76 Questions
What is the purpose of triage assessment?
To determine the extent and severity of clients' problems
During the assessment phase, what does 'establishing a database' refer to?
Reviewing past medical records
What is an essential step in collecting assessment data before seeing the client?
Getting report during hand off communication
When communicating/documenting data during assessments, what should be prioritized?
Accurate representation of data collected
What does 'updating, organizing, and validating data' during assessment activities involve?
Checking the accuracy of provided information
In the context of collecting data after seeing the client, what is important for collaboration with other care providers?
Following up on care and client requests
Why do assessment activities continue through all steps of the Nursing Process?
To ensure ongoing data collection and evaluation
What does the 'AAPIE' acronym stand for in the context of the Nursing Process?
Assessment, Analysis, Planning, Implementation, Evaluation
Which QSEN competency involves incorporating patient/family preferences and values?
Patient-centered care
What is the primary focus of the competency related to teamwork and collaboration in QSEN?
Working with inter- and intra-professional teams
In the context of QSEN, what is the key aspect of evidence-based practice?
Integrating best current evidence with clinical expertise
Which competency in QSEN involves researching interventions and establishing evidence to support their effectiveness?
Quality improvement
What is the main focus of the Safety competency in QSEN?
Assessment and evaluation of interventions for appropriateness
'QSEN Competencies' aim at enhancing which aspect of nursing practice?
Critical thinking and clinical judgment
What type of data includes symptoms and assessments that can be verified by another observer?
Objective data
According to Maslow’s Hierarchy of Needs, what should be done first when prioritizing patient problems?
Address the physiological needs
Which stage in the nursing process involves implementing the plan of care?
Implementation
What type of outcome should be generated to ensure a specific and measurable goal?
SMART outcome
What type of interventions are implemented independently by nurses without requiring supervision?
Independent interventions
When evaluating the desired outcome, which of the following statements indicates successful achievement?
The outcome was met
What part of the nursing process involves identifying priority problems and clustering information?
Analysis
What distinguishes an Actual Problem from a Potential Problem in the context of client/patient issues?
Actual existence of the health problem
What is an example of an Actual Problem?
Decreased Functional Ability due to fracture in left patella
How does the nurse differentiate between Actual and Potential Problems when assessing client/patient issues?
By determining if the problem actually exists
Which term is used to describe a situation where a health problem exists with evidence present?
Actual Problem
What distinguishes a Potential Problem from an Actual Problem?
'Potential for' and lack of evidence of the problem
In the context of client/patient issues, what does 'identifiable risk factors, no evidence of the problem' refer to?
'Potential Problem'
When discussing client/patient problems, what role does 'Actual Problem' play?
It indicates that a health problem exists with evidence present
What is the purpose of writing desired outcomes in nursing interventions?
To provide direction for planning nursing interventions
What does SMART stand for in the context of writing desired outcomes?
Specific, Measurable, Attainable, Realistic, Time bound
Which of the following is a measurable verb used in writing desired outcomes?
Apply
Why is it advised not to use 'at end of shift' when writing desired outcomes?
Because first semester students may not be there until the end of the shift
Which aspect of desired outcomes helps motivate both the client and the nurse?
Providing a sense of achievement
Why should each outcome be derived from only one client problem?
To ensure clarity and focus in addressing specific issues
What should be the starting words in a desired outcome statement according to the text?
'Client will'
'Verbalize' is an example of which type of verb used in writing desired outcomes?
Measurable verb
'Know' is an example of which type of verb used in writing desired outcomes?
'Non-measurable verb'
'At end of shift' is discouraged in desired outcomes for first semester students to ensure goals are _______ and _______.
'Time bound' and 'Realistic'
What is the primary focus of the NCJMM Nursing Clinical Judgement Measurement Model?
To identify client's needs and what matters most
Which step is common between the Nursing Process and NCJMM Skills?
Evaluating outcomes
What is the importance of prioritizing hypotheses in the NCJMM model?
To identify and solve patient problems
In the context of nursing practice, what does 'Analyzing cues' refer to?
Understanding human response needs
What is the key difference between NCJMM Skills and Nursing Process regarding 'Take Action'?
NCJMM emphasizes generating solutions before implementing
Which stage in the NCJMM model aligns with the Nursing Process stage of 'Planning'?
Generate Solutions
What is the main role of 'Recognizing Cues' in the NCJMM model?
Identify client's needs
Which type of data includes sensations, feelings, values, beliefs, attitudes, and perceptions of personal health status?
Subjective Data
What distinguishes Objective Data from Subjective Data in the context of collecting health information?
Objective Data is detectable by an observer, while Subjective Data is based on personal beliefs.
In the context of data collection, where is primary source information primarily obtained from?
Support persons
Which method of data collection involves utilizing the senses of vision, hearing, touch, and smell to gather information?
Observing
When might it be appropriate to use a secondary resource for collecting data according to the text?
When the primary source is unavailable due to illness or confusion
Which type of data is detectable by an observer and can be measured or tested against an accepted standard?
Objective Data
'I feel like my heart is racing' is an example of what kind of data in the context of healthcare?
Subjective Data
'Skin color' (vision), 'Body odors' (smell), and 'Lung sounds' (hearing) are examples of data obtained through which method?
Observing
What does the 'AAPIE' acronym stand for in the context of the Nursing Process?
Assessment, Analysis, Planning, Implementation, Evaluation
Which competency in QSEN involves assessing interventions for their appropriateness based on factors like age and physical capability?
Safety
Why is it important to document and plan patient care in the EHR according to the text?
To facilitate communication among healthcare providers
What is the main focus of the Quality Improvement competency in QSEN?
Researching interventions and establishing evidence for their effectiveness
In the context of nursing practice, what does Patient-centered care involve?
Incorporating patient/family preferences and values
Which step in the Nursing Process involves identifying priority problems and clustering information?
Analysis
What is the purpose of integrating best current evidence with clinical expertise and interventions?
To improve patient outcomes through evidence-based practice
Why is teamwork and collaboration emphasized in developing a patient-centered plan of care?
To work effectively with healthcare providers
What is the purpose of comparing abnormal findings with normal values during data collection?
To determine if the findings need immediate intervention
Why is it important to cluster data during the assessment process?
To identify gaps and inconsistencies in the data
When interpreting and analyzing data, what do nurses primarily compare the data against?
Against standards or norms
Which action is most appropriate when a potential problem has not yet occurred but there is a risk of it happening?
Monitor closely for changes
In the context of nursing, what does prioritizing problems according to Maslow's Hierarchy of Needs entail?
Addressing physiological needs before safety needs
What does it mean when a problem is identified as 'Actual' according to client/patient problem types?
The problem is current and represents a decrease from normal status
How does revising the plan differ when the outcome is 'Unmet' versus 'Partially Met' according to the text?
Revising the entire plan and interventions for Unmet outcomes, while revising interventions only for Partially Met outcomes
What is the main focus of collaborative problems in nursing management?
Monitoring client condition to prevent complications
Which stage involves prioritizing hypothesis by identifying the patient's main problem that the nurse can treat?
Planning
What is the purpose of using Maslow's Hierarchy of Needs when prioritizing patient problems?
To decide which problems to prioritize for developing a plan of care
In the context of nursing, what do physiologic problems typically involve?
Acute peripheral tissue perfusion issues
What does AAPIE stand for in relation to the nursing process?
Assessment, Analyzing, Planning, Implementing, Evaluating
When formulating a problem statement, why is it important to use Maslow's Hierarchy of Needs?
To identify priority problems in the plan of care
What distinguishes psychological problems from physiologic problems in nursing?
Psychological problems are more subjective than physiologic problems
'Analyzing Cues & Identifying Priority Problems' is a crucial step in which phase of the nursing process?
Assessment
Study Notes
QSEN Competencies: Knowledge, Skills & Attitude
- Patient-centered care: incorporating patient/family preferences and values for optimal health care
- Teamwork and collaboration: working with inter- and intra-professional teams in developing a patient-centered plan of care
- Evidence-based practice: integrating best current evidence with clinical expertise and interventions
- Quality improvement: researching and establishing evidence-based interventions
- Safety: assessing and evaluating interventions for level of appropriateness (age/physical capability)
- Informatics: documenting and planning patient care in the EHR
Nursing Process Steps
- Assessment: establishing a database of the client's response to health concerns/illness and their ability to manage health needs
- Analysis: analyzing data and identifying cues, prioritizing hypotheses, and generating solutions
- Planning: creating a plan of care with desired outcomes and interventions
- Implementation: implementing the plan of care
- Evaluation: evaluating the desired outcomes and revising the plan as needed
AAPIE - Analyze Cues & Identify Priority Problem
- Assessment: recognizing cues and collecting data (subjective and objective)
- Analyze: analyzing cues, prioritizing hypotheses, and generating solutions
- Planning: creating a plan of care with desired outcomes and interventions
- Implementation: implementing the plan of care
- Evaluation: evaluating the desired outcomes and revising the plan as needed
Types of Client/Patient Problems
- Actual Problem: a current health problem that exists
- Risk/Potential Problem: a potential health problem that may develop if the nurse does not intervene
- Need for Health Teaching: a need for education or training on self-care or health management
Data Collection
- Methods of data collection: observing, interviewing, and assessing
- Sources of data: the client, family, support persons, health professionals, and medical records
- Clustering (organizing) data and analyzing cues: comparing subjective and objective data, identifying gaps and inconsistencies, and determining client strengths, risks, needs, and problems
Learn about the differences between Actual Problems and Potential Problems in client/patient health scenarios. Understand how to identify health problems based on evidence and reach conclusions for appropriate healthcare interventions.
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