Taylor's Clinical Nursing Skills: Nursing 1 spring 2016 Flashcards

Normal vital infant

Pulse quality

droplet precautions

Standard precautions

contact precautions

Airborne precautions

Ppe

A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which of the following nursing aims should the nurse prioritize in the immediate care of this patient?

A student nurse understands that the primary aim of the Healthy People 2020 initiatives is

The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?

The need for university-based nursing education programs was brought to light during which important historical time?

The registered nurse is teaching a community health class about illness prevention. Which of the following statements reflects understanding of this concept?

A: Assessment
D: Diagnosis
P: Planning
I: Implementation
E: Evaluation

_______—collecting, validating, and communicating of patient data

______________—analyzing patient data to identify patient strengths and problems

________________—specifying patient outcomes and related nursing interventions

____________________—carrying out the plan of care

______________—measuring extent to which patient achieved outcomes

Physiologic (Survival): food, fluids, oxygen, elimination, warmth, physical comfort
Safety and Security: physical safety and psychological security
Love and Belonging: family and significant other
Self-esteem: make people feel good about themselves and confident in their abilities
Self-actualization: need to grow, change, accomplish goals

What is the nurse’s role in the Assessment phase of the Nursing Process?

What type of data is collected?

What are the different types of Nursing Assessments?

What is the purpose of the Nursing Diagnosis?

How does the nurse develop the Nursing Diagnosis?

What is the difference between a Nursing Diagnosis and Medical Diagnosis?

What is the difference between an Actual Nursing Diagnosis, Risk Nursing Diagnosis, Possible Nursing Diagnosis, Wellness Diagnosis, and Syndrome Nursing Diagnosis?

Problem --->> Etiology----->> Characteristics

OR
What is Wrong -------->>Why is Wrong Occurring------->>>

How do you Know What is Occurring

What is the purpose of Planning?

How does the nurse prioritize the nursing diagnosis?

What is the difference between Short and Long term outcomes (goals)?

What is the difference between Cognitive, Psychomotor, and Affective outcomes/goals?

S: Specific
M: Measurable
A: Achievable
R: Realistic
T: Timely

Assessment is done
Diagnosis is developed
Goal is identified
Now to develop the interventions that will meet the goals

Determine the patient’s new or continuing need for assistance.
Promote self-care.
Assist the patient to achieve valued health outcomes.

Developmental stage
Psychosocial background

Resources
Current standards of care
Research findings
Ethical and legal guides to practice

Cognitive—increase in patient knowledge
Psychomotor—patient’s achievement of new skills
Affective—changes in patient values, beliefs, and attitudes
Physiologic—physical changes in the patient

Delete or modify the nursing diagnosis.
Make the outcome statement more realistic.
Increase the complexity of the outcome statement.
Adjust time criteria in outcome statement.
Change nursing interventions

How do you know the problem is occurring (Hint: objective and subjective data)?
Develop (1) SMART goal
Try an intervention

...

...

...

______________—a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity

_________________—the unique response of a person to a disease; an abnormal process involving changed level of functioning

_____________—an active state of being healthy by living a lifestyle promoting good physical, mental, and emotional health

Physical: genetic inheritance, age, developmental level, race, gender
Emotional: stress, emotional intelligence
Intellectual: cognitive abilities, educational background, past experiences
Environmental: housing, sanitation, food, water, air
Sociocultural: culture, economic level, family
Spiritual: beliefs, morals, values

Physiological needs
Safety and security needs
Love and belonging needs
Self-esteem needs
Self-actualization needs

Answer: C. Pneumonia
Rationale:
Pneumonia is an acute illness that has a rapid onset of symptoms and lasts only a relatively short time. Diabetes, rheumatoid arthritis, and osteoporosis are chronic illnesses that cause a permanent change, require special patient education for rehabilitation, and require a long period of care or support.

Generally has a rapid onset of symptoms and lasts only a relatively short time
Examples: appendicitis, pneumonia, diarrhea, common cold

A broad term that encompasses many different physical and mental alterations in health
Examples: diabetes mellitus, lung disease, arthritis, lupus

It is a permanent change.
It causes, or is caused by, irreversible alterations in normal anatomy and physiology.
It requires special patient education for rehabilitation.
It requires a long period of care or support.

Experiencing symptoms
Assuming the sick role
Assuming a dependent role
Achieving recovery and rehabilitation

Tell whether the following statement is true or false.
A person who is experiencing a productive cough and fever takes a sick day to recuperate and decide whether to make an appointment with the doctor. Which stage of illness behavior is the patient experiencing?
Experiencing symptoms
Assuming the sick role
Assuming a dependent role
Achieving recovery and rehabilitation

Factors that the client cannot change
Age
Gender
Race
Family History

Factors that the client can change
Health habits
Lifestyle
Environment
Physiologic

______________: the behavior of an individual that is motivated by a personal desire to increase well-being and health potential. Education is a health promotion activity.

_________________: the behavior motivated by a desire to avoid or detect disease or to maintain functioning with the constraints of illness or disease. A diabetic patient looks at the soles of his feet with a mirror weekly

_______ directed to health promotion and the preventing the development of disease; interventions that prevent actual occurrence of a specific illness or disease; may focus on individuals or groups.

______________ focuses on screening for early detection of disease with prompt diagnosis and treatment

_____________ directed towards recovery or rehabilitation of a disease or illness has developed

1.) A nurse is administrating immunizations at a back to school fair.

2.) The nurse is performing a skin assessment for a patient that works outside in the sun.

3.) A nurse is monitoring the progress of a patient participating in Cardiac Rehab.

1.) A nurse is teaching a class on Heart Healthy Nutrition to a group of middle aged adults

2.) The nurse is completing the health assessment on a patient that includes cholesterol screening and blood pressure measurements.

3.) The nurse is teaching the patient how to take the prescribed cholesterol medicine and dietary restrictions.

______
Weight loss, diet, exercise, smoking cessation
_________
Screenings, examinations, family counseling
_________
Medications, surgical treatment, occupational therapy

Which of the following is an example of a nursing activity that promotes secondary prevention as a level of preventive care?
A. Conducting a smoking cessation class
B. Performing a blood pressure screening at a local mall
C. Performing range-of-motion exercises on a bedridden patient
D. Promoting safer sex practices in school settings

Care must be sensitive to needs of individuals, families, or groups from diverse cultures.
The healthcare system is a culture with customs, rules, values, and a language of its own.
Nursing is the largest subculture of the healthcare system.

Cultural background of each participant
Expectations and beliefs of each person about healthcare
Cultural context of the encounter
Degree of agreement between the sets of beliefs and values of the two persons

Varying cultures
Racial and ethnic origin
Religion
Physical size, age, and gender
Sexual orientation
Disability
Socioeconomic and occupational status
Geographical location

Shared system of beliefs, values, and behavioral expectations
Provides social structure for daily living
Defines roles and interactions with others and in families and communities
Apparent in the attitudes and institutions unique to the culture

Large group of people who are members of a larger cultural group
Have certain ethnic, occupational, or physical characteristics not common to the larger culture

_________________ (usually largest group)
Group has the most authority to control values and sanctions of society
_________ (smaller group)
A physical or cultural characteristic identifies the people as different than dominant group

______________
Minorities living within a dominant group lose the characteristics that made them different
Values replaced by those of dominant culture

_____________
The feelings a person experiences when placed in a different culture
May result in psychological discomfort or disturbances

Belief that everyone should conform to the majority belief system

Ignores differences and proceeds as if they did not exist

Belief that one’s ideas, beliefs, and practice are the best or superior, or are most preferred to those of others

Sense of identification with a collective cultural group
Largely based on group’s common heritage

Race
Typically based on specific characteristics
Skin pigmentation, body stature, facial features, hair texture

One assumes that all members of a culture or ethnic group act alike
May be positive or negative
Negative includes racism, ageism, and sexism

People become aware of differences and feel threatened
Response—ridiculing beliefs and traditions of others to make themselves feel more secure

Physiologic variations
Reactions to pain
Mental health
Gender roles
Language and communication
Orientation to space and time
Food and nutrition
Family support
Socioeconomic factors

Develop cultural self-awareness.
Develop cultural knowledge.
Accommodate cultural practices in healthcare.
Respect culturally based family roles.
Avoid mandating change.
Seek cultural assistance.

Recognize each person holds various beliefs about pain.
Respect the patient’s right to respond to pain in his own fashion.
Never stereotype a patient’s responses to pain based on his culture

Infectious agent—bacteria, viruses, fungi
Reservoir—natural habitat of the organism
Portal of exit—point of escape for the organism
Means of transmission—direct contact, indirect contact, airborne route
Portal of entry—point at which organisms enter a new host
Susceptible host—must overcome resistance mounted by host’s defenses

Bacteria—most significant and most prevalent in hospital settings
Spherical (cocci), rod shaped (bacilli), corkscrew shaped (spirochetes)
Gram positive or gram negative—based on reaction to Gram stain
Aerobic or anaerobic—based on need for oxygen
Virus—smallest of all microorganisms
Fungi—plantlike organisms present in air, soil, and water
Parasites—live in or on a host

Number of organisms
Virulence
Competence of person’s immune system
Length and intimacy of contact between person and microorganism
Infection VS. Colonization

Other humans
Animals
Soil
Food, water, milk
Inanimate objects

Respiratory
Gastrointestinal
Genitourinary tracts
Breaks in skin
Blood and tissue

Contact
Direct
Indirect

Vectors
Air

Incubation period—organisms growing and multiplying
Prodromal stage—person is most infectious, vague and nonspecific signs of disease
Full stage of illness—presence of specific signs and symptoms of disease
Convalescent period—recovery from the infection

Body’s normal flora
Inflammatory response
Immune response

Intact skin and mucous membranes
Normal pH levels
Body’s white blood cells
Age, sex, race, hereditary factors
Immunization, natural or acquired
Fatigue, climate, nutritional and general health status
Stress
Use of invasive or indwelling medical devices

Elevated white blood cell count—normal is 5,000 to 10,000/mm3
Increase in specific types of white blood cells
Presence of pathogen in urine, blood, sputum, or draining cultures

Includes all activities to prevent or break the chain of infection
Two categories
Medical asepsis—clean technique
Surgical asepsis—sterile technique

Use of invasive medical devices
Antibiotic-resistant organisms developed in hospitals

HAND HYGIENE
Constant surveillance by infection-control committees and nurse epidemiologists
Written infection-prevention practices for all agency personnel
Infection control precaution techniques
Keeping patient in best possible physical condition

what does the state's nurse practice act do?

what phenomena underlies the present and predicted nursing shortage in the US?

Florence Nightingale

Clara Barton

Dorothea Dix

Linda Richards

Lillian Ward

Marya Elizabeth Mahoney

Nora Gertrude Livingston

Isabel Hampton Robb

Mary Adelaide Nutting

Mary Breckinridge

Margaret Sanger

name the 4 essential competencies nurses use:

define cognitive competency:

define technical competency

define interpersonal competency

In what culture is good health achieved by the proper balance of yin and yang

In what culture do granny women or folk healers provide care and may be consulted even if the patient is also receiving traditional care

In what culture is self- diagnosis and use of over the counter medication often used, also dieting and extensive use of exercise are common

In what culture is the patient's illness viewed as part of the whole. emphasis is placed on preventive medicine

In what culture may a patient refuse to allow the nurse to draw blood for a test- because he believes blood is the body's life force and cannot be regenerate

What is the most basic culturallly competent nursing care

What disorder might you screen for in an African American man

Held the belief that illness was caused by sin and the gods' displeasure; theory of Animism

The roles of the physician and the nurse were separate and distinct.

Theory of Animism

Early Civilization Nursing