Assume you are scheduled for clinical tomorrow. How would you obtain information about your patient so that you can begin to develop a plan of care?
a.
... [Show More] Read the nursing admissions assessment and recent nurse's notes.
b. Read the health-care provider's admission note and recent progress notes.
c. Listen to the end-of-shift report at the nurse's station.
d. Review the medication administration record and any treatment plans or notes.
All of the above
Objective data
Data that can be assessed through the senses
Primary data
Data provided by the patient
Secondary data
Data obtained from a source other than the patient
Subjective data
Symptoms knowable only by the patient
Care plan
A documented strategy that includes the health-care provider's orders, nursing diagnoses, and nursing orders is called the _____
Critical thinking
_____ is using competent reasoning and logical thought processes to determine the merits of a belief or action
Validate
To avoid making decisions based on assumptions, nurses _______ the information they obtain.
Nursing process
The ______ is an overlapping, five-step method for decision making.
Rapport
Creating a relationship of mutual trust is called establishing a ______.
Nursing diagnosis
The concise statement of a problem that the patient is experiencing as a result of his or her medical diagnoses is called the _______.
Defining characteristics
The signs and symptoms experienced by the patient that directly influence the nursing diagnosis are called the ________.
Expected outcome
The ______ is the overall direction that will indicate improvement in a problem.
Nursing goals
______ are statements of measurable action for the patient within a specific time frame in response to nursing interventions.
Direct patient care
When an individual nurse performs hands-on or one-on-one nursing interventions, it is called ______.
Indirect patient care
Activities that a nurse performs that do not involve hands-on or one-on-one patient care but nonetheless have an impact on the patient are called ______.
Independent interventions
Actions the nurse performs that do not require a written order are called _______.
Dependent interventions
Actions the nurse performs that require a written order are called ______.
Collaborate interventions
Nursing actions that involve working with other disciplines such as physical therapy or social services are called.
Refer to the Real-World Connection feature called Critical Thinking in Patient Care located in Chapter 4 in your textbook. What did the nurse and the therapist do that is a characteristic feature of critical thinking?
a. They made important observations
b. They made a difference in patient care
c. They thought they could get to the bottom of the problem
d. They made a conscious decision to think in a new way about the problem.
d. They made a conscious decision to think in a new way about the problem.
You are accepting a patient who is being transferred to your general care unit after 3 days in the intensive care unit (ICU) following a stroke. Many of the stroke symptoms have resolved, and the patient needs only minimal physical and occupational therapy. Because the care in uncomplicated and you are busy with patients who are sicker, you ask the unlicensed assistant to develop the care plan, after which you will assess it and revise it as needed. Which of the following statements about your actions is true?
a. This is fine; you may delegate care planning as long as a licensed nurse reviews it.
b. This is fine as long as you choose the nursing diagnosis.
c. This is not allowed because nursing decisions and care planning cannot be delegated.
d. This is not allowed because the patient is coming from an ICU.
c. This is not allowed because nursing decisions and care planning cannot be delegated.
Your patient was admitted to the hospital with severe abdominal pain. It was determined that he had pancreatitis as a result of severely elevated triglycerides. He was also diagnosed with type 2 diabetes, and you plan to teach him about his diagnosis. He is not allowed anything by mouth yet because of the pancreatitis, is receiving IV fluids, and requires pain medication every 3 to 4 hours. You enter the room and let him know you want to discuss his health conditions with him. He responds by saying, "Not now, please, I just got my pain shot." Which of the following explains how the patient's comment reflects Maslow's hierarchy of needs?
a. He has to have his safety and security needs met before he can address cognitive needs.
b. Cognitive needs are less important than physical needs.
c. He cannot deal with learning new issues while he feels physically uncomfortable.
d. His discomfort is preventing him from cooperating.
c. He cannot deal with learning new issues while he feels physically uncomfortable.
A student in your class is given the name of a patient for whom she will proved care the following day in clinical. She goes to the unit, which specializes in diabetes care, to find out information and sees the patient sitting in a wheelchair with his chart in his lap. He is on his way to radiology for an x-ray. She notes that his left leg is amputated just below the knee and the right foot s bandaged . Your class has been studying diabetes and the student knows that vascular problems and amputations are unfortunate complications of diabetes. She plans to study about the diabetic foot care tonight so that she will be prepared for clinical the next day. Which of the following represents an accurate statement about her decision to study diabetic foot care?
a. It reflects careful observation and good planning.
b. The amputation and bandage are pretty obvious, so her plan is just common sense.
c. She should read the patient's specific foot care program before reading about general diabetic foot care.
d. She has made a serious thinking error.
d. She has made a serious thinking error.
Which step of the nursing process is concerned with identifying physical findings?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
e. Evaluation
a. Assessment
In which step of the nursing process would you look at outcomes?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
e. Evalutation
e. Evaluation
In which step of the nursing process are priorities set?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
e. Evaluation
c. Planning
In which step of the nursing process do you label problems?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
e. Evaluation
b. Diagnosis
Which step of the nursing process is most associated with action?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
e. Evaluation
d. Implementation
You enter the room to find your patient ashen and gasping for breath. Which part of the nursing process should you perform, formally or informally, in the first 5 minutes?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
e. Evaluation
f. all of the above
f. all of the above
You are caring for a male patient who had a total hip replacement 3 days earlier. You have not cared for the patient before and are assessing him to establish a baseline of information about his health status. The patient states that he felt feverish during the night and broke into a sweat. You check his temperature readings from the previous night and see that it was 99.2 F at midnight and 98. 2 F at 6 a.m. It now is 99 F. Which of the following actions represents the best response to his statement and gives the best explanation for the action as it relates to critical thinking?
a. Tell him not to worry because his temperature was only 99.2 F. This action shows that you understand the normal trends in postoperative care and are applying them to unique situations.
b. Make a mental not to check his temperature a few more times this shift. This action shows that you understand that assessment is the first and most important step in the nursing process.
c. Assess him for signs and symptoms of an infection. This action shows that you are looking for data to validate the patient's comment.
d. Tell him that a low-grade fever is normal after surgery. This shows that you are aware of common clinical conditions.
c. Assess him for signs and symptoms of an infection. This actions shows that you are looking for data to validate the patient's comment.
You have passed your NCLEX-PN examination and have just been employed as an LPN on a medical surgical unit. the registered nurse (RN) in charge asks you to do the admission assessment on a new patient who has just arrived by ambulance from a long-term care facility. The patient had undergone a total hip replacement within the previous 2 weeks and has developed a fever. You tell the nurse you thought an LPN could not do the admission assessment or, at most, could do only certain portions of it. The nurse, who is very busy, says, "Please just do it. I'll cosign it, so it will be fine." Which of the following actions should you take next?
a. Call the supervisor to discuss the nurse's instructions to you.
b. Refuse to do the admission assessment but offer to get the patient settled in., take his vital signs, and review the chart for orders.
c. Check the facility's policy manual.
d. Do the assessment as requested.
c. Check the facility's policy manual.
You are performing the daily assessment of your patient's status. You notice some purplish marks on her arm where the bandage for her IV had been and the skin is torn. Which of the following techniques did you use to obtain these data?
a. Inspection
b. Palpation
c. Auscultation
d. Percussion
a. Inspection
To assess bowel sounds, which assessment technique will you use?
a. Inspection
b. Palpation
c. Auscultation
d. Percussion
c. Auscultation
Your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. You document that the patient's pedal pulses are absent. Which assessment technique did you use to obtain this data?
a. Inspection
b. Palpation
c. Auscultation
d. Percussion
d. Percussion
b. Palpation [Show Less]