Professional Nursing Practice & Overview of the Nursing Process Topics: Chapter 1, Nursing Today , Professional nursing practice , Chapter 17, Nursing Diagnosis , Nursing Diagnosis , Chapter 18, Planning Nursing Care , and Nursing Planning

The nurse educator is delivering a lecture on nursing as a profession to a group of nursing students who have recently joined the baccalaureate nursing degree course. The nurse is explaining the nursing processes by giving examples. Which examples should the nurse give while explaining nursing assessment? Recording body temperature two hours after administering antipyretic medication. Asking the patient about hygiene and sanitation in the patient's community. Identifying the signs of respiratory distress in a hospitalized patient. The nurse is responsible for collecting comprehensive data about the patient's health. The nurse records the body temperature after 2 hours to assess the effectiveness of the antipyretic medication. The nurse also asks the patient about the hygiene of the surrounding environment to assess the risk of acquiring infections caused by unhygienic surroundings. Nursing assessment also includes identifying the signs of a particular condition. Teaching a patient about the lifestyle changes required to reduce risks of ischemic heart disease is an example of the nursing process of implementation, not assessment. Asking the patient to demonstrate a technique after teaching it forms a part of the evaluation process, not the assessment process. The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part-time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? Pacing, Patient getting lost easily and getting up frequently 00:32 01:24 A group of nursing students is being taught independent nursing interventions. Which interventions should be included in the teaching? Independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling. They also include activities such as repositioning a patient to relieve pain. Administration of analgesics and starting an intravenous infusion require an order from a healthcare provider. A student nurse is gathering information from an elderly patient. Which of the student nurse's actions indicates the need for further teaching? While interviewing the patient, the nurse should not sit straight in the chair because it affects awareness, attention, and immediacy. Therefore, the nurse should lean forward while taking the interview. Good eye-to-eye contact is a signal of readiness to initiate interaction with the patient. Therefore, the nurse should maintain good eye contact with the patient. Giving more time for the patient to answer the questions will help the patient to understand the situation and respond accordingly. Nodding the head is an important social function, because it ensures interaction between the nurse and patient. The nurse is caring for a patient who has been admitted to the hospital with pneumonia. Which assessment findings of the patient can the nurse group together to formulate a data cluster? 2 Wheezing in left lung bases 3 Respiration 20 breaths/minute 5 Shortness of breath with ambulation A data cluster is a set of signs or symptoms gathered during assessment and grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Weakness and dysuria aren't directly related to respiratory issues. The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history, and the results of diagnostic tests. Osteoarthritis and diabetes mellitus are medical diagnoses, because these can be diagnosed by a healthcare provider through diagnostic tests and medical history. Medical diagnoses are based on the results of diagnostic tests. A primary healthcare provider is licensed to describe medical diagnoses and treat diseases. Acute pain is a nursing diagnosis. It can be easily identified by observing a patient's signs and symptoms and does not require any specific diagnostic test. A medical diagnosis does not include a clinical judgment about an individual and his or her family. p. 225 Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the S in PES stand for? PES is a three-part nursing diagnosis format. It includes the diagnostic label, etiological statement, and symptoms or defining characteristics. The P stands for problem, the E stands for etiology or related factors, and the S stands for symptoms or defining characteristics. The S does not stand for situation, sensitivity, or separation of data. Nurses are responsible for the quality of care provided to patients. Which will help nurses practice safe nursing? The nursing profession is accountable for the type and quality of care delivered to patients, so nurses should prepare by acquiring and updating knowledge, improving competencies, and acquiring technical skills. Avoiding documentation may generate more complications, such as legal issues. Nurses are given autonomy for various nursing practices, so they should be dependent only in aspects of care beyond their scope of practice. A patient sprained her ankle. The nurse instructs the patient to keep the leg elevated and applies cold compresses on the affected ankle. Which standard of practice is the nurse performing? The nurse is delivering care to the patient; therefore the standard practiced by the nurse is implementation. Assessment is the process of collecting data related to the health and illness of the patient. Nursing diagnosis involves analyzing the assessed data. Evaluation refers to determining the effectiveness of the implemented patient care in meeting the patient goals. An elderly patient has been put on a potentially toxic drug for treatment of arthritis. The patient and family have expressed concern about the drug. What is the role of the nurse in this particular situation? The patient has been put on a potentially toxic drug. Because the patient is elderly, the nurse should act as an advocate and take measures to protect the patient's rights. Therefore, the nurse may provide information that will help the patient decide whether to take the treatment. The nurse should not give the drug in a low dose, because that may not serve the purpose of administering it. The nurse should obey the instructions by the health care providers only after ensuring that the patient's concerns are addressed. At times, in order to protect human rights, the nurse needs to speak out against policies. The nurse is attending to a patient in a coronary care unit. She is revising the care plan after evaluating the patient outcomes. Which steps of the nursing processes is the nurse performing? Assessment and Evaluation A patient has been advised to have a total knee replacement because of osteoarthritis. The patient is not willing to undergo the surgery, but family members want to get the surgery done to relieve the disability. The nurse explains the details of the surgery and the risks associated with it, and also discuss the patient's wishes with the family. Which nursing role is the nurse playing here?