Exam One Study Guide Questions And Answers 2023 LATEST UPDATED, Exams of Nursing

Download Exam One Study Guide Questions And Answers 2023 LATEST UPDATED and more Exams Nursing in PDF only on Docsity! Exam One Study Guide Questions And Answers 2023 LATEST UPDATED Critical Thinking: What are your responsibilities as a nurse? • Recognize health problems • Anticipate and plan for problems • Initiate actions to ensure appropriate and timely treatment, patient safety, and optimal health outcomes Critical thinking defined • Intentional higher-level reasoning • Influenced by knowledge, experience, skills, attitudes, and interpersonal skills • Consider what is important in a given situation Four components of diagnostic reasoning • Cues (ex. Pt staggers into ER) • Diagnostic “working” hypothesis (ex. Pt is intoxicated) • Data collection to support hypothesis (ex. No alcohol on breath, clammy skin, diaphoretic, disoriented, blood glucose level is critical at 61) • Evaluating hypothesis (ex. Pt isn’t intoxicated, pt is hypoglycemic and requires immediate intervention to prevent life-threatening complications) Critical thinking techniques Critical Thinking – is the process of intentional higher-level thinking to define a pts problem, examine the evidence-based practice in caring for the pt, and make choices in the delivery of care Critical Reasoning – is the cognitive process that uses thinking strategies to gather and analyze pt information, evaluate the relevance of the information, and decide on possible nursing actions to improve the pts physiological and psychosocial outcomes Critical Analysis – is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard unimportant information and ideas Socratic Questioning – is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes Inductive Reasoning – generalizations are formed from a set of facts or observations Deductive Reasoning – is reasoning from general premise to the specific conclusion Nursing Process – is a systematic, rational method of planning and providing individualized nursing care. It begins with assessment of the pt and use of clinical reasoning to identify pt problems. Clinical Judgment – is a decision-making process to ascertain the right nursing action • The map maker’s prior knowledge influences what is portrayed on the concept map Something to think about • Nurses are responsible for a unique dimension of healthcare – “the diagnosis and treatment of human responses to actual or potential health problems” • Nurses use knowledge from other disciplines • Nurses deal with change in stressful environments • Nurses make important decisions Nursing process • Is a systematic, rational method of planning and providing individualized nursing care • Its purposes are to identify a pt’s health status and actual or potential health care problems or needs, to establish plans to meet identified needs, and to deliver specific nursing interventions to meet those needs • The pt may be an individual, a family, a community, or a group The nursing process is… Systematic – the nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it Dynamic – the nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity Client Centered – the nursing process ensures that nurses are client-centered rather than taskcentered Goal-Directed – the nursing process is a means for nurses and clients to work • Determine the nurse’s need for assistance • Implement the nursing interventions • Supervise delegated care • Document nursing activities Evaluation • Collect data related to outcomes • Compare data with outcomes • Relate nursing actions to pt goals/outcomes • Draw conclusions about problem status • Continue, modify, or terminate the pt’s care plan Step 1: Assessment Methods • Observation • Interview • Examine Types • Subjective (symptoms), what client states • Objective (signs), observe or measurable by nurse Sources • Primary – nurse obtains information from client • Secondary – information is from a secondary source Fill in the blank review: Secondary source is information that comes from another person like family or another nurse. One method to collect data is an interview. Data that can be measured is objective data. A method of collecting data that occurs first would be observation. A physical assessment is a primary source of data. Data collection methods Observing – gather data by using the senses Interviewing – planned communication to gain information • Focused interview – specific questions • Directive interview – nurse controls interview, used to gain information when time is limited • Nondirective interview – rapport building interview, nurse allows client to • Syndrome diagnosis – nursing clinical judgment to describe a cluster of nursing diagnoses that have similar interventions Components • Problem – and its definition • Etiology – related factors or risk factors (related to) • Defining characteristics – or signs and symptoms (as evidenced by) Medical vs. nursing diagnosis Medical – terminology used for a clinical judgment by the physician. Identifies or determines a specific disease, condition, or pathological state • Upper GI Bleed • Anorexia Nervosa • Pneumonia • Closed Head Injury Nursing – clinical judgment that identifies that client’s responses to a health state, problem, or condition • Constipation • Ineffective Airway Clearance • Deficient Fluid Volume • Imbalanced Nutrition NANDA – nursing uses NANDA-I nursing diagnoses (North American Nursing Diagnosis Association – International) The language of nursing diagnosis (Actual) – Acute Pain, related to surgical incision, as evidenced by pt pain rating 8/10 and pain behaviors (rubbing knee, grimacing) (Risk For) – Risk for Fall, related to diminished lower extremity strength (Health Promotion) – Readiness for Enhanced Nutrition, related to blood sugar control, as evidenced by pt asking questions regarding diet recommendations, low-sugar recipes and sugar substitutes (Syndrome Diagnosis) – Post-Trauma syndrome r/t physical abuse aeb alienation, anger, anxiety, and depression. Note this is a three-part nursing diagnosis The diagnostic process  Analyzing data - Compare data against standards (identify specific cues) • Add second part to the general response or NANDA label to make it more precise Step 3: Planning • A deliberate, systematic phase of the nursing process that involves decision making and problem solving. A “plan of action” designed to improve the pt’s health status and/or better cope with his illness  Prioritize the diagnoses FIRST LEVEL – ABC’s (Airway, Breathing, Circulation) SECOND LEVEL – serious physiological problems or derangements (pain, electrolyte disturbance, safety issue) Maslow’s Hierarchy • Formulate goals (long term and short term) • Select nursing interventions Maslow’s Hierarchy P.S.L.E.S Pushy Salesmen Love Easy Sales Physiological Safety Love/belonging Esteem Self-actualization Planning cont. Types of Planning • Initial • Ongoing • Discharge Formulate Goals – SMART goals • Specific or directly related to the diagnosis (client centered)    • Document Step 5: Evaluation Determining if the outcomes have been met • Goal met – oral intake 1200mL, mucous membranes moist • Goal not met – oral intake <1200mL, mucous membranes dry • Goal partially met – oral intake 1200mL, mucous membranes dry 5 Components of evaluation • Collecting data related to the desired outcomes • Comparing the data with desired outcomes • Relating nursing activities to outcomes    • Drawing conclusions about problem status • Continuing, modifying, or terminating the nursing care plan Ch 30 part 1 Assessment • Includes health history and physical examination • Types of Physical examination - Complete (ex. Head-to-toe) - By body systems - By body area • Factor in client’s energy and time needed - Subjective Data – what the client says    - Objective Data – what is observed • Purposes of examination - Evaluate physiologic outcomes and progress - Make clinical judgments - Identify areas for health promotion and disease prevention - Obtain baseline data - Supplement, confirm, or refute data from the history - Help establish nursing diagnoses and plans of care Preparing the client • Explain when and where • Explain why examination is important    • Trendelenburg • Fowler’s • Semi-Fowler’s Dorsal recumbent Description: back-lying position with knees flexed and hips externally rotated: small pillow under the head; soles of feet on the surface Areas Assessed: female genitals, rectum, and female reproductive tract Cautions: may be contraindicated for pts who have cardiopulmonary problems    Supine Description: back-lying position with legs extended, with or without pillow under the head Areas Assessed: head, neck, axillae, anterior thorax, lungs, breasts, heart, vital signs, abdomen, extremities, peripheral pulses Cautions: tolerated poorly by pts with cardiovascular and respiratory problems Sitting Description: a seated position, back unsupported and legs hanging freely Areas Assessed: head, neck, posterior and anterior thorax, lungs, breasts, axillae, heart, vital signs, upper and lower extremities, reflexes    Cautions: older adults and weak pts may require support Lithotomy Description: back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table Areas Assessed: female genitals, rectum, and female reproductive tract Cautions: may be uncomfortable and tiring for older adults and often embarrassing Sims’ Description: side-lying position with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow Areas Assessed: rectum and vagina    Position, size, consistency, and mobility of organs or masses • Distention • Pulsation • Presence of pain upon pressure - Light palpation (one hand, superficial) - Deep palpation (two hands). Not routine, requires skill (advanced practice nurses and MD’s) Percussion • Striking body surface to elicit sounds or vibrations • Direct, striking body directly • Determines size, shape, and borders of internal organs    Auscultation • Listening to sounds produced within the body - Direct: use of unaided ear - Indirect: use of stethoscope • Pitch, intensity, duration, and quality • Before percussion and palpation - In efforts to not create false body sounds Ch 30 Part 2 General survey • General appearance • Level of comfort • Mental status    • Measurement of vital signs, height, and weight Integumentary • Integumentary system – includes the skin, hair, and nails  Some different findings of skin assessment include: - Pallor – an unhealthy pale appearance P1 - Cyanosis – a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood P2 - Erythema – superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilation of the blood capillaries P3    and size varies (ex. hives and mosquito bites) P6 Integumentary cont.  Nails – normal nail is smooth and rounded - Clubbing – is a condition in which the angle between the nail and the nail bed is 180 degrees or greater  Blanch test – can be carried out to test capillary refill, that is, peripheral circulation - Scale for grading edema below Head • Inspect and palpate simultaneously, then auscultate • Skull and face - Normocephalic – normal head size according to standard size tables - Exophthalmos – protrusion of eyeballs, may result from hyperthyroidism Eyes and vision - Visual acuity - Visual fields – peripheral vision  Common refractive errors of lens: - Myopia (nearsightedness) - Hyperopia (farsightedness) - Presbyopia (loss of elasticity and seeing close objects) - Astigmatism (uneven curvature) • External eye structures • Pupils - Color, shape, and symmetry of size - Direct and consensual reaction to light - PERRLA (Pupils Equally Round and React to Light and Accommodation) Ears and hearing • External ear – check skin  Abnormal breath sounds are called adventitious breath sounds - Crackles (rales) - Gurgles (rhonchi) - Wheeze - Stridor - Friction rub Crackles (rales) Description: fine, short, interrupted cackling sounds; alveolar rales are high pitched. Best heard on inhalation but can be heard on exhalation, may not be cleared by coughing Cause: air passing through fluid or mucus in any air passage Location: most commonly heard in the bases of the lower lung lobes Gurgles (rhonchi) Description: continuous, low-pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality. Best heard on exhalation but can be heard on both inhalation and exhalation Cause: air passing through narrowed air passages as a result of secretions, swelling, or tumors Location: loud sounds can be heard over most lung areas but predominate over the trachea and bronchi Friction rub Description: superficial grating or creaking sounds heard during inhalation and exhalation. Not relieved by coughing Cause: rubbing together of inflamed pleural surfaces Location: heard most often in areas of greatest thoracic expansion (ex. lower anterior and lateral chest) Wheeze Description: continuous, high-pitched, squeaky musical sounds. Best heard on exhalation, not usually altered by coughing Cause: air passing through a constricted bronchus as a result of secretions, swelling, or tumors Location: heard over all lung fields Ch 30 Part 3 Cardiovascular and peripheral  Assess the heart through inspection, palpation, and auscultation  Normal heart sounds include:  Perfusion – blood supply to an area of the body o Assessing the peripheral vascular system includes:  Measuring the blood pressure  Palpating peripheral pulses  +2 and equal findings are normal  Inspecting the skin, hair distribution, and tissues to determine perfusion Abdomen • Inspection, auscultation, percussion, palpation o I APP – of abdomen (look, listen, and feel) • Skin • Abdominal sounds • Specific organs  • Femoral pulses Bowel Sounds • Relatively high-pitched sounds heard with diaphragm of stethoscope • 4 quadrants – must listen in each quadrant and identify the types of sounds heard  Normal bowel sounds include: o Intestinal sounds that are relatively high-pitched o A sound every 5-20 seconds • Abnormal bowel sounds include: o Hyperactive sound – heard every 3 seconds o Hypoactive – one sound per minute, extremely soft sounds and  infrequent o Absent – no sounds at 3-5 minutes o Listen in every quadrant, might be different from one quadrant to another • 4 abdominal quadrants RLQ, RUQ, LUQ, LLQ • RLQ o Lower lobe of right kidney, cecum, appendix, section of ascending colon, right ovary, right fallopian tube, right ureter, right spermatic cord, part of uterus • RUQ o Liver, gallbladder, duodenum, head of pancreas, right adrenal gland, upper lobe of right kidney, hepatic flexure of colon, section of  o Assessed for normal form • Joints o Tenderness o Swelling o Thickening o Crepitation o Range of motion • Body posture • Balance – Romberg test Neurologic • Extent of neurologic exam depends on: o Chief complaint o Physical condition o Willingness of client • Performed throughout health examination • Mental status – general cerebral function including cognitive and affective functioning Mental status o Language   Aphasia – loss of power to express language o Orientation  Person, place, time, and self  Disorientation  Confusion o Memory  Immediate, recent, and long-term memory o Attention span and calculation  Ability to focus on mental task o Level of consciousness (LOC)  Glasgow Coma Scale o Cranial Nerves  12 each o Reflexes  Automatic response of body to stimulus   Tested with percussion hammer o Motor function  Proprioceptors • Sensory nerve terminals that occur chiefly in muscles, tendons, joints, and internal ear Cranial Nerves: On Old Olympus Towering Top A Finn And German Viewed A Hop On – Olfactory Old – Optic Olympus – Oculomotor Towering – Trochlear Top – Trigeminal A – Abducens Gross motor and balance tests • Romberg test • Walking gait test • Standing on one foot with eyes closed • Heel-toe-walking • Toe-to-heel walking Breasts and axillae • Palpate • Supine position • Abduct the arm and place pt’s hand behind head • Place a small pillow or rolled towel under the pt shoulder Female genitals and inguinal area • Inspect pubic hair • Inspect skin of pubic area • Inspect the clitoris, urethral orifice, and vaginal orifice • Palpate the inguinal lymph nodes Male genitals and inguinal area • External genitals o Inspect pubic hair o Inspect penis o Inspect urethral meatus o Inspect scrotum • Prostate gland • Hernia’s o Inspect inguinal or femoral areas for bulges Assessing the anus • Inspect the anus and surrounding tissue for: o Color o Integrity o Skin lesions • Ask the pt to bear down o Inspecting for rectal fissures, rectal prolapse, polyps, or internal hemorrhoids AWIPE A – announce W – wash hands I – ID (name, DOB, MR#) P – privacy E – explain DHCOW D – down H – handrails x2 C – call light in pt hand O – open curtains W – wash hands • Temperature influences o Age o Circadian rhythms o Exercise o Hormones – progesterone o Stress – SNS (stress/anxiety) o Environment • Alterations in body temperature o Pyrexia – body temp above usual range o Hyperthermia – fever o Fever o Hyperpyrexia – a very high fever such as 105.8˚F o Hypothermia – a core body temp below the lower limit of normal o Febrile – pt who has a fever o Afebrile – pt who does not have a fever • Types of fever o Intermittent – body temp alternates at regular intervals between periods of fever and periods of normal or subnormal temps o Remittent – a wide range of temp fluctuations (more than 3.6˚F) occurs over a 24hour period, all of which are above normal o Relapsing – short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temp o Constant – body temp fluctuates minimally but always remains above normal o Fever spikes – a temp that rises to fever level rapidly following a normal temp and then returns to normal within a few hours Clinical manifestations of fever • Increasing pulse, respiratory rate, and depth • Shivering • Pallid, cold skin • c/o feeling cold • Cyanotic nail beds • “Gooseflesh” appearance of the skin • Cessation of sweating Hypothermia • Decreased body temperature, pulse, and respirations • Severe shivering (initially) • Feelings of cold and chills • Pale, cool, waxy skin o Disadvantage – inconvenient and more unpleasant for pts; difficult for pt who cannot turn to the side o Disadvantage – could injure the rectum o Disadvantage – presence of stool may interfere with thermometer placement • Axillary o Advantages – safe and noninvasive o Disadvantage – the thermometer may need to be left in place a long time to obtain an accurate measurement • Tympanic membrane o Advantages – readily accessible; reflects the core temp; very fast o Disadvantage – can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far o Disadvantage – repeated measurements may vary, right and left measurements may differ o Disadvantage – presence of cerumen can affect the reading • Temporal artery o Advantages – safe and noninvasive; very fast o Disadvantage – requires electronic equipment that may be expensive or unavailable o Disadvantage – variation in technique needed if the pt has perspiration on the forehead Heart rate (pulse) • Palpation – assessing the wave of blood created by the contraction of the left ventricle of the heart • Compliance – compliance of the arteries is their ability to contract and expand • Cardiac output – stroke volume multiplied by heart rate • Peripheral pulses – not apical, located away from the heart (ex. foot or wrist) • Apical pulse – central pulse that is located at the apex of the heart (also referred to as the point of maximal impulse PMI) • Hypovolemia/dehydration – loss of blood from the vascular system increases the pulse rate • Stress – in response to stress, sympathetic nervous stimulation increases the overall activity of the heart. Stress increases the rate as well as the force of the heartbeat • Position – when a person is sitting or standing, blood usually pools in dependent vessels of the venous system. Pooling results in a transient decrease in the venous blood return to the heart and a subsequent reduction in blood pressure and increase in heart rate • Pathology – certain diseases such as some heart conditions or those that impair oxygenation can alter the resting pulse rate Assessing the pulse • Assess the pulse volume o Absent, +1, +2, +3, +4 (bounding)  Doppler US and stethoscope o Middle three fingertips  Using the thumb is contraindicated because the nurse’s thumb has a pulse that could be mistaken for the pt’s pulse • Rate and rhythm o Tachycardia o Bradycardia o Arrythmia Respirations • Inhalation – or inspiration refers to the intake of air into the lungs • Exhalation – or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere • Ventilation – is also used to refer to the movement of air in and out of the lungs • Costal breathing – or thoracic breathing, involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles • Diaphragmatic breathing – or abdominal breathing, involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragms contraction and downward movement Hyperventilation – refers to very deep, rapid respirations o Dyspnea – difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed o Orthopnea – ability to breathe only in upright sitting or standing positions Blood pressure • Components of blood pressure o Systolic – is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave o Diastolic – is the pressure when the ventricles are at rest, is the lower pressure, present at all times within the arteries • Pulse pressure – the difference between systolic and diastolic pressures o 120-80= 40mmHg • Measured in millimeters of mercury (mmHg)  Normal blood pressure is 120/80 mmHg Assessing blood pressure • Sphygmomanometer o Use the right cuff size • Electronic devices • Hypertension – a blood pressure that is persistently above normal • Hypotension – a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110mmHg in an adult whose normal pressure is higher than this • Orthostatic hypotension – is a blood pressure that decreases when the client sits or stands Factors affecting blood pressure • Age – the pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline somewhat • Exercise – physical activity increases the cardiac output and hence the blood pressure • Stress – stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of • Always assess the level of pain of your pt because pain can change vital signs • Acute pain will cause the pulse, respirations, and blood pressure to be elevated • The vital signs may be normal in a pt with chronic pain Q. A pt has a fever…what other vital signs will be affected? A. pulse, blood pressure, respiratory rate, pulse Ox, pain Ch 15 Documenting and Reporting • Documenting and reporting helps facilitate conversation between health professionals • Can be formal or informal • Can be oral, written, or computerized • Documenting typically occurs in a pt chart o A pt chart is a legal record of a care rendered to a pt • Recording, documenting, charting o Terms are synonymous Ethical and legal considerations • The pt chart is a legally protected record of pt care • Restricted access • “need to know” • The organization owns the record • Pts maintain the right to the same records • HIPAA not HIPPA o Health Insurance Portability and Accountability Act  Est in 1996; amended in 2003  Maintains regulations over Protected Health Information (PHI)  PHI – is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about pts, and written communications o Duty to protect • Computerized records o Cerner o Epic o SOAP – subjective data, objective data, assessment, planning o SOAPIER – subjective data, objective data, assessment, planning, interventions, evaluation, revision Other types of documentation • PIE o P – problems o I – interventions (NANDA) o E – evaluation • Focus Charting – is intended to make the pt and pt concerns and strengths the focus of care o D – data o A – action o R – response • Charting by exception (CBE) – is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded o Flow sheets o Standards of nursing care o Bedside access to chart forms Documenting nursing activities • Admission nursing assessment • Nursing care plans • Kardex’s • Flow sheets • Progress notes • Nursing discharge/referral summaries General guidelines for recording • Date and time • Timing • Legibility • Permanence • Accepted terminology • Signature • Accuracy • Completeness Reporting • Change-of-shift-reports • Telephone reports o ISBAR  I – introduction  S – situation  B – background  A – assessment  R – recommend • Telephone orders • Care plan conference • Nursing rounds