Nursing foundations exam #4 Flashcards

Orintation

working

termination

Written by a physician and it lists specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when a care is common to a situation.

Level 1- critical

level 2- emergent

level 3- urgent

level 4- nonurgent

level 5- fast tract

Brief individualized physical exam conducted at the beginning of an acute care setting work shift

Includes thorough interview

health history

review of systems

extensive physical head to toe assessment

cranial nerves

Ensures that patients receive sufficient info on which to base consent for care and related treatment

Agent in a leadership role

Provides direction and purpose to others, builds a sense of commitment toward common goals. Communicates effectively, and assists with addressing challenges that arise

Manages all of the activities and treatments for patients

Sense of oneself that is influenced by characteristics, norms, and values of the nursing discipline and resulting in an individual thinking and feeling like a nurse

The nurse delegates certain activities to other health care personal

Doing

being

acting ethically

flourishing

changing identities

Doing the right thing even when nobody is watching

Following through with a pain meds

calling the MD when patient asks you to

checking the code cart by the prescribed time

giving meds within the 30 min window

Clinical judgement

leadershio

ethics

communication

Ethical theory that stresses the rightness or wrongness of an individual behaviors, duties and obligations

"Doing good"

Self determination

Maintains that behaviors are determined to be right or wrong solely on the basis of their consenquences

Based on formal planning and systemic management to reduce errors and ensure the quality of patient testing

Include routine assessment of the sampling practices, standarized evaluations of controls used in assessing the samples and review of the quality testing procesures

One approach to problem resolution. Is systemic, logical, and based on data collection and hypothesis testing

Requires critical thinking. Is based on assessments, diagnosis, planning, implementation and evaluation

Info including the reliability, credibility, and bias of the source is assessed

Investigating plans of actions on the basis of examination of subjective and objective data

Making accurate conclusions that are based on sound reasoning

Consistent use of the essential skills of critical thinking guides clinical decision making

Characterized by failure to follow rational, systematic processes when approaching an issue or problem

Inclination or tendency to favoritism or partiality

Ability to influence and motivate others

Charting technique

situation, background, assessment, and recommedation

nurse to physician interviews

Documentation that records only abnormal or significant data

Subjective data, objective data, assessment, plan, intervention, evaluation

Subjective data, objective data, assessment, plan

Assessment, problem, intervention, evaluation

Subjective data, objective data, assessment, plan, intervention, evaluation, revisions to plan

Data, action, response

used to chart

Leader that assumes that followers are motivated by external forces

Federal standards for the protection of personal health information

Leader who exercises strong control over subordinates

Leader that believes that employees are motivated by internal means and want to participate in decision making

Employ methods that inspire people to follow their lead

Provides little or no direction to followers

Assume that leaders learn certain behaviors

Theories that assume that leaders are born with the personality traits necessary for leadership

Theory that leaders change their approach depending on the situation

Use reward and punishment to gain the cooperation of followers

Negligence committed by a person functioning in a professional role

Creating risk of harm to others by failing to do something

Do not recuscitate, comfort care

Living will- specifies treatment a person wants to receive when he or she is unconscious

durable power of attorney- legal document that allows a designated person to make legal decisions on behave of an individual

health care proxy- specifies the person who can make health care decisions for an individual

Occurs when a person who willingly requests to die is injected with a lethal drug dosage by another individual

Occurs when a person causes his or her death with the assistance of medication or intravenous injection supplied by a physician or other health care provider

Involves organizing patient assessment data into groupings with a similar underlying causes

Concise term or phrase that represents a pattern of related, clustered data. Taken from the official NANDA -I list

Diagnosis label

related factors

defining characteristics

Used in situations in which patients express interest in improving their health status. Through positive change in behavior

Truthfulness

First do no harm

Keeping promises or agreements made with others

Acting politely. Is essential in all intersections amoung faculty and nursing students

Code of ethics- formalized statement that defines the values, morals, and standards guiding practice in a specific discipline or profession

Genetic testing

cloning and embryonic stem cell research

end of life care

Study of ethical and philosophical issues in biology and medicine

Constitutional, statutory, regulatory, and case law

Care that is useless and prolongs the time until death rather than restoring life

Created legislative bodies such as the U.S congress and state legislature

Derived from a formal written constitutional that defines the powers of government and that responsibilities of its elected or appointed officials

Historically referred to as common law because it originally was determined by customs or social mores that were common at that time

Outlines how the requirements of statutory law will be met

Defines the nursing scope of practice in that state

Wrong committed by individuals who deliberately seek to injure or hurt another person

Criminal, misdemeanor, felony, and civil law

All goals must be patient focused

realistic

measurement

Goals that are achievable within an immediate time frame of less than one week

Will take more time to achieve- weeks to months

Data obtained from reviewing a patients chart, medical records, results of labs, and diagnostic tests

Data that comes directly from the patient

Nurses concur research studies and apply research to practice

Event or thoughts initiating the communication

Person who initiates and encodes the communication

Person who receives and decodes or interprets the communication

Information that is being communicated

Method of communication

Respons of the receiver

Translating their thoughts and feelings into communication with a receiver

To avoid misinterpretation of a message, it is essential that the receiver provide feedback to the sender regarding conveyed meaning

Spoke, written or electronic

most communication is nonverbal and provided in the form of body language such as gestures and eye contact

Wordless transmission of information.

93% of communication is nonverbal. Body language constitutes 55% of all nonverbal communication and voice inflection accounts for 38%

More accurate mode of conveying information

The study of the spatial requirements of humans and animals

Intimate - 0-1.5 feet

personal -1.5 to 4 feet

social- 4-12 feet

public 12 feet or more

Children demonstrate a need for greater personal space as they age.

english speaking people typically prefer at least 18 inches of distance between themselves and others when conversing

middle eastern people may be comfortable standing very close while communicating

The second most significant form of nonverbal communication

Occurring internally

Internal conversations that provides motivation and encoraugement. May be used to build self esteem and self confidence

Mindful reflection or contemplation

Takes place between two or more people

Almost 70% of sentinel events were caused by communication breakdown and 50% of those cases occurred during patient handoff

limits and responsibilities of an individual in a given setting

forming

storming

norming

performance

building trust

demonstrating empathy

establishing boundaries

recognizing and respecting culture influences

developing a comprehensive plan of care

the 5 steps of the nursing process are used in each phase of the helping relationships

nursing diagnoses for individual patients are identified during the orientation phase after assessment data are gathered and clustered

with the patients permission relatives and friends may be considered secondary sources of subjective information

the ability to express ideas and concerns clearly while respecting the thoughts of others

the primary focus of therapeutic communication between a patient and nurse is the patient

most often occurs among individuals who know each other or who are getting to know each other informally.

s- encourages the the listener to sit

o- reminds the nurse to maintain an open stance or posture

l- suggest the listener lean toward the speaker

e- to maintain eye contact without staring

r- reminds the nurse to relax

Adults need 6-8 hours per night

Adults while in a hospital need at least 90 minutes of uninterrupted sleep

Cluster care

consult about medication regiment especially meds like diruretics- don't administer past 6 pm

20-30% of adults have some kind of sleep disorder

Stage 1- 3-10 minutes

stage 2- 10-20 minutes

stage 3 - 15-30 minutes

stage 4 - 15-30 minutes

REM sleep- memory is enhanced, cells regenerate, cerebral blood flow

cycle through about 6times/night

Ritual to implement or promote sleep

drinking milk

brushing teeth

turning lights down

Increases agitation, and impulsiveness

Stress hormone

released early in the daytime

Hormone for sleep

induces sleep

Polysomnography

During several 20 minute naps during the day

pt is suspected of having narcolepsy

Difficulty falling asleep

staying asleep

being excessively sleepy

Disorders associated with abnormal sleep behaviors

Grinding teeth

Bed wetting

Sleep walking

Underlying medical or psychiatric problem

COPD-

pain

mentak health disorders

Difficulty with sleep

Excessive day time sleeping

Obstructive sleep

apnea 10 seconds or greater without breathing

Loss of good quality sleep

Restless leg syndrome

constantly needing to move legs

Continuos positive airway pressure

135-145 meq/l normal per textbook

3.5-5.0 normal per textbook

8.5-10.5

1.3-2.1

1.76-2.6

Behavior issues

Hyponatremia

Causes confusion, lethargy

Hypernatremia

irritability, hallucinations

Cardiac/ neuromuscular

Weak, cardiac dysrhythmia

Dysrhythmia

Too much volume

too much IV fluid

Too low volume

low BP, low heart rate

Good reason to keep electrolytes balanced

7.35-7.45

95-100

Respiratory- 1st thing to kick in with acid imbalance

renal - excretes hydrogen- doesn't kick in for 3 days

Deep shallow breathing

you exahule c02 when you breathe