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A nurse is demonstrating the Caritas philosophy in her practice. Which action best reflects the principle of altruism?
A nurse is demonstrating the Caritas philosophy in her practice. Which action best reflects the principle of altruism?
Which approach by a nurse best demonstrates patient-centered care?
Which approach by a nurse best demonstrates patient-centered care?
What is a key characteristic of professional formation in nursing?
What is a key characteristic of professional formation in nursing?
Which component is not part of evidence-based practice in nursing?
Which component is not part of evidence-based practice in nursing?
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A nursing student exhibits unprofessional behavior by:
A nursing student exhibits unprofessional behavior by:
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A nurse is assigned to a patient who underwent abdominal surgery 12 hours ago. The nurse notes the following assessment findings: BP 88/56 mmHg, HR 118 bpm, temperature 101°F (38.3°C), shallow breathing at 24 breaths/min, and the patient reports abdominal pain rated at 7/10. Which of the following actions should the nurse prioritize?
A nurse is assigned to a patient who underwent abdominal surgery 12 hours ago. The nurse notes the following assessment findings: BP 88/56 mmHg, HR 118 bpm, temperature 101°F (38.3°C), shallow breathing at 24 breaths/min, and the patient reports abdominal pain rated at 7/10. Which of the following actions should the nurse prioritize?
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A nurse is caring for a patient recovering from a motor vehicle accident. The patient reports feeling anxious and expresses concern about being able to return to work. What is the nurse's priority intervention based on Maslow's Hierarchy of Needs?
A nurse is caring for a patient recovering from a motor vehicle accident. The patient reports feeling anxious and expresses concern about being able to return to work. What is the nurse's priority intervention based on Maslow's Hierarchy of Needs?
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A new graduate nurse is following a step-by-step process when administering medications but is unable to adjust for a patient's unique needs. According to the levels of critical thinking, what level is this nurse demonstrating?
A new graduate nurse is following a step-by-step process when administering medications but is unable to adjust for a patient's unique needs. According to the levels of critical thinking, what level is this nurse demonstrating?
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A nurse demonstrates confidence, integrity, and humility while asking for assistance when managing a complex patient case. Which component of critical thinking does this behavior represent?
A nurse demonstrates confidence, integrity, and humility while asking for assistance when managing a complex patient case. Which component of critical thinking does this behavior represent?
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A nurse is monitoring a patient post-laparoscopic cholecystectomy. Which observation requires immediate intervention?
A nurse is monitoring a patient post-laparoscopic cholecystectomy. Which observation requires immediate intervention?
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A nurse is assessing a newly admitted patient with a history of heart failure. The patient reports experiencing fatigue and difficulty breathing while lying flat. During the assessment, the nurse observes bilateral pitting edema in the lower extremities and an oxygen saturation level of 89%. How should the nurse classify these findings?
A nurse is assessing a newly admitted patient with a history of heart failure. The patient reports experiencing fatigue and difficulty breathing while lying flat. During the assessment, the nurse observes bilateral pitting edema in the lower extremities and an oxygen saturation level of 89%. How should the nurse classify these findings?
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A patient is admitted with a chief complaint of severe abdominal pain, nausea, and vomiting. During the comprehensive admission assessment, the nurse notes a tense, distended abdomen and absent bowel sounds. Which action should the nurse prioritize?
A patient is admitted with a chief complaint of severe abdominal pain, nausea, and vomiting. During the comprehensive admission assessment, the nurse notes a tense, distended abdomen and absent bowel sounds. Which action should the nurse prioritize?
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A patient complains of lightheadedness and dizziness when standing up. Which assessment technique should the nurse prioritize?
A patient complains of lightheadedness and dizziness when standing up. Which assessment technique should the nurse prioritize?
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During an interview, a patient mentions, "I feel so tired all the time and can't sleep at night." The nurse notices dark circles under the patient's eyes and a slouched posture. Which of the following represents an inference based on these cues?
During an interview, a patient mentions, "I feel so tired all the time and can't sleep at night." The nurse notices dark circles under the patient's eyes and a slouched posture. Which of the following represents an inference based on these cues?
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A nurse is reviewing a patient's electronic health record (EHR) on a shared computer. Which of the following actions violates HIPAA regulations?
A nurse is reviewing a patient's electronic health record (EHR) on a shared computer. Which of the following actions violates HIPAA regulations?
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A nurse is assessing a patient admitted with leg pain and edema. The patient now reports sudden chest pain while ambulating to the restroom. What should the nurse do next?
A nurse is assessing a patient admitted with leg pain and edema. The patient now reports sudden chest pain while ambulating to the restroom. What should the nurse do next?
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A patient has undergone a right total hip arthroplasty and is reporting a pain level of 7/10 at the incision site. The nurse also observes redness, swelling, and drainage at the incision. Which type of nursing diagnosis is most appropriate?
A patient has undergone a right total hip arthroplasty and is reporting a pain level of 7/10 at the incision site. The nurse also observes redness, swelling, and drainage at the incision. Which type of nursing diagnosis is most appropriate?
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During an assessment, the nurse gathers the following patient data: low urine output (300 mL/24 hours), BP 90/50 mmHg, HR 110 bpm, and dry mucous membranes. What is the priority nursing diagnosis for this patient?
During an assessment, the nurse gathers the following patient data: low urine output (300 mL/24 hours), BP 90/50 mmHg, HR 110 bpm, and dry mucous membranes. What is the priority nursing diagnosis for this patient?
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A patient with pneumonia is admitted with labored breathing, oxygen saturation of 88%, and crackles in the lungs. Which nursing diagnosis is most appropriate, and what is its etiology?
A patient with pneumonia is admitted with labored breathing, oxygen saturation of 88%, and crackles in the lungs. Which nursing diagnosis is most appropriate, and what is its etiology?
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The nurse is creating a care plan for a patient with opioid-induced constipation following surgery. Which nursing diagnosis is most appropriate?
The nurse is creating a care plan for a patient with opioid-induced constipation following surgery. Which nursing diagnosis is most appropriate?
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A nurse is caring for a patient with a medical diagnosis of chronic obstructive pulmonary disease (COPD) who has dyspnea and fatigue during minimal exertion. The nurse uses the PES (Problem-Etiology-Symptoms) format to create a nursing diagnosis. Which statement best demonstrates the correct structure?
A nurse is caring for a patient with a medical diagnosis of chronic obstructive pulmonary disease (COPD) who has dyspnea and fatigue during minimal exertion. The nurse uses the PES (Problem-Etiology-Symptoms) format to create a nursing diagnosis. Which statement best demonstrates the correct structure?
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Which statement best differentiates between a nursing diagnosis and a medical diagnosis?
Which statement best differentiates between a nursing diagnosis and a medical diagnosis?
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Study Notes
Nursing Profession: Caritas Philosophy
- A nurse demonstrates Caritas philosophy in practice by volunteering at a community clinic to provide free health care.
- This action reflects altruism, focusing on caring for others without personal gain.
Nursing Profession: Patient-Centered Care
- Patient-centered care involves engaging the patient as a partner in decision-making, respecting their preferences and values.
- This approach contrasts with developing a care plan based solely on research, or providing care aligned only with standard procedures.
- Educating the patient's family without involving the patient is not patient-centered.
Nursing Profession: Professional Formation
- A key characteristic of professional formation in nursing is adhering to the profession's code, goals, and ethical standards.
Evidence-Based Practice
- Evidence-based practice involves clinical expertise, patient preferences and values, and research evidence.
- Nursing intuition and personal beliefs are not part of evidence-based practice.
Unprofessional Behavior
- Arriving late to a clinical setting without notifying the instructor is unprofessional.
- Following clinical procedures correctly, even if consulting a peer, is professional.
- Discussing patient cases in private post-clinical meetings is unprofessional.
Clinical Decision Making
- Prioritizing low blood pressure (hypotension) in a post-surgical patient is crucial.
- Assessing vital signs, oxygen saturation, and taking immediate action are essential steps for patient safety in critical situations, especially sudden chest pain.
- Determining the priority of interventions, based on Maslow's hierarchy, involves prioritizing the patient's physiological needs, including oxygenation, before addressing higher-level needs like self-esteem.
Priority Setting
- A patient with a blood pressure of 90/50 mmHg should be assessed first.
- This is due to the potential for severe internal bleeding or shock, which can be life-threatening.
Critical Thinking Components
- A nurse demonstrating confidence, integrity, and humility while asking for assistance reflects positive attitudes toward critical thinking.
Preventing Complications
- A respiratory rate of 28 breaths/minute with shallow breathing requires immediate intervention, as it suggests possible complications like atelectasis or respiratory distress.
Assessment: Data Collection
- Subjective data are verbal reports from the patient, like fatigue or difficulty breathing.
- Objective data can be observed and measured, such as edema, oxygen saturation levels, or vital signs.
Assessment Priority
- Assessing a patient with a tense, distended abdomen and absent bowel sounds immediately warrants reporting to the healthcare provider, as it may indicate a possible bowel obstruction.
Focused Assessment
- Assessing for orthostatic blood pressure changes is essential when a patient reports lightheadedness and dizziness upon standing.
HIPAA Compliance
- Accessing a patient's electronic health record (EHR) for a patient not assigned to the nurse is a violation of HIPAA regulations.
Analysis and Action
- Assessing vital signs and administering pain medication should be the priority, rather than returning the patient to bed and immediately applying oxygen.
Nursing Diagnosis Types
- An actual pain diagnosis, related to a surgical incision, is supported by reported pain level and observed signs like swelling and redness. This approach uses objective and subjective data to support the diagnosis.
Etiology in Nursing Diagnosis
- Impaired gas exchange, related to the disruption of alveolar-capillary membrane, is a suitable nursing diagnosis for a patient with pneumonia.
Application of NANDA Guidelines
- COPD exacerbation is correctly identified as the etiology for activity intolerance, supported by symptoms like dyspnea and fatigue upon exertion.
Differentiating Diagnoses
- A nursing diagnosis focuses on identifying the patient's human response to health conditions, in contrast to a medical diagnosis, which identifies diseases or conditions.
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