Nursing Interview and Diagnosis: Recognizing and Addressing Patient Health Issues, Exams of Nursing

Download Nursing Interview and Diagnosis: Recognizing and Addressing Patient Health Issues and more Exams Nursing in PDF only on Docsity! Exam 1 Study Guide Questions with Accurate Answers 1. What would you do if you realize that your colleagues or other health care team member is not recording data in the patient’s chart? Approach the nurse Report to charge nurse 2. Explain on your own words the difference between subjective and objective data Subjective data is the patient’s verbal description of their health problems. • ONLY patients provide subjective data • Usually feelings, perceptions, and self-report of symptoms Objective data is observation or measurements of a patient’s health status 3. Explain what assessment data you can infer from the subjective information. For example, is there any patient’s expression that indicates fears? Anxiety Sweating Jittery Nausea 4. Give three different examples of patient’s possible cultural behaviors related to respect beliefs during the nursing interview. Eye contact is discouraged as a sign of respect in some cultures Family decisions are encouraged in some cultures Men in some culture hide pain in Latin culture The men make all the decisions in Arab culture 5. How will you prompt your patient to elaborate in her complaint regarding difficulty sleeping? Give examples of different questions you can ask in order to obtain more information about her complaint. I would prompt the patient to elaborate by asking open ending questions, which are questions that allow the patient to talk about the issue. For example, “Tell me more about your difficulty sleeping?” “Can you elaborate as to when you experience these difficulties?” 6. Would you ignore patient’s complain assuming that it has no relationship with the actual health problem? Explain your position Page 1 of 13 Never assume always look for clarification and accurate information. Remember our care is patient centered. The patient is the most important person at all times. 7. *Summarize all information needed regarding patient’s allergies Ask about what allergies they have and investigate more about the allergy. You will ask the patient to describe the type of reaction in order to determine if the patient is actually having an allergy or just experiencing side effects of the medication. 8. How will you correlate the subjective and objective data when assessing a patient? By checking to see if the subjective data is evidenced by the objective data. Watch for visual cues when a patient is giving subjective information. For example, if patient claims she is having back pain, watch for grimacing of the face when sitting or standing or sudden movement. Another example, if patient c/o shortness of breath, the subjective would correlate with the objective if, upon auscultation there is decreased breath sounds or dullness to percussion. What would you do if the patient statement is opposite of what you are observing? Explain your answer If the patient statement is conflicting with what is being observed, further data collection needs to be done. Make sure everything is documented. 9. Identify the elements needed in the ideal environment for a nursing interview (for example, privacy, lighting, etc) • Environment is free of distractions, unnecessary noise, and interruptions • Right lighting • Privacy (close door or curtains) • Right temperature 10. What is the role of the patient’s family during the nursing interview? • Support • Primary source (for infants, children, mentally handicap, disoriented, or unconscious) & Secondary source of information 11. Identify all possible nursing diagnosis for a patient with a medical diagnosis of pneumonia • Impaired gas exchange (collection of mucus in airways; fluid-filled alveoli) Page 2 of 13 What assessment findings would you expect to find in a patient that presents with diarrhea? • Dehydration • Loose or liquid stools • Rectal skin irritation, skin breakdown 20. What is urinary retention? • Urinary Retention is incomplete emptying of the bladder Identify how you would rule out urinary retention during your assessment • By Palpating the abdomen for distention • By assessing the amount, frequency, and character of the urine • By measuring the intake and output (intake greater than output may indicate retention) • Monitor blood urea nitrogen and creatinine ( elevation in these values will differentiate between urinary retention and renal failure as causes of decreased urine output) 21. Identify the proper steps to follow when a patient shows a sudden change of condition. • Reassess the patient to determine what possibilities made the patient’s condition suddenly change. • ADPIE again 22. Identify the characteristics of nursing goals. Outline 3 goals for a patient who is in your orthopedic unit with a total hip replacement post- operatory day number 2. • Patient reports satisfactory pain control at a level less than 3 to 4 on a 0 to 10 rating scale • Patient uses pharmacological and non-pharmacological pain relief strategies • Patient exhibits increased comfort such as baseline levels for pulse, BP, respirations, and relaxed muscle tone or body posture 23. Elaborate a strategy for taking care of seven patients at the same time. How are you going to organize your day? You will prioritize in order to start the care with the patient that needs the most Use Maslow’s basic needs pyramid to determine which patient you will see first. Physiological needs will require to always be attended to FIRST. Page 5 of 13 You will also use the ABC method  Airway Then you will begin with the highest priority diagnosis in order to select the appropriate interventions. • B • C 24. Identify all possible desired outcomes for a patient with the nursing diagnosis of “Constipation” • Patient passes soft, formed stool at a frequency perceived as “normal” by the patient • Patient or caregiver verbalized measures that will prevent recurrence of constipation 25. Analyzes the differences between dependent, independent and collaborative nursing interventions. Give 3 examples in each category. Dependent intervention- need a doctors order to give medication Independent intervention- turning a patient every two hours, doctors order not needed Collaborative intervention- calling a respiratory therapist for suctioning 26. Identify all possible nursing interventions for the nursing diagnosis: “Impaired skin integrity” • If patient is restricted to bed, encourage a turning schedule, restricting time in one position to 2 hrs or less • Encourage implementation of pressure-relieving devices • Encourage the patient to maintain functional body alignment Page 6 of 13 Encourage ambulation if patient is able • Increase tissue perfusion by massaging around affected area • Clean, dry, and moisturize skin • Encourage adequate nutrition (2000 to 3000 kcal/day) and hydration (2000ml/day) 27. Identify all possible nursing interventions for the nursing diagnosis: “Risk for fall” • Yellow wristband risk for fall • Move patient room close to nurses’ station • Answer call light immediately • Place mechanical bed in lowest possible position • Use side rail but keep 2 of the 4 down • Use appropriate room lighting • Wear Nonskid slipper or shoes when ambulating • Use bed or chair alarms to alert staff when the patient gets up w/o assistance 28. Analyze and contrast the statement differences between nursing goals and nursing interventions. • Nursing goals is a broad statement that describes a desired change in a patient’s condition or behavior. • Nursing intervention is any treatment based on clinical judgments and knowledge that a nurse performs to enhance patient outcomes. Example: Nursing goal: “the patient will tolerate out of bed to the chair for at least 30 minutes twice a day”. Nursing intervention: “Provide assistance for the patient to get out of bed twice a day”. Write 5 nursing goals and its corresponding nursing interventions for a patient with a nursing diagnosis of “impaired gait” GOALS: • Patient performs physical activity independently or within limits of disease • Patient demonstrates use of adaptive techniques that promote ambulation and transferring Page 7 of 13 39. Identify which patient will signify a greatest concern regarding communication, for example a patient with facial trauma (not sure) • The elderly: because some have difficulty hearing, seeing, and speaking as they age. Their children want to answer for them, or take charge. Some become incapacitated by stroke or disease. They take medications that can affect cognitive skills. 40. Write three examples where HIPPA legislation and patient’s rights and privileges of his/her protection of privacy will be involved Page 10 of 13  Showing the patients chart to their child.-->right to access patient health info • When a patient has DNR and family want to resuscitate  41. Identify all possible nursing intervention for a patient diagnosed with compromised immune system. • Hand washing • Limit amount of visitors • Limit use of invasive devices 42. Identify ethical dilemmas involved in an organ donation situation. What would you do if the patient tells you his/her wishes? Who gets the organ the elderly or the young adult? Contact the organ place 43. What would you do if your patient has to sign consent but does not speak English and you do not speak the patient language? • Request an official Interpreter 44. What considerations should the charge nurse take into account when assigning patients to a nurse who is floating from another unit? For example telemetry to ICU or oncology to NICU. • Floating can cause legal problems for nurses, especially if they are not qualifies or trained to work with a specific patient. When nurses float, they need to ask for an orientation to the unit. 45. Critically think in this situation: Your patient just has surgery, his pain is 10/10, you give pain medication and right after his pain level is 9/10. What do you do next? • I would explain to the patient that it will take at least 10-15 min for the medication to work since he just received pain meds. • Then I would explain an alternative measure to relieve the pain while waiting for the medication to start working. 46. Identify all possible food in a high-protein diet. Elaborate 5 different menus in this category. • Fruits • Eggs • Vegetables • Whole grains • Nuts • Seeds • Olives • Oils • Fish • Avocado • Lean meats • Beans • Soy Dairy foods 47. Patient’s readiness for teaching • Make sure patient is Alert oriented x3 and not in pain before teaching 48. All that apply (Subjective vs Objective data) 49. All that apply (prioritizing nursing interventions) 50. All that apply (nursing interventions vs. nursing goals and objectives) 51. Medication Calculation 52. Nasogastric Tube, nursing interventions • Having a Nasogastric tube puts the patient as Risk for Aspiration  Nursing Interventions would include: Page 12 of 13