Nursing 105 Exam 2 > Exam 2 comp. > Flashcards

Exam 2 comp. Flashcards

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1
Q

What influences delegation to nursing assistive personnel?

A

Clinical decision-making

Effective delegation requires assessing if the task is appropriate based on the patient’s condition.

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2
Q

Reflection in clinical decision making is described as __________.

A

“Instant Replay”

It allows a nurse to review the accuracy of the assessment and improve for the future.

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3
Q

The purpose of nursing evaluation in critical thinking is to determine __________.

A

“Does something WORK OR NOT”

It assesses if the patient met expected outcomes.

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4
Q

List the steps for the application of the clinical decision-making nursing process.

A
  • Assess
  • Diagnose
  • Plan
  • Interventions
  • Evaluate

The acronym used is ADPIE.

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5
Q

Critical thinking in the nursing assessment process involves which skills?

A
  • Interpretation
  • Analysis

Nursing practice includes cognitive, interpersonal, and psychomotor skills.

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6
Q

Nurses should make decisions based on __________.

A

ONLY OUR OWN ASSESSMENTS

This emphasizes the importance of individual assessment in decision-making.

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7
Q

Differentiate between objective and subjective assessment data.

including interpretation

A
  • Subjective: Patient’s feelings, perceptions
  • Objective: Measurable data
  • Interpretation: Involves orderly data collection, finding patterns, and clarifying uncertain data.

Subjective: (e.g., pain).
Objective: (e.g., vital signs, lab results)

Interpretation involves orderly data collection and finding patterns.

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8
Q

Effective communication techniques for client situations include __________.

A
  • Building trusting relationships
  • Clear communication

caring, compassion, look at the patient directly, consd. cultural issues

Important when dealing with older or non-English speaking patients. Don’t assume they dont understand.

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9
Q

The components of a diagnostic statement follow the PES format: P, E, S. What do they stand for?

A
  • P - Problem (NANDA label)
  • E - Etiology (Related to…)
  • S - Symptoms (As evidenced by…)

This format helps structure nursing diagnoses.

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10
Q

Defining characteristics for diagnostic labels are the __________.

A

Symptoms

They are observable assessment cues that support the nursing diagnosis.

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11
Q

The correct order of steps when developing a nursing diagnosis is:

A
  • Assess
  • Data Clustering
  • Interpretation
  • Formulate the Nursing Diagnosis

This sequence ensures a systematic approach.

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12
Q

Outcomes must be formulated using the S.M.A.R.T. criteria. What does S.M.A.R.T. stand for?

A
  • S - Specific
  • M - Measurable
  • A - Achievable
  • R - Realistic
  • T - Timed

This framework ensures clear and attainable outcomes.

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13
Q

Prioritization of nursing interventions is based on __________.

A
  • High Priority: ABCs, Safety, Pain
  • Intermediate: Non-emergent
  • Low: Future well-being

This helps in managing patient care effectively.

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14
Q

Nursing interventions can be categorized as __________.

A
  • Nurse-initiated (independent)
  • Health care provider-initiated (dependent)
  • Collaborative (interdependent)

These categories help in planning patient care.

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15
Q

When a consultant provides recommendations, the nurse must __________.

A

Incorporate the consultant’s recommendations into the care plan

This includes specialized care like wound care or speech therapy.

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16
Q

A Comprehensive Assessment is performed for newly admitted clients to __________.

A

Establish a complete baseline

This is crucial for ongoing patient care.

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17
Q

Clinical reasoning in evaluating vital signs involves __________.

A

Using specific parameters

For example, holding medication based on blood pressure readings.

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18
Q

Implementation in nursing involves three types of skills: __________.

A
  • Cognitive
  • Interpersonal
  • Psychomotor

These skills are essential for effective nursing practice.

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19
Q

After administering pain medication, the nurse must __________.

A

Evaluate if it works within a specific timeframe

For example, 30 minutes post-administration.

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20
Q

The nurse is responsible for the decision-making process of delegation. What are the key responsibilities?

A
  • Decision to delegate
  • Assessment of the patient
  • Supervision of the task

The nurse retains accountability for the outcome.

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21
Q

Signs of nurse stress over a clinical decision include:

A
  • Muscles tense/tired
  • Reactive/Snappy
  • Emotions not managed
  • Trouble focusing

Recognizing these signs is important for self-care.

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22
Q

Types of nursing diagnoses include __________.

A
  • Problem-focused : problem, etiology, and symptoms.
  • Risk Diagnosis : Has “Risk for…” and risk factors, but NO etiology or symptoms.

Each type has specific criteria for formulation.

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23
Q

Nursing interventions are prioritized by __________.

A

Urgency

High priority interventions address life-threatening issues first.

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24
Q

Classify interventions into indirect or direct nursing care.

A
  • Direct Care: Treatments through patient interaction
  • Indirect Care: Treatments performed on behalf of the patient

This classification helps in understanding the nature of care provided.

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25
Evaluation involves comparing the patient's current status with __________.
Expected Outcomes ## Footnote If the plan does not work, it must be revised.
26
The **5 Rights of Delegation** are:
* Right Task * Right Circumstance * Right Person * Right Direction/Communication * Right Supervision/Evaluation ## Footnote These rights ensure safe and effective delegation.
27
The **Hypothalamus** controls __________.
Temperature set points ## Footnote It acts as the body's thermostat.
28
The body loses heat through four mechanisms: __________.
* Radiation : Transfer of heat without contact (e.g., removing a blanket). * Conduction : Transfer of heat with direct contact (e.g., ice packs, cooling blanket). * Convection : Transfer of heat by air movement (e.g., a fan). * Evaporation : Transfer of heat when liquid changes to gas (e.g., sweating/diaphoresis). ## Footnote Understanding these mechanisms is crucial for managing body temperature.
29
Temperature follows a **Circadian Rhythm**. What are the lowest and highest temperature times?
* Lowest: Between 1:00 AM and 4:00 AM * Highest: Around 4:00 PM ## Footnote This rhythm affects daily temperature variations.
30
If a client has smoked or eaten before taking an oral temperature, the nurse must wait __________.
20 to 30 minutes ## Footnote This ensures accuracy in temperature readings.
31
Define **hyperthermia** and **hypothermia**.
* Hyperthermia: Elevated body temperature due to inability to lose heat * Hypothermia: Heat loss during prolonged exposure to cold ## Footnote Both conditions require immediate attention.
32
The **5 P's** of a Neurovascular Assessment include:
* Pain * Pulse * Pallor * Paresthesia * Paralysis ## Footnote This assessment is crucial for evaluating potential fractures.
33
Correct ways of obtaining **vital signs** include ensuring the BP cuff width is __________.
40% of arm circumference ## Footnote This helps prevent false readings.
34
Pulse pressure is calculated as __________.
Systolic - Diastolic ## Footnote Low pulse pressure can indicate decreased cardiac output.
35
Oxygen is usually indicated if SpO2 falls below __________.
<90-92% ## Footnote Signs of hypoxia include restlessness and confusion.
36
Normal temperature range is __________.
36°C - 38°C (96.8°F - 100.4°F) ## Footnote This range is critical for assessing patient health.
37
African Americans have a higher incidence of __________.
Hypertension ## Footnote Education on lifestyle modifications is essential.
38
Smoking and caffeine cause __________.
Vasoconstriction ## Footnote This leads to a temporary increase in blood pressure.
39
Older adults generally have a lower baseline temperature of approximately __________.
95-97°F ## Footnote They are more sensitive to temperature extremes.
40
When analyzing vital signs in a group of clients, the nurse compares data against __________.
Standard normal ranges ## Footnote This helps identify deterioration.
41
Factors influencing **home blood pressure monitoring** include using a validated monitor and __________.
Checking at the same time each day ## Footnote Proper cuff size and positioning are also important.
42
Priority in care is given to clients with __________.
Hemodynamic instability ## Footnote New onset of abnormal BP takes precedence.
43
The nurse should reassess abnormal vital signs reported by an AP before __________.
Making a decision or notifying the provider ## Footnote This ensures accuracy in patient assessment.
44
Reasons for performing a **physical assessment** include establishing a baseline and __________.
Monitoring the status of a previously identified problem + screening for health problems ## Footnote This is essential for ongoing patient care.
45
Steps for prevention of healthcare-acquired infections include __________.
* Hand Hygiene * Cleaning equipment * Standard Precautions ## Footnote These practices are vital for patient safety.
46
Abnormal findings in testicular self-examinations include __________.
* Painless lump * Swelling * Enlargement ## Footnote It is best performed monthly after a warm shower.
47
To prepare for assessment of a possible fracture, perform a __________.
Neurovascular Assessment ## Footnote This includes checking pain, pulse, pallor, paresthesia, and paralysis.
48
What is the purpose of **Hygiene** in patient care?
Washing hands ## Footnote Essential for preventing infection.
49
What should be done with **cleaning equipment** like stethoscopes between patients?
Use alcohol ## Footnote Important for infection control.
50
What are **Standard Precautions** in patient care?
Do not set equipment on patient care areas without barriers ## Footnote Aims to prevent the spread of infections.
51
What are **abnormal findings** to predict during testicular self-examinations?
* Painless lump * Swelling * Enlargement ## Footnote Best performed monthly after a warm shower.
52
What is the **Neurovascular Assessment** for a possible fracture?
* Pain * Pulse (distal to injury) * Pallor * Paresthesia * Paralysis ## Footnote Important for assessing circulation and nerve function.
53
How is **higher-level thinking** assessed in the mental status examination?
By testing **Abstract Thinking** ## Footnote Method: Ask the patient to interpret a proverb.
54
Identify the **adventitious sounds** heard during auscultation.
* Crackles * Wheezes * Rhonchi * Pleural Friction Rub * Bruit * Thrill ## Footnote Each sound has specific clinical significance.
55
What is the priority order for seeing patients based on **ABCs**?
Airway, Breathing, Circulation ## Footnote Prioritize patients with acute changes in condition.
56
What is the correct sequence for performing an **abdominal assessment**?
* Inspection * Auscultation * Palpation ## Footnote Auscultation must come before palpation to avoid altering bowel sounds.
57
What are the **normal** and **abnormal** assessment findings?
Normal: *Skin warm/dry; Bowel sounds active; Lungs clear.* Abnormal: *Cyanosis; Dyspnea; Absent bowel sounds.* ## Footnote Nurses must compare data against standards.
58
What is the technique for assessing **skin turgor**?
Grasp a fold of skin and release ## Footnote Normal skin lifts easily; abnormal skin stays pinched.
59
Differentiate between **Sensory** and **Motor Aphasia**.
* Sensory (Receptive): Cannot understand speech * Motor (Expressive): Cannot speak or write appropriately ## Footnote Important for effective communication assessment.
60
What are the primary functions of the **respiratory system**?
* Ventilation * Perfusion * Diffusion ## Footnote Each function plays a critical role in gas exchange.
61
What is the process of **Diffusion** in the respiratory system?
Exchange of gases at the Alveolocapillary membrane ## Footnote Oxygen moves into the blood; carbon dioxide moves into the alveoli.
62
What are the **late signs** of respiratory problems?
* Cyanosis * Clubbing of the nail bed ## Footnote Cyanosis indicates hypoxia; clubbing indicates chronic hypoxemia.
63
What are the **oxygen delivery systems** in order?
* Nasal Cannula: 1-6L/min * Simple face mask: 6-12L/min * Partial/Nonrebreather: 10-15L/min * Venturi Mask: COPD ## Footnote Each system has specific flow rates and indications.
64
What are the types of **wound drainage**?
* Serous: Clear, thin plasma * Serosanguineous: Pink/light red mix * Sanguineous: Bright red blood * Purulent: Thick, opaque ## Footnote Each type indicates different healing stages.
65
What are the **stages of wounds**?
* Stage 1: Non-blanchable redness * Stage 2: Partial-thickness loss * Stage 3: Full-thickness skin loss * Stage 4: Full-thickness tissue loss * Unstageable: Base covered by slough or eschar ## Footnote Important for assessing wound healing.
66
What factors can affect **pulse oximetry readings**?
* Nail polish * Cold extremities * Carbon Monoxide poisoning * Motion * Outside light sources ## Footnote These factors can cause false readings.
67
What are the **risk factors** for respiratory and cardiac conditions?
Respiratory: *Smoking; occupational hazards.* Cardiac: *Obesity; high cholesterol; hypertension; stress.* ## Footnote Identifying risk factors is crucial for prevention.
68
What are the different **breathing patterns**?
* Eupnea: Normal * Tachypnea: Fast (>20) * Bradypnea: Slow (<12) * Apnea: Absence * Cheyne-Stokes: Abnormal with apnea * Kussmaul: Deep, rapid * Biot’s respiration: Irregular ## Footnote Each pattern indicates different physiological states.
69
What is the importance of the **flu vaccine**?
Annual requirement due to virus changes ## Footnote Recommended for everyone 6 months and older, especially vulnerable populations.
70
What is a priority nursing diagnosis for clients with respiratory function alterations?
* Impaired Gas Exchange * Ineffective Airway Clearance * Ineffective Breathing Pattern ## Footnote Prioritize based on oxygen saturation levels.
71
What skills can be **delegated** to assistive personnel?
* Vital signs (stable patients) * Ambulating stable patients * Feeding (no swallow risk) * Hygiene/bathing ## Footnote Cannot delegate teaching, assessment, planning, evaluation.
72
What factors influence **respirations**?
* Exercise * Acute Pain * Anxiety * Smoking * Body Position * Medications * Neurological Injury * Hemoglobin Function ## Footnote Each factor can change breathing patterns.
Nursing 105 Exam 2
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