NUR 101 Exam 1 Question and Answers with complete solution

Handwashing - ANSWER Simplest, easiest, cheapest way to prevent spread of disease Correct hand washing should occur when: - ANSWER 1. before/after doing a procedure that involves direct or indirect client contact 2. after contact with wastes 3. after handling food or receptacles 4. between clients 5. after removing gloves IPPA - ANSWER Inspection Palpation Percussion Auscultation When performing an abdominal exam, is IPPA appropriate? If not, what it? - ANSWER No. IAPP Inspection, Auscultation, Palpation, Percussion Inspection - ANSWER Use of senses of vision, smell and hearing. To observe and detect normal and abnormal findings. Palpation - ANSWER Using parts of the hand to touch & feel: Texture, Temperature, Moisture, Mobility, Consistency, Strength of pulses, Size, Shape, Pain or Tenderness Percussion - ANSWER Tapping body parts to produce sound, waves/vibrations to assess underlying structures. To know: Location, Size, Shape, Density, Masses, Reflexes Auscultation - ANSWER Use of stethoscope to listen for sounds: Heart, Lungs, Abdomen, Blood Vessels Lydia Hall - ANSWER 1950s: Developed the nursing process (APIE) What is the Nursing Process - ANSWER ADPIE Assessment Diagnosis Planning Implementation Evaluation NANDA - ANSWER Developed in 1973 by North American Nursing Diagnosis Association (NANDA) Nursing Diagnosis - ANSWER Used to: Diagnose and treat human responses to actual or potential health problems. What kind of problems does a nursing diagnosis treat? - ANSWER A problem that can be independently managed by the RN within the scope of nursing practice. There are over 200 NDs in use. HIPAA - ANSWER Health Insurance Portability Accountability Act Confidentiality - ANSWER Any information a pt/client related will not be made public or available to others Informed Consent - ANSWER The pt/client has been informed about the procedure/treatment/surgery, etc including the risks involved to be able to make a decision Written Informed Consent - ANSWER Protects pt/client, facility, caregivers Signature is done in presence of witness who also signs the form Critical Thinking - ANSWER The way a nurse processes information using the following to formulate conclusions or diagnoses: Knowledge, past experiences, intuition, cognitive abilities Essential elements of critical thinking - ANSWER Open minded, use rationale to support opinions/decisions, reflect on thoughts before reaching conclusion, use past clinical experiences to build knowledge, etc Florence Nightingale - ANSWER The Mother of Modern Nursing When did public health nursing come about? - ANSWER 1900s Nurse practitioners emerged in what year? - ANSWER 1960s Purpose of health assessments - ANSWER Identify state of wellness, strengths and weaknesses, problems/needs in order to implement appropriate nursing care. Evaluate effects of therapeutic plan of care and interventions. Gordon's 11 Functional Health Patterns - ANSWER 1. Health perception/ health management 2. Nutrition- metabolism 3. Elimination 4. Activity- Exercise 5. Sleep- rest 6. Cognitive- perceptual 7. Self perception- self concept 8. Role relationship 9. Sexuality- Reproduction 10. Coping- stress tolerance 11. Value- belief Classifications of GFHP - ANSWER Functional, Dysfunctional and Potentially Dysfunctional Functional Classification of GFHP - ANSWER Optimal level of function, strengths identified, state of wellness or health Dysfunctional Classification of GFHP - ANSWER Deficits, health problems, illness Potentially Dysfunctional Classification of GFHP - ANSWER Can develop a dysfunctional state, at risk for disability or illness Assessment is a continuous process in which: - ANSWER a. subjective & objective data collected b. clinical judgements are made c. Client's level of function is determined d. First step of the nursing process is initiated Health History is based on: - ANSWER subjective data (what the patient says) Physical exam is based on: - ANSWER objective data (signs the nurse sees) Types of Health Assessments - ANSWER 1. Comprehensive 2. Focused/Problem - based 3. Episodic/Follow up 4. Shift 5. Screening Comprehensive Assessment - ANSWER -Detailed History -Physical exam Focused/Problem-based - ANSWER Problem focused 1. History 2. Physical (limited to specific problem or complaint) Episodic/Follow up - ANSWER Follow up visit with HCP Shift - ANSWER Nursing assessments conducted each shift Screening - ANSWER short exam done for disease detection Steps of Assessment - ANSWER 1. Preparation 2. Data Collection 3. Validation 4. Documentation What does health history do? - ANSWER 1. Lays groundwork for identifying nursing problems 2. Provides focus for physical exam 3. Identifies client strengths/weaknesses/limitations What does a health history include? - ANSWER Biographical data, Reasons for seeking health care, History of present health concern, Past health history, Family history, Review of body systems (ROS) for current health problem, Lifestyle and health practices, Developmental level 3 Levels of Health Promotion - ANSWER 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention Primary Prevention of Health Promotion - ANSWER 1. Prevent disease from developing 2. Promotion of healthy lifestyle Secondly Prevention of Health Promotion - ANSWER 1. Screening to promote early detection Tertiary Promotion of Health Promotion - ANSWER 1. Minimize the disability from acute/chronic disease or injury 2. To Maximize health Risk factors - ANSWER 1. Help reveal vulnerability to disease/illness/injury 2. Enables to devise plan to decrease risk ENVIRONMENTAL FACTORS - ANSWER 1. Assess external environment for hazards 2. Assess for prevention/improvement of conditions COMPLIANCE - ANSWER 1. Following instructions, protocols, orders in regard to health care 2. Assess why or why not client is noncompliant Clinical Judgment - ANSWER an interpretation or conclusion about a patient/client Clinical Judgement Process Includes: - ANSWER 1. Notice 2. Interpreting 3. Responding 4. Reflecting Actual ND - ANSWER Confirmed by presence of major defining characteristics Risk ND - ANSWER A clinical judgment that the client is more vulnerable to develop a problem more than others Health Promotion NDs - ANSWER A judgement about a desire to increase well-being and actualize human potential Syndrome NDs - ANSWER A clincal judgement describing a specific cluster of nursing diagnoses that occur together 3 Components of Planning Care - ANSWER 1. Establishing priorities 2. Formulating goals 3. Prescribing nursing interventions Types of Interventions - ANSWER 1. Nurse Initiated (Independent) 2. Physician Initiated (Delegated) 3. Collaborative Interventions (Interdependent) Implementation - ANSWER Providing care with interventions that are appropriate for the client *Includes documentation of care Evaluation - ANSWER 3 types of evaluation that nurse must complete: 1. Evaluate collaborative problems 2. Evaluate ND and progress to goal achievement 3. Evaluate POC status and currency Ethical criteria for Nursing judgment - ANSWER Code of Ethics Criteria for evaluation - ANSWER ANA Standards of Care