Hondros Nur 155 final exam questions and answers 2023 updated & verified for accuracy

Tanner's Model of Clinical Judgement A model based on how a nurse THINKS, it explains the 4 steps in the critical thinking process that nurses use to solve any problem: Noticing Interpereting Responding Reflecting Nursing Process Uses the Scientific Method to complete a Step by step approach to PROVIDE PATIENT centered care: ADPIE Assessment Diagnosis -RN only Planning/Outcomes Implementation Evaluation Why study Critical Thinking? Thinking with a purpose, know why you do what you do. Discipline specific reasoning process that ensures a nurse is generating, implementing, and evaluation approaches. Benner's Theory of Stages of Clinical Competence 5 Stages of developing nursing clinical competence: Stage 1: Novice Stage 2: Advanced Beginner Stage 3: Competent Stage 4: Proficient Stage 5: Expert Credit to Stage 1: Novice Nursing Student in first year of clinical education; limited and inflexible, rule based, limited ability to predict what might happen in a particular situation. Credit to Stage 2: Advanced Beginner New grads in their first jobs, nurses have more experience and are able to recognize recurrent, meaningful components of a situation. They have the knowledge and the knowhow but not the in-depth experience. Credit to Stage 5: Expert Nurses that are able to recognize demands and resources in situations and attain their goals. No longer do they rely solely on rules to guide actions under certain situations. They area able to intuitively grasp the situation based on their deep knowledge and experience. Credit to Noticing First step of Tanner's model of clinical judgement. 1. Identifying signs and symptoms 2. Gathering complete and accurate data 3. Assessing systematically and comprehensively 4. Predicting and managing potential complications 5. Identifying assumptions Noticing-1. Identifying signs and symptoms The ability to recognize that a situation is different, changed, and not of a normal state. Indcates that something is different than expected. Noticing-2. Gathering complete and accurate data Collecting pertinent data from various sources. This data is used as the basis for identifying issues/concerns, solving problems, and making decisions. Must verify that data is complete and accurate. Noticing-3. Assessing systematically and comprehensively An organized manner to collect data to make sure nothing is omitted or forgotten. Examining the whole, piece-by-piece in a thorough manner. Noticing-4.Predicting and managing potential complications Looking at the big picture to consider possible complications for an individual patient. Must know common complications and consider individual differences. In Noticing, you are predicting complications, which means you are identifying possible problems. Noticing-5. Identifying assumptions Taking something for granted or hastily arriving at a conclusion without supporting evidence. A misconception. Nursing Process Assessment Observe and report to Charge Nurse or HCP. Determine risk for injury or infection. Nursing Process Diagnosis Assist with accurate diagnosis. Gather data to confirm or eliminate problems. Specific causes of safety risk to an individual. Nursing Process Planning/Outcomes Identifications Assist with setting priorities and goals, suggestions interventions. To prevent threats to safety. Nursing Process Implementation Carry out planned interventions. Interventions, education, environment/development considerations. Nursing Process Evaluation Assist with re-evaluation and make suggestions. Compare response/results to the original goals, plan of care. Data Collection-Scope of Practice LPN's collect data, RN's complete Assessments. Main Assessments 3 types: Focus Assessment Systemic Assessment Head to Toe Assessment Focus Assessment Focusses on one body part. example: Heart, Lung, Stomach, etc... Systemic Assessment Focusses on one body system. example: Respiratory, Digestive, Cardiac, etc... Head to Toe Assessment Total body examination. Parts of Clinical Thinking -Assess/learn/gain knowledge -Understand and ask questions -Store information/memorize -Recall information/bring it back -Know what to do when information isn't in memory (know where to look it up) -Draw your own conclusion Humble Attitude We don't know everything. 2 main types of data Objective vs Subjective Objective Data (Signs) Observable and measurable data that can be seen and heard, or felt, smelled by someone other than you, or by physical examination and lab data. example: elevated temperature, vomiting, skin moisture... Subjective Data (Symptoms) Information perceived only by the affected person, personal taste, symptoms, verbal statements provided by the patients point of view or perception. What the patient tells you. Clinical Is related to/or conducted in a healthcare setting involving direct observation of the patient. Judgement Your interpretation that influences your actions to take. Clinical Judgement Interpretation or conclusion about a patient's needs, concerns, or health problems. Whether or not you should take action. Sometimes you have to improvise new actions or plans. Why do we need Clinical Judgement? We need it to provide safe quality care. How do we develop Clinical Judgement? We use the Nursing Process, and Tanner's Model to develop the skills to establish Clinical Judgement. Emergency! Emergencies cease to exist when you prepare for them! SPICES A tool that can be used to obtain information necessary to prevent health alterations in older adult patients. SPICES-S Sleep Disorders SPICES-P Problems with Eating or Feeding SPICES-I Incontinence bowel and/or bladder SPICES-C Confusion SPICES-E Evidence of Falls SPICES-S(2) Skin Breakdown Epworth Sleepiness Scale Tool used to measure average daytime sleepiness. This information is used to determine if person is getting enough sleep. Scored 0-6: healthy 7-8 borderline 9-10 seek medical attention! (Most nursing students ;))