Nursing Study Material Test Bank - Current Edition Solutions

Nursing Study Material Test Bank - Current Edition Solutions The Difference in Nursing is the program is patient related - answer - use critical thinking, maybe hes in pain What Goes into Decision Making for a Nurse? - answer - Critical thinking: -process for choosing best actions to meet a desired goal Intellect: -Ability to think, understand, and reason (Salient cues) Creativity: -thinking outside the box Inquiry: -search for knowledge & facts through research Reasoning: -deductive -inductive Clinical Judgement - answer - Thought process (clinical reasoning) that allows healthcare providers to arrive at a conclusion (clinical decision- making) based on objective and subjective information about a patient How does this lead to Clinical Decision Making? - answer - Decision Making Skills and Clinical Expertise/Judgement + Client Preferences + Evidence = Clinical Decision Making Overview - answer - Phases Assessment Nursing Diagnosis Planning Implementation Evaluation Assessment - answer - Gathering Data • Systematic, continuous data collection • Carried on through all phases of nursing process • Focused on client's response to a health problem Types of data Subjective • Client, family Objective • Physical examination • Sources of Data Primary the client Secondary any other source Assessment, continued - answer - Organizing data Nursing models • Gordon's 11 functional health patterns • Roy's adaptation model • Maslow's hierarchy of needs Non-nursing model • Body systems Diagnosis - answer - Use critical thinking skills to: Cluster assessment data Identify problems Give the problem a name! • NANDA's Taxonomy II Nursing Diagnosis Versus Medical Diagnosis - answer - Nursing diagnosis Statement of nursing judgment Nurses are licensed to treat Human response to health condition Medical diagnosis Made by physician, advanced practice nurse, or physician assistant Disease focused An Example - answer - The Medical Focus • Open Compound Fracture The Nursing Focus • They will be in pain! • They could get an infection! • They will not be able to take care of themselves the same way! • They might get additional injuries! • Will need to learn how to walk on crutches! • Will need a high protein diet to help with healing! • And More! Types of Nursing Diagnoses - answer - Actual Diagnosis-Problem Focused Diagnosis where the problem is actually present • Risk Diagnosis- problem doesn't exist but has risk factors • Health Promotion Diagnosis- readiness to improve • Syndrome Diagnosis- Cluster of ND that can occur together Requires Prioritization - answer - Each patient may have multiple diagnosis. Which is MOST important? • Nurses care for multiple patients. Which patient needs your attention FIRST? Components of a Nursing Diagnosis - answer - Diagnostic label (problem) Approved by NANDA Qualifiers give additional meaning You look it up! • Etiology (related factors and risk factors) One or more probable causes of health problem • Defining characteristics Cluster of signs, symptoms that indicate presence of a particular diagnostic label What's the error? - answer - Patient reports blisters in her mouth. She is concerned that they might be contagious and is worried about friends seeing them. The patient reports that she does not know how to care for them. Should she use a special mouth wash? • Diagnosis- Pain Planning - answer - Deliberate, systematic phase • Client goals formulated Basis for nursing interventions To prevent, reduce, eliminate, or improve nursing diagnosis situation • Involves decision making, problem solving • Client support necessary for effectiveness • Serve as criteria for evaluating progress • Must involve the client. Developing a Goal - answer - Questions to ask What needs to be changed? Is there a healthy response to correct problem stated in diagnosis? How will client look, behave if healthy response achieved? What action must client do? • How well must client do it to d