension, and cardiovascular accidents healthy waist circumference for men - CORRECT ANSWER-less than 40 inches healthy waist circumference for women - CORRECT ANSWER-less than 35 inches What are vital signs? - CORRECT ANSWER-temperature, pulse, respiration, blood pressure, and oxygen saturation what does the hypothalamus do? - CORRECT ANSWER-it is the body's thermostat; maintains a steady temperature and maintains homeostasis What is the conversion of temperature from celsius to Fahrenheit? - CORRECT ANSWER-C= (F-32) x 5/ 9 what is the conversion of Fahrenheit to Celsius? - CORRECT ANSWER-F = (9 / 5 x C) + 32 normal oral temperature - CORRECT ANSWER-37° C (98.6° F) what is the range of normal temperature? - CORRECT ANSWER-36° to 38° C or 96.8° to 100.4° F